This document discusses core components of cancer survivorship care plans, which include a treatment summary and follow-up care plan. It outlines key elements of the treatment summary, such as demographics, disease details, and specific treatments received. The follow-up care plan includes schedules for cancer surveillance, managing late effects, referrals, and health promotion recommendations. Guidelines for survivorship care and models of care delivery are also reviewed. The importance of comprehensive survivorship clinics to address the complex needs of the growing cancer survivor population is emphasized.

1. Cancer Survivorship:Cancer Survivorship:
A New BeginningA New Beginning
Arlene O’Rourke APRN

2. Core Components of aCore Components of a
Survivorship Care PlanSurvivorship Care Plan
• Treatment Summary
• Follow-up Plan of Care

3. Treatment SummaryTreatment Summary
• Demographics/Contact information
Care providers, treatment location,
contact information of facility
• Disease specifics
Diagnosis, Pathology, Stage of disease

4. Treatment SummaryTreatment Summary
• Treatment specifics
• Surgery: date, procedure, persistent and/or possible late
effects
• Chemotherapy/biotherapy: dates, regimen, clinical trials,
agents, doses, supportive care, persistent or possible late
effects
• Hormonal therapy: dates, agents, doses, persistent and
possible late effects
• Radiation: dates, sites, type, dose, persistent or possible
late effects
• Symptoms to report

5. Follow-Up Care PlanFollow-Up Care Plan
• Cancer surveillance visit and test schedule
• Acute/long term toxicity/expected course of
recovery
• Actual and potential late effects and screening
recommendations
• Subspecialty referrals including psychosocial
• General health promotion
• Cancer related resources

6. GuidelinesGuidelines
• ASCO-www.asco.org
• NCCN-
www.nccn.org/professionals/physician.gls/
f.guidelines.asp
• Livestrong-www.livestrongcareplan.org
• Journey Forward- www.journeyforward.org

7. The Survivorship VisitThe Survivorship Visit
• Comprehensive-medical/surgical/family
history, psychosocial status, ROS, PE,
current health behaviors
• Evaluate
• Educate
• Intervene
for potential and actual late effects,
disease prevention and health promotion

8. Models of CareModels of Care
• Shared Model
• Risk Based follow-up
• Disease specific clinics
• Institution-based programs

9. Barriers to Survivorship CareBarriers to Survivorship Care
• Finances
• Educated and dedicated personnel
• Lack of acceptance and/or integration with disease-
based or general oncology programs or practice
• Space
• Complexity of survivorship care
• Lack of clear, evidenced-based guidelines on proper
management
• Limited knowledge of evolving management of co-
morbidities

10. Issues to ConsiderIssues to Consider
• The ideal model for survivorship care does not
exist at this time
• Models may be different in academic medical
centers where care is often diseased-based and
community cancer programs where 80-85% of
patients receive care
• Care plans must eliminate redundant and
unnecessary care
• Must assure excellent cancer follow up care and
general primary care- outcome improvement

11. Why Cancer Survivor Clinics?Why Cancer Survivor Clinics?
• Increasing numbers of cancer survivors
• Complex care required by cancer survivors
• The need for the oncology community to
educate patients and providers about
survivorship issues to adequately transition
cancer survivors back to their PCPs
• Supply and demand

12. Future DirectionsFuture Directions
• Improve the quality of life for patients and their
families with a diagnosis of cancer
• Develop community based interdisciplinary cancer
survivorship program to support and care for the
patient and family.
• Alleviate the burden of cancer care in long-term
survivors to reflect the decreasing supply of
oncologists and primary care providers
• Perform research that demonstrates improvement in
outcomes associated with cancer survivorship clinic
care