When to Start a Conversation With Patients About Subsequent Primary Cancers

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Among patients who survive a primary cancer, concern about recurrence, especially metastatic disease, is extremely common; however, information about future risk for subsequent primary cancers is seldom communicated to these patients, leading to missed opportunities to prevent or detect subsequent primary cancers at an early stage.” So wrote Patricia A. Ganz, MD, and ­Jacqueline N. Casillas, MD, MSHS, of the UCLA Jonsson Comprehensive Cancer Center, Los Angeles, in a JAMA editorial1 on the study by Sung et al.2 In that study, they found the risk of developing or dying of a new primary cancer was greater among survivors of adult-onset cancers than the expected risk in the general population.

“Cancers associated with smoking or obesity comprised substantial proportions of overall subsequent primary cancers incidence and mortality among all survivors and highlight the importance of ongoing surveillance and efforts to prevent new cancers among survivors,” the study authors wrote.2 A cancer diagnosis could be a teachable moment to start the conversation,” the study’s lead author, Hyuna Sung, PhD, told The ASCO Post. Dr. Sung is Principal Scientist, Cancer Surveillance Research, American Cancer Society, Atlanta.

“Clinicians have an important role in counseling regarding behavioral and lifestyle risk factors that may attenuate the risk for subsequent primary cancers,” Dr. Ganz and Dr. Casillas stated. It is necessary for clinicians to ensure that “patients with prior cancers are aware of this potential risk, engage in relevant cancer screenings, and receive immunizations as appropriate,” they added.

National health organizations such as the American Cancer Society and the National Cancer Institute also have a key role to play. “For research groups and any organization that is concerned with cancer survivorship, it is really a prime time to consider the risks of subsequent primary cancers,” Dr. Sung said.

Promoting a Healthy Lifestyle

Another editorial in JAMA Oncology,3 by Perez et al, noted that the study “reminds us of the importance of encouraging a healthy lifestyle in cancer survivors as well as in previvors (ie, those who are at high risk of cancer but have not yet been diagnosed).” Along with preventing or decreasing the use of alcohol and tobacco and promoting healthy eating and regular exercise, that editorial advises the following steps: “Mitigating cancer risks associated with cancer-causing infections by promoting vaccination for human papillomavirus and hepatitis B, treating hepatitis C and human immunodeficiency virus, making condoms available to reduce sexual transmission of infections, and implementing needle exchange programs to reduce infection transmission among intravenous drug users.” 

DISCLOSURE: Dr. Ganz is serving as editor for the cancer survivorship section of Up-to-Date and Editor-in-Chief of the Journal of the National Cancer Institute and has received honorarium from Wolters-Kluwer and Oxford University Press. Dr. Casillas and Dr. Sung reported no conflicts of interest.


1. Ganz PA, Casillas JN: Incorporating the risk for subsequent primary cancers into the care of adult cancer survivors moving beyond 5-year survival. JAMA 324:2493-2495, 2020.

2. Sung H, Hyun N, Leach CR, et al: Association of first primary cancer with risk of subsequent primary cancer among survivors of adult-onset cancers in the United States. JAMA 324:2521-2535, 2020.

3. Perez DG, Loprinzi C, Ruddy KJ: Lifestyle factors can lead to multiple cancers over a lifetime. JAMA Oncol. December 22, 2020 (early release online).


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