{"id":"survivorship-roadmap","name":"Supportive care and survivorship roadmap: making treatment bearable → proving it extends life → caring for tens of millions afterwards","route":"/roadmaps/survivorship-roadmap/","eras":[{"era":"1970s-1990s","title":"Making chemotherapy deliverable","description":"Curative regimens depended on drugs and devices that never made a headline: 5-HT3 antiemetics replaced days of vomiting, G-CSF let full doses be given on schedule by preventing febrile neutropenia, implanted ports and ambulatory pumps moved infusions out of hospital, and the WHO analgesic ladder made cancer pain a treatable problem. Hospice and palliative medicine became specialties in the same years.","status":"historic","refs":[{"id":"g-csf-growth-factors","kind":"technology","name":"Growth factors: G-CSF and febrile neutropenia prevention","route":"/technologies/g-csf-growth-factors/","status":"standard-of-care","tldr":"Injections of filgrastim or its long-acting form pegfilgrastim after chemotherapy make white cells recover faster, cutting the risk of life-threatening infections and allowing chemotherapy on schedule."},{"id":"infusion-devices-vascular-access","kind":"technology","name":"Infusion pumps, ports, and ambulatory chemotherapy devices","route":"/technologies/infusion-devices-vascular-access/","status":"standard-of-care","tldr":"Infusion devices are the implanted ports, smart pumps, and take-home pumps that deliver chemotherapy safely, including 46-hour infusions patients carry home."},{"id":"pain-management","kind":"technology","name":"Cancer pain management","route":"/technologies/pain-management/","status":"standard-of-care","tldr":"Systematic treatment of cancer pain with opioids, adjuvant drugs, radiation and procedures such as nerve blocks and intrathecal pumps. Most pain can be controlled, yet under-treatment remains common, especially where opioids are unavailable."},{"id":"hospice-end-of-life","kind":"technology","name":"Hospice and end-of-life care","route":"/technologies/hospice-end-of-life/","status":"standard-of-care","tldr":"Care in the last months of life focused entirely on comfort, at home or in a hospice, when cancer treatment no longer helps. Enrolling earlier than the typical two to three weeks gives patients and families more benefit."},{"id":"cancer-associated-thrombosis","kind":"technology","name":"Cancer-associated thrombosis prevention and treatment","route":"/technologies/cancer-associated-thrombosis/","status":"standard-of-care","tldr":"Blood clots are the second commonest cause of death in people with cancer. Risk scores identify who should take preventive blood thinners during chemotherapy, and direct oral anticoagulants have largely replaced injections for treatment."}],"trials":[],"papers":[]},{"era":"1994-2016","title":"Counting the cost of cure","description":"The Childhood Cancer Survivor Study, following tens of thousands of people cured as children, showed that anthracyclines, chest radiation and alkylators leave heart failure, second cancers and infertility decades later, and produced the first risk-based follow-up guidelines. Cardio-oncology, oncofertility and survivorship care plans grew from this evidence; dexrazoxane was shown to protect the heart from anthracyclines.","status":"historic","refs":[{"id":"ccss","kind":"trial","name":"Childhood Cancer Survivor Study (CCSS)","route":"/trials/ccss/","status":"active","tldr":"The largest study of what happens to children after cancer is cured. Following tens of thousands of survivors for decades, it showed that heart damage, second cancers and other late effects were common after older treatments, and that gentler modern protocols have already halved late deaths."},{"id":"survivorship-care-plan","kind":"technology","name":"Survivorship care and late-effects surveillance","route":"/technologies/survivorship-care-plan/","status":"established","tldr":"Organised follow-up for the 18 million US and 50+ million global cancer survivors: watching for recurrence and second cancers, managing long-term side effects such as heart damage, infertility, neuropathy and fatigue, and helping people return to work and life."},{"id":"cardio-oncology","kind":"technology","name":"Cardio-oncology","route":"/technologies/cardio-oncology/","status":"established","tldr":"Cardio-oncology builds heart risk assessment, monitoring and prevention into cancer care so patients can finish curative treatment without trading cancer for heart failure. It targets anthracycline and trastuzumab damage, checkpoint-inhibitor myocarditis and radiation heart disease using echocardiography, troponin tests and protective drugs; specialist clinics are concentrated in large centres."},{"id":"dexrazoxane","kind":"drug","name":"Dexrazoxane","route":"/drugs/dexrazoxane/","status":"approved","tldr":"Dexrazoxane protects the heart from the cumulative damage of doxorubicin in women with metastatic breast cancer who need to keep receiving it, and, as Totect, limits tissue destruction when an anthracycline leaks out of a vein."},{"id":"fertility-preservation","kind":"technology","name":"Oncofertility and fertility preservation","route":"/technologies/fertility-preservation/","status":"established","tldr":"Protecting the ability to have children before cancer treatment that damages eggs, sperm or the womb: sperm and egg or embryo freezing, ovarian tissue freezing, ovarian shielding and, for some breast cancers, temporary ovarian suppression."},{"id":"idea-moon-fertility-preservation-default","kind":"idea","name":"Fertility preservation offered and funded by default before gonadotoxic treatment","route":"/ideas/idea-moon-fertility-preservation-default/","tldr":"Everyone of reproductive age about to have treatment that can cause infertility is offered egg, sperm or tissue freezing, paid for, before treatment starts."}],"trials":[{"id":"ccss","name":"Childhood Cancer Survivor Study (CCSS)","route":"/trials/ccss/","outcomes":[{"endpoint":"15-year cumulative all-cause mortality by treatment era","primary":true,"unit":"%","arms":[{"name":"Diagnosed early 1970s","value":12.4},{"name":"Diagnosed 1990s","value":6}],"p":"<0.001 for trend","source":"https://doi.org/10.1056/NEJMoa1510795"},{"endpoint":"15-year health-related mortality by treatment era","unit":"%","arms":[{"name":"Diagnosed early 1970s","value":3.5},{"name":"Diagnosed 1990s","value":2.1}],"p":"<0.001 for trend","source":"https://doi.org/10.1056/NEJMoa1510795"}],"setting":"Retrospective cohort with prospective follow-up of five-year survivors of childhood cancer diagnosed 1970-1999 at 31 North American centres, with sibling controls","enrolled":50000,"enrolledBasis":"registry"}],"papers":[]},{"era":"2010-2026","title":"Supportive care that lengthens life","description":"Randomised trials moved supportive care from kindness to treatment. Early integrated palliative care improved quality of life and, in some trials, survival; weekly electronic symptom reporting with nurse response reduced emergency visits and extended survival; geriatric assessment before chemotherapy cut severe toxicity in older patients. In 2025 CHALLENGE showed that a three-year coached exercise programme after colon cancer treatment reduces recurrence and improves survival, and PREHAB showed that four weeks of training before colorectal surgery cuts complications.","status":"current","refs":[{"id":"palliative-care","kind":"technology","name":"Early integrated palliative care","route":"/technologies/palliative-care/","status":"standard-of-care","tldr":"Specialist care for symptoms, decision-making and quality of life given alongside cancer treatment from diagnosis, not just at the end. Trials show it improves quality of life and mood and may lengthen survival."},{"id":"remote-patient-monitoring","kind":"technology","name":"Electronic patient-reported outcomes and remote monitoring","route":"/technologies/remote-patient-monitoring/","status":"established","tldr":"Apps and sensors that let patients report symptoms between visits, which in trials improved survival and cut emergency visits."},{"id":"geriatric-assessment","kind":"technology","name":"Geriatric assessment","route":"/technologies/geriatric-assessment/","status":"established","tldr":"Geriatric assessment is a structured check of an older patient's fitness, memory, and support that predicts treatment tolerance better than age."},{"id":"challenge","kind":"trial","name":"CHALLENGE (CCTG CO.21)","route":"/trials/challenge/","status":"positive","tldr":"The first randomised trial to show that a coached exercise programme after cancer treatment reduces recurrence and death, in colon cancer."},{"id":"exercise-oncology","kind":"technology","name":"Exercise & lifestyle oncology","route":"/technologies/exercise-oncology/","status":"established","tldr":"Structured exercise during and after treatment, which the CHALLENGE trial showed improves survival in colon cancer."},{"id":"structured-exercise-survivorship","kind":"technology","name":"Structured exercise programmes after curative treatment","route":"/technologies/structured-exercise-survivorship/","status":"established","tldr":"A supervised, coached exercise programme for three years after bowel cancer treatment cut recurrence and death in a large randomised trial. It is the first lifestyle intervention proven to work like an adjuvant drug."},{"id":"prehabilitation","kind":"technology","name":"Prehabilitation before cancer surgery","route":"/technologies/prehabilitation/","status":"emerging","tldr":"Prehabilitation is a few weeks of structured exercise, nutrition and psychological preparation between diagnosis and surgery to make patients fitter for the operation and speed recovery."},{"id":"prehab-trial","kind":"trial","name":"PREHAB: multimodal prehabilitation before colorectal cancer surgery","route":"/trials/prehab-trial/","status":"positive","tldr":"PREHAB showed that four weeks of supervised training, protein and support before bowel cancer surgery cut severe complications and sped recovery, in an international randomised trial of 251 patients."},{"id":"psycho-oncology","kind":"technology","name":"Psycho-oncology and distress screening","route":"/technologies/psycho-oncology/","status":"established","tldr":"Psycho-oncology recognises and treats the anxiety, depression, fear of recurrence and existential distress that affect a third of people with cancer, using screening, psychotherapy adapted to cancer, and medication."},{"id":"idea-acc-geriatric-assessment-by-default","kind":"idea","name":"Geriatric assessment by default for every patient over 70 starting cancer treatment","route":"/ideas/idea-acc-geriatric-assessment-by-default/","tldr":"A short structured check of memory, mobility, nutrition and medicines before treatment cuts serious side effects in older patients without reducing benefit. It should be automatic, not optional."},{"id":"idea-acc-automatic-early-palliative-triggers","kind":"idea","name":"Automatic palliative care referral triggered by diagnosis, not by decline","route":"/ideas/idea-acc-automatic-early-palliative-triggers/","tldr":"Palliative care given from the start of treatment for advanced cancer improves quality of life and may extend it. Instead of waiting for an oncologist to remember, the system should refer automatically when the diagnosis is recorded."}],"trials":[{"id":"challenge","name":"CHALLENGE (CCTG CO.21)","route":"/trials/challenge/","outcomes":[{"endpoint":"Disease-free survival at 5 years","primary":true,"unit":"%","arms":[{"name":"Structured exercise","n":445,"value":80.3},{"name":"Health education","n":444,"value":73.9}],"hr":0.72,"ci":[0.55,0.94],"p":"0.02","source":"https://doi.org/10.1056/NEJMoa2502760"},{"endpoint":"Overall survival at 8 years","unit":"%","arms":[{"name":"Structured exercise","value":90.3},{"name":"Health education","value":83.2}],"hr":0.63,"ci":[0.43,0.94],"source":"https://doi.org/10.1056/NEJMoa2502760"}],"setting":"Resected stage III or high-risk stage II colon cancer after adjuvant chemotherapy: 3-year structured exercise programme vs health-education materials","enrolled":889,"enrolledBasis":"registry"},{"id":"prehab-trial","name":"PREHAB: multimodal prehabilitation before colorectal cancer surgery","route":"/trials/prehab-trial/","outcomes":[{"endpoint":"Severe postoperative complications (Comprehensive Complication Index > 20)","primary":true,"unit":"%","arms":[{"name":"Multimodal prehabilitation","n":123,"value":17.1,"note":"Odds ratio 0.47 (95% CI 0.26-0.87)"},{"name":"Standard care (ERAS)","n":128,"value":29.7}],"p":"0.02","source":"https://doi.org/10.1001/jamasurg.2023.0198"},{"endpoint":"Medical complications","unit":"%","arms":[{"name":"Multimodal prehabilitation","value":15.4,"note":"Odds ratio 0.48 (95% CI 0.26-0.89)"},{"name":"Standard care (ERAS)","value":27.3}],"p":"0.02","source":"https://doi.org/10.1001/jamasurg.2023.0198"},{"endpoint":"6-minute walking distance at 4 weeks post-operatively (change from baseline)","primary":true,"arms":[{"name":"Multimodal prehabilitation","note":"Mean difference 15.6 m (95% CI -1.4 to 32.6); not significant. Trial stopped early because of COVID-19."},{"name":"Standard care (ERAS)"}],"p":"0.07","source":"https://doi.org/10.1001/jamasurg.2023.0198"}],"setting":"Non-metastatic colorectal cancer scheduled for elective resection within an ERAS pathway: 4-week supervised multimodal prehabilitation (high-intensity exercise, nutrition, psychological support, smoking cessation) vs ERAS alone","enrolled":251,"enrolledBasis":"registry"}],"papers":[]},{"era":"2015-2026","title":"Cheap fixes with strong evidence","description":"Scalp cooling preserves hair through chemotherapy, sodium thiosulfate halves permanent hearing loss from cisplatin in children, a 2.5 mg dose of olanzapine restores appetite and weight for pennies (Tata Memorial), acupuncture eases hot flushes and aromatase inhibitor joint pain, cognitive behavioural therapy treats the insomnia that persists for years, and compression and exercise reverse early lymphoedema. Each is proven; none is universally offered.","status":"current","refs":[{"id":"scalp-cooling","kind":"technology","name":"Scalp cooling (cold caps: DigniCap, Paxman)","route":"/technologies/scalp-cooling/","status":"established","tldr":"A tightly fitted cap chilled to a few degrees above freezing, worn before, during and after each chemotherapy infusion, narrows the blood vessels of the scalp so less drug reaches the hair roots. In a randomised trial about half of women on taxane-based chemotherapy kept most of their hair, compared with none who went without."},{"id":"sodium-thiosulfate","kind":"drug","name":"Sodium thiosulfate (otoprotectant)","route":"/drugs/sodium-thiosulfate/","status":"approved","tldr":"An old antidote proven in two paediatric trials to halve permanent hearing loss from cisplatin, and approved in 2022 as the first drug to prevent a chemotherapy side effect in children."},{"id":"olanzapine-appetite-tmh","kind":"trial","name":"Low-dose olanzapine for cancer anorexia (Tata Memorial)","route":"/trials/olanzapine-appetite-tmh/","status":"positive","tldr":"A double-blind trial at Tata Memorial in India randomised 124 patients starting chemotherapy to 2.5 mg of olanzapine, a decades-old tablet costing a few cents a day, or placebo. Six in ten gained more than 5% of their weight against one in ten on placebo, and ASCO listed it in its 2024 cachexia guideline; it was small and single-centre."},{"id":"integrative-oncology","kind":"technology","name":"Evidence-based integrative oncology","route":"/technologies/integrative-oncology/","status":"established","tldr":"Using complementary approaches with real evidence, such as acupuncture for nausea and pain, yoga and mindfulness for anxiety and fatigue, alongside standard treatment, while steering patients away from unproven 'alternative' therapies that can shorten life."},{"id":"cbt-insomnia-cancer","kind":"technology","name":"Cognitive behavioural therapy for insomnia (CBT-I)","route":"/technologies/cbt-insomnia-cancer/","status":"established","tldr":"Insomnia is one of the most persistent problems after cancer treatment. A short structured talking therapy that retrains sleep habits works better and for longer than sleeping tablets, and digital versions bring it to people who cannot reach a therapist."},{"id":"lymphoedema-decongestive-therapy","kind":"technology","name":"Compression, decongestive therapy and exercise for lymphoedema","route":"/technologies/lymphoedema-decongestive-therapy/","status":"standard-of-care","tldr":"Arm or leg swelling after lymph node surgery or radiotherapy is managed with compression garments, specialised massage, skin care and exercise. Weight lifting, once forbidden, was shown in a randomised trial to reduce flare-ups rather than cause them."},{"id":"minoxidil-chemotherapy-alopecia","kind":"technology","name":"Minoxidil for persistent chemotherapy- and endocrine-therapy hair loss","route":"/technologies/minoxidil-chemotherapy-alopecia/","status":"emerging","tldr":"Most hair grows back after chemotherapy, but a minority, especially after docetaxel, are left with thin hair, and tamoxifen and aromatase inhibitors cause gradual thinning. Minoxidil lotion or low-dose tablets, the same treatment used for pattern hair loss, improved regrowth in most patients in dermatology series and shortened regrowth time in an early randomised trial."},{"id":"idea-acc-lymphoedema-prospective-surveillance","kind":"idea","name":"Prospective arm-volume surveillance to catch and reverse lymphoedema early","route":"/ideas/idea-acc-lymphoedema-prospective-surveillance/","tldr":"Arm swelling after breast cancer surgery is common and lifelong once established, but if caught early with simple measurements and treated with a sleeve, most cases can be prevented from becoming permanent."}],"trials":[{"id":"olanzapine-appetite-tmh","name":"Low-dose olanzapine for cancer anorexia (Tata Memorial)","route":"/trials/olanzapine-appetite-tmh/","outcomes":[{"endpoint":"Weight gain greater than 5% at 12 weeks","primary":true,"unit":"%","arms":[{"name":"Olanzapine 2.5 mg","n":63,"value":60},{"name":"Placebo","n":61,"value":9}],"p":"<0.001","source":"https://doi.org/10.1200/JCO.22.01997"}],"setting":"Untreated, locally advanced or metastatic gastric, hepatopancreaticobiliary or lung cancer starting chemotherapy: olanzapine 2.5 mg daily vs placebo for 12 weeks, plus standard nutritional advice","enrolled":124,"enrolledBasis":"registry"}],"papers":[]},{"era":"2026-2029","title":"Cachexia gets a drug","description":"Wasting kills many patients with advanced cancer and stops many more from tolerating treatment, and no drug has been approved for it in most of the world. Ponsegromab, an antibody that blocks GDF-15, the hormone that drives much of the wasting, improved weight and activity in phase 2; anamorelin is licensed only in Japan; resistance training and protein remain the only widely available intervention. A physical-function endpoint that regulators accept is the gating step for approval.","status":"emerging","refs":[{"id":"cachexia-therapy","kind":"technology","name":"Cachexia-directed therapy (GDF-15 blockade)","route":"/technologies/cachexia-therapy/","status":"phase-3","tldr":"Cachexia-directed therapy treats cancer wasting by blocking GDF-15, a hormone that rises in advanced cancer and acts on the brainstem to suppress appetite. Pfizer's antibody ponsegromab improved weight in a phase 2 trial and is in phase 2/3 in pancreatic cancer cachexia; whether weight gain translates into function is the open question."},{"id":"ponsegromab-phase-2","kind":"trial","name":"Ponsegromab phase 2 in cancer cachexia","route":"/trials/ponsegromab-phase-2/","status":"positive","tldr":"The first drug to hit the hormone behind cancer wasting: patients on the highest dose gained nearly 3 kg more than placebo in 12 weeks and reported better appetite and more activity."},{"id":"cachexia-appetite-pharmacotherapy","kind":"technology","name":"Cachexia pharmacotherapy: GDF-15 blockade, anamorelin, olanzapine","route":"/technologies/cachexia-appetite-pharmacotherapy/","status":"phase-3","tldr":"Cachexia pharmacotherapy covers three drug approaches to cancer wasting: ponsegromab, an antibody that blocks the appetite-suppressing hormone GDF-15 and is in phase 3; anamorelin, a ghrelin mimic approved only in Japan; and low-dose olanzapine, a generic tablet available everywhere that ASCO added to guidance in 2024. None has yet been shown to improve physical function."},{"id":"romana-1-2","kind":"trial","name":"ROMANA 1 and ROMANA 2","route":"/trials/romana-1-2/","status":"mixed","tldr":"ROMANA 1 and 2 were two phase 3 trials of an appetite-hormone mimic in lung cancer patients with wasting. Patients gained muscle but not grip strength, which split regulators: approved in Japan, rejected in Europe."},{"id":"resistance-training-cachexia","kind":"technology","name":"Resistance training and protein for cachexia and sarcopenia","route":"/technologies/resistance-training-cachexia/","status":"emerging","tldr":"Lifting weights and eating enough protein is the only treatment shown to build muscle in people with cancer wasting, but most are too unwell to do it alone and the trials are small."},{"id":"oncology-nutrition","kind":"technology","name":"Nutrition support and cachexia management","route":"/technologies/oncology-nutrition/","status":"established","tldr":"Screening for malnutrition, dietitian-led counselling, supplements and tube or intravenous feeding where indicated, plus treatment of cancer cachexia, the muscle-wasting syndrome that affects up to 80% of advanced patients."},{"id":"idea-bio2-cachexia-function-endpoint","kind":"idea","name":"Qualify a physical function endpoint so anti-wasting drugs can be approved","route":"/ideas/idea-bio2-cachexia-function-endpoint/","tldr":"Regulators are unsure what to accept as proof that an anti-wasting drug helps. Agreeing on a simple measure such as stair climbing would unblock the whole field."},{"id":"idea-moon-cachexia-as-treatable-disease","kind":"idea","name":"Treat cachexia as a disease: GDF-15 blockade plus anabolic and nutrition bundles","route":"/ideas/idea-moon-cachexia-as-treatable-disease/","tldr":"The wasting that kills many cancer patients has had no effective drug. New antibodies against GDF-15 restored weight in early trials. Combine them with exercise and nutrition and test properly."},{"id":"idea-fund-cachexia-programme","kind":"idea","name":"A dedicated programme for cachexia and treatment toxicity research","route":"/ideas/idea-fund-cachexia-programme/","tldr":"Wasting and side-effects kill or stop treatment for a large share of patients but attract almost no dedicated funding. This would create a standing programme for them."}],"trials":[{"id":"ponsegromab-phase-2","name":"Ponsegromab phase 2 in cancer cachexia","route":"/trials/ponsegromab-phase-2/","outcomes":[{"endpoint":"Change in body weight at 12 weeks (placebo-adjusted)","primary":true,"unit":"kg","arms":[{"name":"Ponsegromab 400 mg","value":2.81},{"name":"Ponsegromab 200 mg","value":1.92},{"name":"Ponsegromab 100 mg","value":1.22},{"name":"Placebo","value":0}],"source":"https://doi.org/10.1056/NEJMoa2409515"}],"setting":"NSCLC, pancreatic or colorectal cancer with cachexia and elevated serum GDF-15: ponsegromab 100, 200 or 400 mg subcutaneously every 4 weeks vs placebo for 12 weeks","enrolled":187,"enrolledBasis":"registry"},{"id":"romana-1-2","name":"ROMANA 1 and ROMANA 2","route":"/trials/romana-1-2/","outcomes":[{"endpoint":"Change in lean body mass over 12 weeks (ROMANA 1)","primary":true,"unit":"kg","arms":[{"name":"Anamorelin","n":323,"value":0.99},{"name":"Placebo","n":161,"value":-0.47}],"p":"<0.0001","source":"https://doi.org/10.1016/S1470-2045(15)00558-6"},{"endpoint":"Change in lean body mass over 12 weeks (ROMANA 2)","primary":true,"unit":"kg","arms":[{"name":"Anamorelin","n":330,"value":0.65},{"name":"Placebo","n":165,"value":-0.98}],"p":"<0.0001","source":"https://doi.org/10.1016/S1470-2045(15)00558-6"}],"setting":"Unresectable stage III/IV NSCLC with cachexia (weight loss over 5% in 6 months or BMI under 20): anamorelin 100 mg/day vs placebo for 12 weeks","enrolled":979,"enrolledBasis":"registry"}],"papers":[]},{"era":"2026-2030","title":"Survivorship as a system, not a leaflet","description":"Tens of millions of people live after cancer, and follow-up is still organised by habit. The system being built: risk-stratified follow-up with low-risk survivors in primary care and fast re-entry, survivorship plans generated automatically from the treatment record, late-effects registries that link exposures to outcomes decades later, biomarker-guided cardioprotection for everyone on cardiotoxic therapy, screening for financial toxicity as a vital sign, and vocational rehabilitation so people can return to work.","status":"emerging","refs":[{"id":"idea-acc-risk-stratified-follow-up","kind":"idea","name":"Risk-stratified follow-up: low-risk survivors to primary care with fast re-entry","route":"/ideas/idea-acc-risk-stratified-follow-up/","tldr":"Not every survivor needs to see an oncologist every six months for years. Sort people by recurrence risk, send low-risk survivors back to their family doctor with a clear plan, and guarantee rapid return if something changes."},{"id":"idea-acc-nurse-led-follow-up-clinics","kind":"idea","name":"Nurse-led follow-up clinics for survivors, freeing oncologists for active treatment","route":"/ideas/idea-acc-nurse-led-follow-up-clinics/","tldr":"Most follow-up visits after successful treatment are routine. Nurse practitioners can run them well, giving survivors more time and oncologists more capacity for new patients."},{"id":"idea-acc-auto-generated-survivorship-plans","kind":"idea","name":"Survivorship care plans generated automatically from the treatment record","route":"/ideas/idea-acc-auto-generated-survivorship-plans/","tldr":"Every patient finishing treatment should get a clear document listing what they had, what to watch for, and when to be checked. Software can write it from the record so it actually happens."},{"id":"idea-acc-national-late-effects-registry","kind":"idea","name":"A national late-effects registry linking treatment exposures to outcomes decades later","route":"/ideas/idea-acc-national-late-effects-registry/","tldr":"We know surprisingly little about what happens to cancer survivors twenty years on. Linking their treatment records to later health records would show which treatments cause which problems and who needs watching."},{"id":"idea-moon-adult-late-effects-registry","kind":"idea","name":"A lifelong late-effects registry linked to every treatment for adult survivors","route":"/ideas/idea-moon-adult-late-effects-registry/","tldr":"Children treated for cancer are followed for decades in a study that has changed how they are treated. Adults have nothing similar. Build it."},{"id":"idea-acc-risk-stratified-cardio-oncology-pathway","kind":"idea","name":"A risk-stratified cardio-oncology pathway for everyone receiving heart-toxic cancer therapy","route":"/ideas/idea-acc-risk-stratified-cardio-oncology-pathway/","tldr":"Some chemotherapy and antibody drugs damage the heart. Checking heart function before and during treatment and starting protective drugs early for those at risk could prevent much of that damage."},{"id":"idea-moon-cardioprotection-by-default","kind":"idea","name":"Biomarker-guided cardioprotection for everyone on cardiotoxic cancer therapy","route":"/ideas/idea-moon-cardioprotection-by-default/","tldr":"Anthracyclines, HER2 drugs and some newer agents can damage the heart. Monitor with blood tests and scans and start cheap heart-protective drugs early in those at risk."},{"id":"idea-acc-tailored-second-cancer-screening","kind":"idea","name":"Tailored screening for second cancers in survivors with known high-risk exposures","route":"/ideas/idea-acc-tailored-second-cancer-screening/","tldr":"Survivors who had chest radiotherapy as young women, or certain chemotherapies, have much higher risks of specific second cancers. They should be screened like people with inherited risk, and today most are not."},{"id":"idea-reg-financial-toxicity-vital-sign","kind":"idea","name":"Screen every cancer patient for financial toxicity as a vital sign, with navigation","route":"/ideas/idea-reg-financial-toxicity-vital-sign/","tldr":"Cancer costs push patients into debt and make them skip treatment. Asking about money at every visit, and having someone to help, catches this before it does harm."},{"id":"idea-acc-return-to-work-rehabilitation","kind":"idea","name":"Vocational rehabilitation integrated into cancer care so survivors can return to work","route":"/ideas/idea-acc-return-to-work-rehabilitation/","tldr":"Cancer survivors are substantially more likely to be unemployed than the general population, though with support they could often work. Vocational rehabilitation covering fatigue management, cognitive strategies, employer liaison and phased return has moderate trial evidence, mostly from Europe, and should be part of cancer care from diagnosis with a named coordinator, as it is for stroke."},{"id":"idea-moon-survivor-lifelong-care-model","kind":"idea","name":"Risk-stratified lifelong care for tens of millions of survivors, automated and shared with primary care","route":"/ideas/idea-moon-survivor-lifelong-care-model/","tldr":"Cancer survivors are a huge and growing population with specific long-term risks. Give each a plan matched to their risk, run automatically and shared with their family doctor."},{"id":"idea-moon-peer-navigator-workforce","kind":"idea","name":"Paid survivor peer-navigators as a recognised health workforce role","route":"/ideas/idea-moon-peer-navigator-workforce/","tldr":"Train and pay people who have been through cancer to guide newly diagnosed patients through the system, especially where oncologists and nurses are scarce."}],"trials":[],"papers":[]},{"era":"2030+","title":"Predicting late effects before they happen","description":"A survivor biobank could show who will develop heart failure or a second cancer before they do; an open commons of patient-reported outcome data from trials would let side-effects be compared across drugs the way efficacy is; exercise could be dosed like a drug once dose-finding trials exist; and chemotherapy-induced neuropathy, still without a proven prevention, has candidates in SARM1 inhibitors and limb cooling. An ARPA-style programme for supportive-care drugs that no company will develop is the funding proposal that would make most of this happen.","status":"speculative","refs":[{"id":"idea-acc-survivor-biobank-late-effect-prediction","kind":"idea","name":"A survivor biobank to find who will develop late effects before they do","route":"/ideas/idea-acc-survivor-biobank-late-effect-prediction/","tldr":"Two people can have identical treatment and only one develops heart failure or a second cancer years later. Collecting blood and genetic data from survivors could reveal who is at risk and who can be reassured."},{"id":"idea-moon-open-pro-data-commons","kind":"idea","name":"An open commons of patient-reported outcome data from cancer trials","route":"/ideas/idea-moon-open-pro-data-commons/","tldr":"Pool the side-effect and quality-of-life data patients report in trials into one open database so regimens can be compared honestly and models can be built."},{"id":"idea-nl-exercise-dose-finding","kind":"idea","name":"A dose-finding trial for exercise after cancer","route":"/ideas/idea-nl-exercise-dose-finding/","tldr":"CHALLENGE proved exercise works in colon cancer but not how much is needed. A trial comparing doses, as we would for a drug, would tell health systems what to fund."},{"id":"idea-moon-neuropathy-prevention-programme","kind":"idea","name":"A prevention programme for chemotherapy nerve damage: SARM1 inhibitors, cooling and compression","route":"/ideas/idea-moon-neuropathy-prevention-programme/","tldr":"Nerve damage from taxanes and platinum is common, often permanent and has no approved preventive. Test the most promising candidates head to head in one programme."},{"id":"idea-moon-pro-ctcae-in-every-pivotal-trial","kind":"idea","name":"Patient-reported side-effects (PRO-CTCAE) collected and published in every registrational trial","route":"/ideas/idea-moon-pro-ctcae-in-every-pivotal-trial/","tldr":"Doctors record only part of what patients suffer. Make it compulsory that patients report their own side-effects in every trial used to approve a drug, and that those data are published next to the doctor-graded ones."},{"id":"idea-moon-supportive-care-arpa","kind":"idea","name":"An ARPA-style programme to develop supportive-care drugs nobody else will","route":"/ideas/idea-moon-supportive-care-arpa/","tldr":"A supportive-care ARPA would be a well-funded, milestone-driven agency that develops drugs for nausea, nerve damage, mouth sores, fatigue and brain fog from cancer treatment, which the market has largely ignored."}],"trials":[],"papers":[]},{"era":"What sets the pace","title":"No sponsor, no registry, no organiser","description":"Supportive care has no patent to protect, so its trials are publicly funded or not run. Late effects are not systematically recorded, so their scale is estimated rather than known. Toxicity and quality of life are measured less rigorously than survival in registrational trials. And most people who die of cancer worldwide do so without adequate pain relief. A survivorship research endowment funded by a levy on curative therapies is one proposal to fix the first problem.","status":"current","refs":[{"id":"b-survivorship","kind":"bottleneck","name":"Survivorship and late effects are neglected","route":"/bottlenecks/b-survivorship/","tldr":"Tens of millions of people live after cancer with heart damage, infertility, second cancers and fear, and few services."},{"id":"b-cachexia-supportive","kind":"bottleneck","name":"Cachexia, toxicity and the limits of the patient","route":"/bottlenecks/b-cachexia-supportive/","tldr":"Cancer cachexia, the muscle and fat wasting driven by tumour and host inflammatory signals, affects most patients with advanced pancreatic, gastric and lung cancer, and treatment-limiting toxicities decide what dose a patient can receive. Only Japan has an approved cachexia drug, and supportive care research gets a small share of funding relative to its effect."},{"id":"b-toxicity-qol","kind":"bottleneck","name":"Toxicity and quality of life are undervalued","route":"/bottlenecks/b-toxicity-qol/","tldr":"Trials measure how long people live, not how they live. Side-effects are under-reported and under-treated."},{"id":"b-aging-comorbidity","kind":"bottleneck","name":"Older and multimorbid patients are excluded and undertreated","route":"/bottlenecks/b-aging-comorbidity/","tldr":"Most people with cancer are over 65 but most trial patients are younger and fitter. We guess how to treat the majority."},{"id":"b-palliative","kind":"bottleneck","name":"Pain relief and palliative care are unavailable to most","route":"/bottlenecks/b-palliative/","tldr":"Most people who die of cancer worldwide do so without adequate pain relief."},{"id":"b-funding-allocation","kind":"bottleneck","name":"Funding follows fashion, not burden","route":"/bottlenecks/b-funding-allocation/","tldr":"Research money follows visibility, not burden: breast, prostate and leukaemia receive far more funding per death or year of life lost than lung, pancreatic, liver, oesophageal, gastric, bladder and uterine cancers, and metastasis research gets an estimated 5% of funding despite causing most deaths. Advocacy strength and peer review that rewards mechanism explain the skew."},{"id":"idea-fund-survivorship-endowment-levy","kind":"idea","name":"A survivorship research endowment funded by a levy on curative therapy prices","route":"/ideas/idea-fund-survivorship-endowment-levy/","tldr":"Tens of millions of people live after cancer with heart damage, infertility and second cancers. A tiny levy on the price of curative treatments would build a permanent fund to study and treat late effects."}],"trials":[],"papers":[]}],"watch":[]}