Survivorship Care Plan

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
  • 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
    • 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