AOCNP Survivorship and Long-Term Follow-Up 2 — Questions and Answers
Question 1: A female cancer survivor treated with cyclophosphamide-based chemotherapy reports amenorrhea and hot flashes. These symptoms are most likely related to:
- Adrenal insufficiency from chemotherapy
- Premature ovarian insufficiency (POI) / chemotherapy-induced menopause (Correct answer)
- Hypothyroidism from radiation scatter
- Paraneoplastic syndrome
Correct answer: Premature ovarian insufficiency (POI) / chemotherapy-induced menopause
Alkylating agents (cyclophosphamide, ifosfamide) and platinum compounds are the most gonadotoxic chemotherapy drugs, causing premature ovarian insufficiency (POI) in premenopausal women through direct destruction of primordial follicles. POI manifests as amenorrhea, vasomotor symptoms, infertility, sexual dysfunction, and accelerated bone loss.
Question 2: Bone health surveillance is especially critical for which category of cancer survivors?
- Survivors of localized prostate cancer treated with active surveillance
- Survivors receiving androgen deprivation therapy (ADT) or aromatase inhibitors long-term (Correct answer)
- Survivors of testicular cancer after orchiectomy only
- Survivors who completed chemotherapy more than 10 years ago with no endocrine therapy
Correct answer: Survivors receiving androgen deprivation therapy (ADT) or aromatase inhibitors long-term
Prolonged ADT (prostate cancer) and aromatase inhibitors (breast cancer) cause significant bone mineral density loss. DEXA scans, calcium/vitamin D supplementation, weight-bearing exercise, and bisphosphonate/denosumab therapy are indicated based on FRAX score and T-score to prevent fragility fractures.
Question 3: Lymphedema education for breast cancer survivors should include which key preventive behaviors?
- Avoid all exercise involving the affected arm
- Avoid venipuncture and blood pressure measurement in the affected arm, practice skin care, and report early swelling (Correct answer)
- Wear compression garments only when flying
- Restrict protein intake to reduce fluid retention
Correct answer: Avoid venipuncture and blood pressure measurement in the affected arm, practice skin care, and report early swelling
Lymphedema prevention education includes avoiding injury, infections, and constriction of the affected extremity; practicing meticulous skin care; avoiding venipuncture/BP cuffs in the affected arm; wearing compression garments for air travel and strenuous activity; and reporting new or worsening swelling promptly for early intervention.
Question 4: Secondary malignancy risk is particularly elevated in survivors who received which type of treatment?
- Hormonal therapy with tamoxifen only
- Alkylating agents and/or radiation therapy, which increase risk of therapy-related MDS/AML and solid tumors (Correct answer)
- Anti-HER2 therapy
- Immunotherapy checkpoint inhibitors
Correct answer: Alkylating agents and/or radiation therapy, which increase risk of therapy-related MDS/AML and solid tumors
Alkylating agents (cyclophosphamide, nitrogen mustard, melphalan) and topoisomerase II inhibitors cause therapy-related myelodysplastic syndrome (t-MDS) and acute myeloid leukemia (t-AML). Radiation exposure increases risk of secondary solid tumors in the radiation field (sarcoma, breast cancer after chest RT, lung cancer). Lifelong surveillance is essential.
Question 5: Fertility preservation counseling is a standard of care recommendation that should be offered:
- Only to women under age 35 with hormone-sensitive cancers
- To all patients of reproductive age BEFORE initiation of potentially gonadotoxic therapy (Correct answer)
- Only if the patient specifically requests it
- Only after treatment is complete and fertility is confirmed lost
Correct answer: To all patients of reproductive age BEFORE initiation of potentially gonadotoxic therapy
ASCO and NCCN guidelines mandate that fertility preservation options (oocyte cryopreservation, embryo cryopreservation, ovarian tissue cryopreservation, sperm banking) be discussed with all patients of reproductive age BEFORE initiating gonadotoxic therapy, with urgent referral to reproductive endocrinology when indicated.
Question 6: The primary tool used to formally screen cancer survivors for distress at regular intervals is:
- The PHQ-9 (Patient Health Questionnaire-9)
- The NCCN Distress Thermometer and Problem List (Correct answer)
- The Hamilton Anxiety Rating Scale
- The SF-36 Health Survey
Correct answer: The NCCN Distress Thermometer and Problem List
The NCCN Distress Thermometer (DT) with the accompanying Problem List is the most widely used validated rapid distress screening tool in oncology. A score ≥4 on the 0–10 scale indicates clinically significant distress warranting psychosocial evaluation. It screens across practical, family, emotional, spiritual, and physical domains.
AOCNP Survivorship and Long-Term Follow-Up 2
A female cancer survivor treated with cyclophosphamide-based chemotherapy reports amenorrhea and hot flashes.
These symptoms are most likely related to: