The Commission on Cancer (CoC) announced that effective December 11, 2017, the percentage of delivered survivorship care plans (SCPs) to eligible patients required for CoC compliance with Standard 3.3 has been lowered to 50% for 2018. This is sure to bring a welcome sigh of relief for many navigators and survivorship nurses. By now, the development of a survivorship program should not be a new concept to CoC-accredited comprehensive cancer centers or to those working toward accreditation. However, the idea of the yearly increase in the percentage of delivered SCPs was no doubt overwhelming for most of us.
Unfortunately, many barriers to survivorship care still remain and are common among many institutions. Some common barriers expressed by nurses include lack of staff, physician, administration, and even patient buy-in. A lack of funding has caused a lack of knowledge about, and training in, survivorship care. Further causes of our lacking knowledge in survivorship care can be attributed to institutional structure (ie, multiple divisions, private practices) as well as insufficient time and physical space allotted to complete SCPs. One of the most frustrating is the lack of standardization in electronic medical records, as well as lack of access. There are financial and other social constraints of patients to return for survivorship visits. This has left many of us to become very creative in how we deliver SCPs, as we are trying to meet our numbers for accreditation.
We all know the purpose of the SCPs is to improve patient outcomes and assist cancer survivors to transition to their “new normal.” SCPs relay information about the cancer, its treatment, and next steps for care to the patient and the team involved in the patient’s care. This can assist in continuity of care between the patient’s primary care provider and oncology care team. SCPs can improve provider communication and coordination of care by indicating who will be in charge of each aspect of the patient’s care. It can also help open the door to discussions with patients about needed referrals. It is important to remember patient populations, and to keep SCPs brief—but provide information that is understandable and useful to patients. SCPs should include healthy living recommendations and focus on cancer screening recommendations.
Likewise, the goal of survivorship care is to transition the patient from a focus of disease state to one of health and wellness, while addressing the needs related to their cancer diagnosis and treatment. Is it possible that meeting our goal of SCP numbers for CoC standards is overshadowing the purpose of SCPs and the goal of survivorship care? Are we delivering the care plans without focusing on delivering the care?
With the number of cancer survivors booming, it is more important than ever to provide quality survivorship care. Survivorship is a distinct phase of the cancer care continuum with specific needs. More than 12 years ago, the Institute of Medicine drew attention to the many problems survivors face once their treatment ends and recommended some of the following important national survivorship initiatives to improve care, including increase awareness of late effects and need for survivorship care, use of evidence-based clinical practice guidelines, improve access to care for survivors, improve provider communication, and improve professional education and training. Overall, we have delivered on many of these initiatives, but we may need to change our focus to improve on others.
Improving survivorship care could start with one basic idea—the definition of a cancer survivor. A person is considered a survivor from the time of diagnosis throughout the remainder of their life. If we follow this definition, survivorship care should start at the time of diagnosis, not when the SCP is delivered and treatment is completed. Oncology nurse navigators are an important part of this idea. They meet with or speak with patients most often prior to the start of any cancer treatment (including surgery, chemotherapy, and radiation therapy). This is actually the perfect time to start survivorship care. This can include genetic testing if appropriate, screening for distress, and promoting wellness. This is also the optimal time to refer to other members of the cancer care teams, such as social workers, dietitians, pastors, psychologists or behavioral wellness counselors, and financial counselors. This may also fit in nicely with those participating in the Oncology Care Model, as patients are now meeting with nurse educators and financial counselors prior to starting treatment.
How have patients benefited from comprehensive end-of-treatment visits to review SCPs that include expected late effects of cancer and its treatment, recommendations for follow-up care and surveillance for recurrence, as well as referrals for follow-up and cancer screenings? The answer is, we still do not know. Research gaps exist and need to be addressed to improve care to this population. Increased research to help prevent and improve late effects is also needed.
Survivorship care is still evolving, and it is one of the most challenging and complex phases of the cancer continuum. We still do not know to what extent survivorship care has impacted quality of life for survivors. But we do know this is the time to identify, prevent, and treat any actual or potential health issues. Each survivor has unique psychosocial and physical needs throughout the cancer care continuum. We can start to address these needs at the time of diagnosis, follow the patient through their cancer treatment, reassess their needs while reviewing their SCP, and provide education at the end of treatment. Nurses (all oncology nurses, navigators, advanced practice nurses) have significant roles in the planning and delivery of survivorship care. They can assist with development of strategies for communicating with both internal and external providers for smooth transition into survivorship. Quality evidence-based survivorship care is essential if we hope to improve patient outcomes and quality of life for an ever-growing survivorship population.
All CoC-accredited programs will be expected to meet or exceed the delivery of SCPs to 50% of eligible patients by the end of 2018. This announcement replaces the previous requirement for the delivery of SCPs to 75% of eligible patients for 2018. Additional revisions to CoC Standard 3.3 announced in the first quarter of 2018 will not go into effect until January 1, 2019. All CoC-related questions should be submitted to the CAnswer Forum (http://cancerbulletin.facs.org/forums/help).
Institute of Medicine and National Research Council. Hewitt M, Greenfield S, Stovall E, eds. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: National Academies Press; 2005.
American College of Surgeons. Important information regarding CoC Survivorship Care Plan Standard. www.facs.org/quality-programs/cancer/news/survivorship. Accessed March 12, 2018.