The SEER survival data show that among long-term cancer survivors (those living 5 years or longer beyond the date of their cancer diagnosis), 60% are older than 64 years and approximately 40% are in the working adult age bracket (20–64 years), or those in their productive years of life who are concerned about maintaining employment. It is projected that within the next 40 years the population of long-term cancer survivors aged 65 years or older will double compared with today’s numbers. This is very important because a higher frequency of concurrent illness occurs among survivors aged 65 years or older than among other age groups, and this can significantly influence both the management of cancer and the long-term complications of treatment. Therefore, managing the concurrent health problems of cancer patients and survivors is equally as important as managing the cancer itself.

Patients who reach long-term survivorship status can be well and reintegrate into a normal life. Unfortunately, many cancer survivors do not recover their health and do not receive adequate health care. The Institute of Medicine published a comprehensive assessment of the status of cancer survivors in the United States in 2005. This assessment noted that a significant proportion of survivors suffered from chronic, long-term physical, social, or emotional distress. The study, entitled From Cancer Patient to Cancer Survivor: Lost in Transition, found that a critical issue for many patients was limited access to health care and lack of coordination of their health care once the cancer treatment and intermediate surveillance was concluded (Hewitt et al. 2006). The study made several recommendations for health care providers, as well as for policy-makers and government bodies, to improve the care of survivors. A more recent updated report emphasizes ten additional recommendations (Levit et al. 2013). One of these recommendations is that care must be coordinated and integrate multidisciplinary expertise. At our own institution, we have developed a multidisciplinary care delivery model that incorporates the elements of care outlined in this chapter.

The development of chemotherapeutic regimens as primary or adjunctive treatment for various cancers evolved rapidly in the 1960s and 1970s, as did the application and awareness of early cancer screening. In 1986, the founders of National Coalition for Cancer Survivorship set out to establish an organization that would change the phrase “cancer victim” to “cancer survivor.” To this end, the National Coalition for Cancer Survivorship crafted the definition of a survivor: from the time of diagnosis and for the balance of life. By the early 1990s, there was evidence of a sustained increase in the number of persons diagnosed with cancer who were living 5 years or longer beyond their diagnosis (Fig. 2.1). In 1996, the National Cancer Institute established an Office of Cancer Survivorship (OCS) in response to this trend, as well as in response to the concern that knowledge about the health of cancer survivors and the long-term effects of cancer treatment was significantly lacking. The OCS’s first challenge was answering the question: who is a cancer survivor? The OCS adapted the National Coalition for Cancer Survivorship’s definition of a survivor: “An individual is considered a cancer survivor from the time of diagnosis through the balance of his or her life” (National Cancer Institute 2012). OCS also expanded that definition to include the family and primary caregivers of the patient, because they all are influenced by the experience of cancer. Given the OCS’s very broad definition of who is a cancer survivor, when we speak of survivors’ health care needs we are speaking of a large and changing landscape; the cancer survivor’s journey today can cover a long chronologic trajectory.

The health care needs of cancer survivors, then, do not remain the same in later phases of survivorship as they were in the early phases of survivorship. The concept of “seasons of survival” was described in 1985 by Fitzhugh Mullan in an article in which he described his personal experience as a physician and a cancer survivor (Mullan 1985). Dr. Mullan described three principally different cancer survival phases, distinct from each other both on an experiential level and from a clinical perspective.

The acute phase begins with the diagnosis of cancer and includes testing for and treatment of the malignancy. Clinical care at this point is principally oncologic (i.e., administered by surgical, radiation, and medical oncologists), with a focus on eradication of the malignancy and management of any acute complications of treatment. From the patient’s perspective, the primary experience is one of illness, treatment side effects, anxiety about the treatment, and fear of the cancer, as well as hope of reaching a remission.