Supportive care and survivorship roadmap: making treatment bearable → proving it extends life → caring for tens of millions afterwards

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.

Infusion devices are the implanted ports, smart pumps, and take-home pumps that deliver chemotherapy safely, including 46-hour infusions patients carry home.

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.

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.

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.

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.

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.

Protecting the heart from cancer treatments, which is increasingly important as patients live longer.

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.

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.

Everyone of reproductive age about to have treatment that can cause infertility is offered egg, sperm or tissue freezing, paid for, before treatment starts.

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.

Apps and sensors that let patients report symptoms between visits, which in trials improved survival and cut emergency visits.

Geriatric assessment is a structured check of an older patient's fitness, memory, and support that predicts treatment tolerance better than age.

The first randomised trial to show that a coached exercise programme after cancer treatment reduces recurrence and death, in colon cancer.

Structured exercise during and after treatment, which the CHALLENGE trial showed improves survival in colon cancer.

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.

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.

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.

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.

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.

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.

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.

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.

A randomised trial in India of a 2.5 mg dose of a decades-old, very cheap tablet. Six in ten patients gained more than 5% of their weight, against one in ten on placebo.

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.

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.

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.

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.

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.

Treating the wasting that kills many cancer patients, by blocking the hormone that suppresses appetite.

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.

Cachexia pharmacotherapy covers three drug approaches to cancer wasting: a new antibody that blocks the hormone suppressing appetite, an appetite hormone mimic approved only in Japan, and a very cheap old tablet. None is yet standard everywhere; all beat what came before.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Children treated for cancer are followed for decades in a study that has changed how they are treated. Adults have nothing similar. Build it.

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.

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.

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.

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.

Many survivors of working age lose their jobs or income after treatment, though they could work with the right support. Job-focused rehabilitation should be part of cancer care, as it is for stroke.

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.

Train and pay people who have been through cancer to guide newly diagnosed patients through the system, especially where oncologists and nurses are scarce.

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.

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.

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.

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.

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.

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.

Tens of millions of people live after cancer with heart damage, infertility, second cancers and fear, and few services.

Wasting and treatment intolerance stop many patients from receiving the doses that would work. Treating the patient, not just the tumour, lags far behind.

Trials measure how long people live, not how they live. Side-effects are under-reported and under-treated.

Most people with cancer are over 65 but most trial patients are younger and fitter. We guess how to treat the majority.

Most people who die of cancer worldwide do so without adequate pain relief.

Money goes to the cancers and questions that are easy or popular, not the ones with the greatest burden or where a dollar would do most.

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.