as difficulty performing any of 12 routine physical or social activities without assistance (e.g., sitting for more than two hours or participating in social activities) more than doubled from 3.6 million in 1999 to 8.2 million in 2018 (558). The functional limitations can vary based on the type of cancer diagnosed and were highest among survivors of pancreatic cancer (80.3 percent) and lung cancer (76.5 percent) and lowest for those who had melanoma (62.2 percent), or cancers of breast (61.8 percent) and prostate (59.5 percent) (558). While cancer researchers and physicians have learned a lot about these challenges over the years, implementation of groundbreaking new treatments, such as immunotherapies, presents unique short- and long-term challenges that are only beginning to be understood (see Immunotherapy: Pushing the Frontier of Cancer Medicine, p. 99). A greater understanding of these challenges and ways to address them is urgently required to support cancer survivors. Physical Challenges Survivors can experience a wide range of short- and long-term symptoms caused by cancer or its treatments. Short-term effects include hair loss, pain, nausea, vomiting, and loss of smell and appetite with varying severity of symptoms depending on the person, cancer type, and treatment. As cancer survivors are living longer due to better therapies, the development of longterm side effects such as heart damage (cardiotoxicity), lung damage, loss of bone density, and cognitive decline is becoming more common and demands a greater understanding to reduce or manage these conditions (see Sidebar 42, p. 134). Cachexia is the loss of body weight and muscle mass, and weakness that may occur in patients with cancer or other chronic diseases. Cachexia is estimated to occur in up to 80 percent of patients with advanced cancer. For instance, cachexia occurs in 87 percent of patients with pancreatic and gastric cancers, and in 61 percent of patients with NHL or with cancers of the colon and rectum, lung, and prostate. The development of cachexia indicates poor prognosis and accounts for 20 to 30 percent of all cancer-related deaths. Loss of muscle, especially heart and skeletal muscle, leads to widespread disturbances in biological functions (559). In patients with metastatic cancer, who are at the highest risk for cachexia, reduced nutrient intake coupled with high energy demand caused by cancer and its side effects results in a negative energy balance. In some instances, pain management can help to increase appetite, which can slow the advancement of cachexia (560). Understanding the biological underpinnings and addressing cancer-related cachexia are areas of ongoing basic and clinical investigation (561). Chemotherapy-related cognitive impairment, often termed as “chemo brain,” has been reported by many cancer survivors to describe thinking and memory problems before, during, and after cancer treatment. Accumulating evidence from brain imaging studies shows the biological effects of cancer therapeutics on the brain, including changes in glucose consumption, blood flow, and expression of certain proteins (562), all of which may contribute to cognitive impairment. Many survivors report having increased cognitive impairment even after a year following the completion of cancer treatment, indicating these effects can be long-standing (563). Cardiotoxicity from certain types of anticancer therapeutics has been reported in many studies and increases the risk of clinical hypertension, coronary artery disease, heart failure, and atrial fibrillation, among others. Research has also shown that cancer survivors have an “excess heart age”—a measure of cardiovascular damage and risk of a heart attack—compared to individuals who have never received a cancer diagnosis. Studies of cancer survivors have shown an excess heart age of eight and a half years in men and six and a half years in women (564). Furthermore, there are disparities in severity of adverse cardiac events among cancer survivors. Non-Hispanic Black cancer survivors had higher rates of cardiovascular disease-related mortality compared to Hispanic, non-Hispanic Asian/Pacific Islander, and White patients (565). Immunotherapies, including immune checkpoint inhibitors and adoptive cell therapies, are still a relatively new class of treatment compared to other types of cancer therapies. Their long- and late-term side effects are being studied as successful treatment with these therapeutics has led to many more people living longer (see Immunotherapy: Pushing the Frontier of Cancer Medicine, p. 99). Psychosocial Challenges A diagnosis of cancer can pose serious challenges to a person’s mental and emotional health. Based on recent data, one in six patients with cancer has pre-existing psychiatric conditions, which can lead to longer hospital stays, higher rates of readmission, and increased risk of suicidal thoughts after the treatment ends in patients undergoing surgery for their cancer (567). Many survivors experience anxiety (7 to 21 percent of patients), depression (8 to 24 percent of patients), and distress (25 to 41 percent of patients) following the completion of cancer treatment (13,568-570). A study that examined 26 different cancer types found that 98 percent of patients with testicular cancer, 78 percent of patients with cervical Severe immune-related adverse events occur in up to 60 percent of patients with melanoma treated with immune checkpoint inhibitors (566). Supporting Cancer Patients and Survivors AACR Cancer Progress Report 2023 133
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