. Author manuscript; available in PMC: 2017 Apr 10.

Published in final edited form as: CA Cancer J Clin. 2015 Sep 8;65(6):428–455. doi: 10.3322/caac.21286

Table 4.

Guidelines for the Assessment and Management of Physical and Psychosocial Long-Term and Late Effects

Guideline	Level of Evidence^a
Bowel/Gastrointestinal Issues Discuss frequency and/or urgency of bowel movements or loose bowels Assess for rectal ulceration and/or bleeding Assess for rectal emptying problems/incontinence Discuss bowel function and symptoms (e.g., rectal bleeding) with survivors. Refer survivors with persistent rectal symptoms (e.g., bleeding, sphincter dysfunction, rectal urgency and frequency) to the appropriate specialist.	III
Cognitive Function Screen for problems such as depression and anxiety that might worsen cognition and refer for treatment Refer patients with a positive screen for formal Neurocognitive training.	0
Dental/Oral Monitor for loss of taste and dry mouth Recommend saliva substitutes or medications to provide symptom relief Recommend attention to good oral hygiene (flossing, brushing with fluoride toothpaste, regular dental care)	0
Distress / Depression / Anxiety Level of risk: Higher for those with a stoma and those with sexual dysfunction Screen for distress / depression / anxiety periodically (at least annually) using a simple screening tool, such as the Distress Thermometer. Manage distress / depression using in-office counseling resources, pharmacotherapy, or prescribe exercise as appropriate. If office-based counseling and treatment are insufficient, refer survivors experiencing distress / depression for further evaluation and or treatment by appropriate specialists.	I
Fatigue Assess with a validated instrument such as the MDASI, BFI, FACT G-7 or FACT-C Recommend psychosocial support interventions and/or mind-body interventions Recommend 150 minutes of physical activity per week plus strength training per ACS Nutrition & Physical Activity Guidelines for Cancer Survivors Recommend optimizing nutrition per ACS Nutrition & Physical Activity Guidelines for Cancer Survivors For chronic fatigue, refer to rehabilitation	I
Neuropathy Focus on prevention; strong evidence for therapy is lacking Assess with Total Neuropathy Score (TNSc) or other validated tool for patients receiving oxaliplatin Higher risk criteria ◦ Patients who receive a cumulative dose of >900mg/m2 are at higher risk ◦ Patients with pre-existing neuropathy, alcoholism and diabetes mellitus Treat with duloxetine (moderate recommendation) No evidence to support tricyclic antidepressants, gabapentin or topical gel containing baclofen, amitriptyline HCL, and ketamine, but these therapies have been used for other neuropathic pain conditions Refer to rehabilitation and pain management as needed	0
Ostomy/Stoma Issues Rectal cancer survivors are more likely to need a permanent stoma than colon cancer survivors Monitor and manage sexual dysfunction as needed Monitor and refer for psychosocial support for increased distress, depression and anxiety, and poorer quality of life	I
Pain Assess for incisional hernia with complications Consider opioid analgesics, utilization of pain management services, if available, and incorporation of behavioral interventions/physical activity and/or rehabilitation/physical therapy have demonstrated efficacy in pain control in systematic reviews in other cancers or pain syndromes	I
Sexual Functioning/Fertility Level of risk: Affects small percent of CRC survivors Higher risk criterion: women who receive pelvic radiotherapy Discuss urogenital dysfunction/sexual dysfunction (e.g., erectile dysfunction, dyspareunia, vaginal dryness, incontinence) Men who receive pelvic radiotherapy or oxaliplatin may be at higher risk for gonadotoxicity (limited evidence) ◦ Evaluate for Leydig cell dysfunction ◦ Initiate testosterone replacement as indicated Women survivors of rectal cancer with a stoma are at higher risk for vaginal dryness and dyspareunia ◦ Recommend vaginal moisturizers and water or silicone-based lubricants during intercourse For men with erectile dysfunction, treat with oral phosphodiesterase-5 inhibitors Sexual dysfunction is correlated with greater psychosocial distress – see below for management recommendations	0, IA (oral phosphodiesterase-5 inhibitors in men), IC (vaginal moisturizers and lubricants for women)
Urinary/Bladder Post-Surgical Assess for stress, urge and overflow urinary incontinence in patients who received surgery Recommend Kegel exercises for stress incontinence unless denervation occurred during surgery Recommend anticholinergic drugs for stress incontinence Recommend antimuscarinic drugs for urge or mixed incontinence Patients with hypocontractile bladders may require catherization Refer patients with prolonged urinary retention post operatively to urologist Radiation Assess for incontinence, frequency, urgency, dysuria or hematuria in patients who received surgery Recommend limiting caffeine and fluid intake and avoiding foods that irritate the bladder such as citrus and tomatoes for irritative symptoms Refer patients who received radiation with persistent hematuria to a urologist for cystoscopy to investigate secondary causes	IC

Level of evidence: I, meta analyses of randomized controlled trials (RCTs); IA, RCT of colorectal cancer survivors; IB, RCT based on cancer survivors across multiple sites; IC, RCT not based on cancer survivors, but on general population experiencing a specific long-term or late effect (e.g., chronic diarrhea, sexual dysfunction, etc.); IIA, non-RCT based on colorectal cancer survivors; IIB, non-RCT based on cancer survivors across multiple sites; IIC, non-RCT not based on cancer survivors but on general population experiencing a specific long-term or late effect (e.g., chronic diarrhea, sexual dysfunction, etc.); III, case study; 0, expert opinion, observation, clinical practice, literature review, or pilot study.