Cancer survivorship care services are provided on-site or by referral for all patients completing cancer treatment. Cancer survivorship services should include surveillance for cancer spread, recurrence, or second cancers; intervention for consequences of cancer and its treatment; prevention and detection of new cancers and recurrence; and care coordination among specialists and primary care providers to meet survivors’ full healthcare needs. Patients should also receive a survivorship care plan, including a treatment summary and follow-up care summary after completion of active treatment and no longer than one year from diagnosis of cancer.
In From Cancer Patient to Cancer Survivor: Lost in Transition (2006), the National Academy of Medicine (formerly, the Institute of Medicine) outlined core components of survivorship care as surveillance for cancer spread, recurrence or second cancers; intervention for consequences of cancer and its treatment; prevention and detection of new cancers and recurrence; and care coordination among specialists and primary care providers to meet survivors’ full health care needs.
Cancer survivorship clinical care symptom-based guidelines and holistic guidelines available (see resource section). As yet, there is no research describing who on the healthcare team should be compiling survivorship care plans or educating patients about their care plans; however, research is underway to answer these questions. The CoC and NAPBC require accredited programs to provide survivorship care plans to patients treated with curative intent.
The American College of Surgeons Commission on Cancer Optimal Resources for Cancer Care: 2020 Standards, Standard 4.8 Survivorship Program and National Accreditation Program for Breast Centers (NAPBC) Standard 2.20 require accredited programs to provide survivorship care plans to patients treated with curative intent.
American Cancer Society Survivorship Care Guidelines
American Society of Clinical Oncology (ASCO)
Association of Community Cancer Centers
The George Washington University Cancer Center
National Academy of Medicine (formerly, Institute of Medicine)
National Comprehensive Cancer Network (NCCN) Guidelines
The number of patients a survivorship program cares for varies widely based on available time, resources, and institutional commitment. The National Accreditation Program for Breast Centers standards require that patients receiving curative treatment receive survivorship care plans. (NAPBC: 100% of breast survivors.) The American College of Surgeons Commission on Cancer 2020 Standards address survivorship in Sandard 4.8 Survivorship Program overseen by the cancer committee and "directed at meeting the needs of cancer patients treated with curative intent." While the Commission on Cancer "recommends and encourages" that patients receive a survivorship care plan, under the 2020 Standards, delivery of a survivorship care plan is not a required component of Standard 4.8.
Details on tumor characteristics, site stage, grade, prognostic factors, treatment type, and agents used (regiment, number of cycles, dosages), dates of treatment, family history, side effects, support services available, key contact information for treating providers, possible long-term and late effects of treatment and their symptoms, psychological impacts, a surveillance schedule, and referral for individually indicated services should be included in a patient’s survivorship care plan.
Currently, survivorship care services and education consultations can be billed as any other clinic visit; however, the time to gather medical records and compile a survivorship care plan is not covered by insurance plans at this time.
New England Cancer Specialists (NECS), an large independent oncology practice, has a specialized ongoing survivorship care program. An oncology nurse practitioner (NP) conducts a survivorship care plan visit with the patient during the first year post-treatment. This visit is then followed by a 5-year and 10-year survivorship review with the patient.
NECS uses a modified American Society for Clinical Oncology (ASCO) treatment summary and/or the Passport to Care treatment summary template, updating them as living documents that change over time as the patient’s medical care progresses. Treatment summary information includes whether the patient was on a clinical trial, treatment information, and biomarker status.
NECS developed follow-up care templates based on tumor types and provides these within its EHR system, OncoEMR. The follow-up care plan includes health promotion information, surveillance and screening schedule, and referrals to services and specialty care based on the patient’s individual needs and risk factors.
Survivorship care includes visits every 1-3 months in year 1 post-treatment, every 2-6 months in Year 2, every 4-8 months in year 3-5, and annually thereafter. Distress screening is conducted throughout survivorship care to identify and meet patient needs as they arise.
Learn about Survivorship & Beyond, a community-based survivorship program, offered by NECS.