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

Treatment Summary

• Details of the cancer diagnosis
  • Diagnosis date
  • Type of cancer
  • Location
  • Stage
  • Histology
• Names and contact information of the providers and treatment facilities
• Treatments administered
  • Chemotherapy/biotherapy — regimen, drug, dose, cycles; clinical trial information
  • Radiation — type, dose, site
  • Surgery — procedure

Follow-up Plan

• 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?