Survivorship care plans are an important component of follow up cancer care. In keeping with the Institute of Medicine recommendations, all cancer patients who have completed treatment should receive a summary of treatment delivered and detailed plan of ongoing care, including follow-up schedules for visits and testing, and recommendations for early detection and management of treatment-related effects and other health problems.
What Is a Survivorship Care Plan?
A survivorship care plan is the record of a patient’s cancer history and recommendations for follow-up care. The plan should provide clear designation of provider responsibilities, oncology and non-oncology, to optimize care coordination, avoid unnecessary use of resources, and ensure that care does not “fall through the cracks.” Patients should be encouraged to provide a copy of the care plan to their primary care providers and other healthcare providers throughout life.
Elements of a Survivorship Care Plan
Details of the cancer diagnosis
- Diagnosis date
- Type of cancer
- Names and contact information of the providers and treatment facilities
- Chemotherapy/biotherapy — regimen, drug, dose, cycles; clinical trial information
- Radiation — type, dose, site
- Surgery — procedure
Specific recommendations for ongoing care
- Schedule of visits with oncology specialist
- Surveillance testing for recurrence
- Identify and manage long-term and late effects
Health promotional strategies
- Smoking cessation
- Alcohol and dietary modifications
- Regular weight-bearing exercise
Questions To Be Considered When Implementing Care Plans
- How will the treatment data be collected and from where?
- Who will be responsible for collecting and entering the data?
- What resources will be needed?
- What the services will be included in the follow-up care?
- What guidelines will be followed for surveillance?
- What patient groups will be included?
- When is the most appropriate time to review the survivorship care plan with patients — at the end of treatment or sometime later?
- Should there be a formal transition visit?
- Who will receive the care plan?
- Will the care plan be stored electronically?
- Will the care plan be periodically updated?
|Online Resources for Survivorship Planning
|American Society of Clinical Oncology
|Care plan templates, guidelines for breast and colorectal cancer follow-up
|Tool for developing care plans based on ASCO recommendations
|National Comprehensive Cancer Network
|Disease-specific treatment follow-up guidelines
Registration is required, but access to these guidelines is free.
|LiveStrong Care Plan
Powered by Penn Medicine’s OncoLink
|Patients can develop their own care plan to be reviewed by their healthcare team
|Memorial Sloan Kettering Cancer Center
|Treatment summary and care plan