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
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
