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Women with breast cancer account for the largest group of female cancer survivors. It is estimated that there are currently 10.5 million cancer survivors in the United States; 40% of the female survivors are breast cancer survivors. 1 The growing number of breast cancer survivors reflects increasing incidence of the disease, diagnosis at earlier stages when outcome is better, and widespread adoption of effective adjuvant treatment.

Of the more than 200,000 men diagnosed each year with prostate cancer in the United States, 1 most live with their disease or the effects of treatment for many years. 2 Although many men remain asymptomatic throughout their lives, others face a multitude of physical and psychosocial challenges. Because the duration of survival is typically long, patients and their families are particularly interested in optimizing their quality of life. At the generic level, health-related quality of life (HRQOL) encompasses an individual’s perceptions of his or her own health and ability to function in the physical, emotional, and social domains. 3 , 4 In prostate cancer survivors, the medical outcomes of urinary, bowel, and sexual impairments that result from treatment will influence the rest of the patient’s life. The psychosocial aspects of HRQOL are impacted by the intimate nature of these medical side effects. Urinary leakage and erectile dysfunction may cause both private and public social embarrassment. In addition, such treatment-related complications may be compounded by the additional stressors associated with aging, such as retirement or death of peers. 5 Nearly onethird of men diagnosed with prostate cancer in a genitourinary clinic had levels of psychologic distress that met criteria for anxiety disorder. 6

Lung cancer emerged during the 20th century as an epidemic of enormous proportions. 1 A rare disease at the beginning of the past century, lung cancer continues to be one of the most common cancers in the world, affecting 174,470 Americans (92,700 men and 81,770 women) in 2006. 2 Mirroring changes in smoking patterns, the incidence of lung cancer among men continues to decline. Large-scale smoking among women occurred almost 20 years after men in the United States, with a subsequent delay in increased cases, peaking in the 1990s. Encouragingly, the most recent evidence demonstrates that lung cancer incidence among women is declining, as are death rates. 3 In 2000, approximately 13% of men and 17% of women (age-adjusted, 15% overall) diagnosed with lung cancer were expected to survive at least 5 years (an estimated 26,065 Americans each year). 2

Colon and rectal cancers (CRC) are among the most common adult malignancies worldwide, and for a variety of reasons, the numbers of survivors of colorectal cancer are likely to increase in coming years. The incidence of these cancers doubles with each successive decade of life beyond 50 years, and with the expansion of the older population in the coming years, the absolute numbers of CRC patients in the United States will grow substantially. 1 It is estimated that by the year 2030 the number of persons over the age of 65 years will have doubled and the number of persons over the age of 85 years will have quadrupled (see Chapter 16). 2 Given this expanding and aging population, projections suggest that the numbers of CRC patients may increase by as much as 30%. 3 Thus, with these profound demographic changes, it will be imperative to have a better understanding of the late effects and health care needs of long-term CRC survivors.

Survival rates for hematopoietic cell transplantation (HCT) have improved with advances in supportive care that have reduced acute, transplant-related mortality. More than 40,000 transplants were performed worldwide in 2002, mostly for the treatment of leukemia, lymphoma, or multiple myeloma. 1 The probability of successful transplantation is generally greater for patients transplanted early in their disease course, for younger patients, and for patients who receive stem cells from donors whose human leukocyte antigens (HLA) match the patient’s. For survivors who receive HCT for acute leukemia or chronic myeloid leukemia and who remain free of disease after 2 years, the probability of living 5 or more years is 89%. 2

Advancing age comes bundled with increased cancer incidence and mortality. 1 , 2 Indeed, the median age at diagnosis of all cancers combined is 69 years for men and 67 years for women.3 Age-adjusted cancer incidence is ten times higher in the 65+ population compared to their younger counterparts (2,151.2 versus 208.8/100,000 persons). 2 Similarly, age-adjusted cancer mortality is 15-fold higher in the 65+ population (1,068.2 versus 67.3/100,000 persons). 2 Figures 16.1 and 16.2 illustrate the proportions of the commonest cancers incidence and mortality in the 65+ population. 2 As a result, while the total US population is expected to grow by 9% between 1990 and 2010, the incidence of cancer is expected to increase by a disproportionate 32% in the same timeframe. 4 , 5 These trends are mirrored in countries across the globe. 6 , 7

Cancer survivors have been shown to have an increased risk for second malignant neoplasms (SMN). These increased risks result from genetic predisposition, harmful environmental exposures, or cancer treatment therapies. Regardless of their cause, SMNs now comprise the sixth most common group of malignancies after skin, prostate, breast, lung, and colorectal cancers. 1 It is important to emphasize that the fear of SMN related to the treatment of the first cancer diagnosis should not outweigh the positive effects of curative therapy for the first cancer. Both physicians and patients should, however, be aware of the consequences of the cancer treatment regimens, specifically radiation therapy (RT) and chemotherapy, and consider them while devising follow-up plans.

Prevalence data on psychosocial morbidity indicate that from 30% to 50% of cancer patients may experience distress significant enough to warrant professional intervention at some time during survivorship. 1 , 2 These patients may require professional attention to manage the debilitating effects of diagnosis, treatment, and morbidity that can wax and wane over time depending upon a host of other variables. It is in this group that some form of psychosocial rehabilitation may be useful. 3 , 4

This chapter will review risk factors and management for three types of reproductive complications of cancer treatment: infertility, menopausal symptoms, and sexual dysfunction. Each problem area affects unique, albeit overlapping, populations of cancer patients and survivors.

The employment and insurance concerns of cancer survivors have changed dramatically during the past generation. In the 1970s, fewer than one-half of those diagnosed with cancer survived more than 5 years. Treatment options were few, often disabling, and commonly ineffective. Myths about cancer prevailed. Consequently, many survivors experienced substantial problems obtaining and retaining employment and adequate health insurance.