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Survivorship Care Plan

Survivorship care plans have received increasing attention since the release of the Institute of Medicine report From Cancer Patient to Cancer Survivor: Lost in Transition. The report strongly recommends that at completion of cancer treatment, clinicians provide patients with a summary of treatment delivered and a detailed plan of ongoing care, including follow-up schedules for visits and testing, as well as 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 define responsibilities of cancer-related, non-cancer-related, and psychosocial providers. Clear designation of who is responsible for the various aspects of care can 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?
Online Resources for Survivorship Planning
American Society of Clinical Oncology Care plan templates, guidelines for breast and colorectal cancer follow-up
Journey Forward 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