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The Cancer Registry's Role in Creating Survivorship Care Plans

by Barbara J. Dearmon, BS, CTR


December 1, 2017
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Survivorship Care Plans  are required by facilities accredited by the American College of Surgeons Commission on Cancer (CoC) and the National Accreditation Program for Breast Centers (NAPBC). These plans assist patients in being active participants in their post-treatment plan of care. The Survivorship Care Plan (SCP) helps promote continuity of care, provides a plan for future care, alerts the patient to delayed effects long after treatment has concluded, and provides a source document to share with future providers. Having a SCP helps patients maintain appropriate follow-up, such that late effects can be properly managed and recurrences identified and treated quickly. The SCP also provides the opportunity to address psychosocial and other health issues related to the cancer experience. The CoC’s Survivorship Care Plan requirements are outlined in Standard 3.3; the NAPBC’s requirements are detailed in Standard 2.20.

St. Vincent’s Medical Center Riverside in Jacksonville, Florida, is accredited by both the CoC and NAPBC. To meet these organizations’ SCP standards, St. Vincent established a Survivorship Committee in 2014 to examine the requirements and develop a process for disseminating SCPs and comprehensive treatment summaries to cancer patients who completed cancer treatment at the facility. The process also included a system to monitor and evaluate these efforts annually. The Survivorship Committee was multidisciplinary and included representatives from administration, cancer registry, information services, medical oncology, radiation oncology, surgery, clinical staff (physicians and nursing), and the survivorship nurse navigator.

The Survivorship Committee unanimously agreed that the cancer registry was the most complete data source for creating SCPs and treatment summaries to meet compliance with both standard-setting organizations. The cancer registry currently captures the majority of required data elements that will ultimately be included in these care plans. Some cancer registry software applications have the ability to interface data into a preformatted care plan template or Word document. St. Vincent’s reviewed several resources and decided to use Journey Forward, which interfaced easily with its cancer registry database. Policies and procedures were established to guide the process. Specific policies outlined the roles of the cancer registry staff and the survivorship nurse navigator and detailed the purpose, case eligibility, and dissemination process for the Survivorship Care Plans.

Role of the Cancer Registry:

  • The cancer registry generates a list of eligible cases abstracted using the cancer registry software and exports the data into Journey Forward.
  • The information for the care plans derived from the cancer registry database includes: cancer diagnosis, demographics, first course of treatment, stage of disease, and treating physicians. Treatment information to be captured includes chemotherapy, drugs administered (start and end dates), hormones, immunotherapy, radiation, and surgery.
  • Follow-up information on date-of-last contact is captured on the template. Cases are selected retrospectively, eight months from date-of-first contact at facility.
  • The cancer registry interfaces (exports) registry data into Journey Forward’s breast, colon, and lung templates.
  • For the primary sites that to do not correspond with Journey Forward templates, the cancer registry saves the information in a secured Excel file on a shared drive. The survivorship nurse navigator, with assistance from the cancer registry, manually enters demographics, treatment, stage, physician contact, and prognostic indicators into the Journey Forward’s generic template. The completed templates generated monthly from the registry database are saved in a folder located on the secured shared drive for the survivorship nurse navigator to access.

Role of the Survivorship Nurse Navigator:

  • The survivorship nurse navigator accesses the shared drive and selects the current cases for the month. The survivorship nurse navigation obtains from patient records and/or the physician office the clinical documentation necessary to complete the survivorship care plan and treatment summary.
  • The survivorship nurse navigator reviews information for accuracy and contacts the cancer registry if there are questions related to data interfaced from the registry database.
  • The survivorship nurse navigator works with outside physician offices to obtain necessary information to complete the remaining care plans.
  • The survivorship nurse navigator contacts the patient and offers an appointment to review the SCP in-person.
  • If the patient declines an appointment, a hard copy of the SCP with a cover letter and contact information is mailed to both the patient and the patient’s primary care provider.
  • All correspondence with the patient is documented in Nursenav Oncology, St. Vincent’s nurse navigator software. In addition to generating templates in Journey Forward, clinical staff use Nursenav to chart information and all correspondence with patients.
  • The survivorship nurse navigator maintains an electronic copy of all completed SCPs.

The Survivorship Care Plan process at St. Vincent’s is evaluated and monitored on a regular basis by the survivorship nurse navigator and the facility’s Cancer Committee. Tracking to ensure compliance with the process is presented to the Cancer Committee and the breast program leadership annually at a minimum.

Implementation of a Survivorship Care Plans benefits patients, who will be better informed about the treatment they’ve received and the resources available to ensure continuity of care. There are a variety of ways for a facility to develop Survivorship Care Plans and to ensure these plans are disseminated and the needed follow-up conducted. At St. Vincent’s, the multidisciplinary team that formed its Survivorship Committee, believed the cancer registry and the survivorship nurse navigator played critical roles. As facilities develop their process for implementing SCP plans, they too may want to consider the role of the cancer registry. Resources to help a facility get started include the American Cancer Society; American Society of Clinical Oncology; Institute of Medicine; Journey Forward; LIVESTRONG; and the National Cancer Institute.


Guest blogger Barbara J. Dearmon, BS, CTR, is manager, Oncology Support Services, at ACCC Cancer Program Member St. Vincent’s Medical Center, Jacksonville, Florida.

Note: This blog was first published in December 2017.

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