Mullan, in the New England Journal of Medicine (Mullan, 1985). It describes his personal experience as a cancer survivor.
Actuarial and population-based figures give us survival estimates for various cancers, but those figures do not speak to the individual patient, whose experience is unique and not determined or described by aggregate data. Many patients are “cured” long before they pass the five-year mark, and others go well beyond the five-year point with overt or covert disease that removes them from the ranks of the “cured,” no matter how well they feel. Survival is a much more useful concept, because it is a generic idea that applies to everyone diagnosed as having cancer, regardless of the course of the illness. Survival, in fact, begins at the point of diagnosis, because that is the time when patients are forced to confront their own mortality and begin to make adjustments that will be part of their immediate, and to some extent, long-term future (Mullan, 1985).
Mullan described three “seasons” of survival, each with unique sets of concerns:
Acute survival begins with the diagnosis of the illness and is dominated by diagnostic and therapeutic efforts. Fear and anxiety are important and constant elements of this phase.
Extended survival is a period during which a patient goes into remission or has terminated the basic, rigorous course of treatment and enters a phase of watchful waiting, with periodic examinations and “consolidation” or intermittent therapy. Psychologically, this time is dominated by fear of recurrence. This is usually a period of physical limitations since the tumor and treatment have exacted a corporal price. Diminished strength, fatigue, a reduced capacity for exercise, amputation of a body part, or hair loss may have occurred in the acute phase, but now they must be dealt with in the home, the community, and the workplace.
Permanent survival is roughly equated with “cure,” but the person who has come through a cancer experience is indelibly affected by it. Problems with employment and insurance are common for persons who have been treated for cancer and are ready to resume a full life. The long-term, secondary effects of cancer treatment on health represent another area in which permanent survivors are at risk.
Welch-McCaffrey and colleagues (1989) further developed the concept of survivorship and described several potential cancer survival trajectories:
Live cancer free for many years
Live long cancer free, but die rapidly of late recurrence
Live cancer free (first cancer), but develop second primary cancer