Nuts and Bolts of Survivorship Care Plans

June 2015 Vol 6, No 3


Phoebe Starr

Advances in cancer treatment have led to a growing number of survivors, with 14.5 million survivors in 2014 and a projection of 19 million survivors by 2124. Survivorship care planning is now considered a quality metric, and survivorship care plans are a component of accreditation by the Commission on Cancer (CoC). Originally, the CoC stipulated that survivorship plans must be phased in by 2015; however, that date has been pushed to 2019, because this has been difficult to accomplish.

Although not strictly a survivorship care plan, the American Society of Clinical Oncology (ASCO)’s Quality Oncology Practice Initiative includes a summary of chemotherapy treatment and dissemination to patients and practitioners as core measures for certification, explained Erin Ferrell, APN, Tennessee Oncology, Nashville, at her “Survivorship Care: Implementing the Essentials” presentation at the 2015 Oncology Nursing Society annual meeting.

According to Ms Ferrell, survivors have an array of needs that must be addressed, including physical issues, psychosocial issues, education, follow-up care, and management of long-term and late effects of treatment.

“It is empowering for patients to have this information, and it helps allay their anxiety,” she said.

Ms Ferrell also noted, “We need to get patients’ buy-in on adopting healthier behaviors and improving their quality of life. We need to provide survivor-specific resources and support, and we need to direct survivors to community resources.” Lifestyle behaviors impact survivorship, yet it can be difficult to get some survivors to adopt healthy or healthier behaviors.

The cancer trajectory involves acute survivorship, transitional survivorship, extended survivorship, and permanent survivorship.

In the transitional survivorship phase, patients need to be encouraged to define a “new normal.” They may still suffer from emotional, mental, and physical fatigue. Their intimate relationships may be stressed by their illness and treatment, and they may have shifting expectations. Nurses need to step in and help patients through these transitions so their expectations are realistic.

Models of Survivorship Care

There are several models of survivorship care. Primary care is perhaps the most feasible setting, but it does not have resources for a separate survivorship clinic. Also, patients with cancer may be resistant to transitioning to a primary care provider, and may incorrectly perceive that oncology care involves taking care of their general health.

However, a shared care model with the primary care provider and the oncologist is now being adopted by the Affordable Care Act, Ms Ferrell explained. This requires effective communication between these specialties. There will be a learning curve, because primary care providers prefer the shared care model, whereas oncologists generally prefer an oncology-based model.

According to the Institute of Medicine, components of survivorship care include coordinating the prevention of recurrent cancers, new cancers, and other late effects; surveillance for cancer spread and recurrence, second cancers, and medical and psychosocial long-term and late effects; and intervention for the physical, psychological, social, and spiritual consequences of cancer.

Developing a Survivorship Program

In 2015, every cancer survivor should have a comprehensive written survivorship care plan, Ms Ferrell emphasized. Part A includes diagnostic and treatment information, information about any genetic mutations, and documentation of who provided the treatments. Part B is the plan itself. Ms Ferrell cited ASCO’s website and LIVESTRONG Foundation’s website for survivorship care plan templates. City of Hope also has an excellent survivorship care plan template on its website. Part B, the written follow-up care plan, should incorporate evidence-based standards of care for the following categories:

  • Likely course of recovery and possible late or long-term effects
  • Need for any ongoing maintenance or adjuvant therapy
  • Recommended cancer screening and other periodic testing or examinations
  • Information on possible signs of recurrence and second malignancy
  • Specific recommendations for healthy behaviors
  • Referrals to specific follow-up care providers and/or support groups
  • A list of cancer-related resources and information.

“I can’t emphasize enough how this empowers patients. And it may cut down on your phone time,” Ms Ferrell said. Not all practices can develop a full survivorship program. For practices that can find the resources for such a program, the specific survivor population needs to be defined.

“Survivorship programs are expensive, and they are not money makers, but they provide patient satisfaction. Patients are healthcare consumers, and they can decide where they go for healthcare,” Ms Ferrell concluded.

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Last modified: August 10, 2023

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