BOX 3-16

Survivorship Care Plan

Upon discharge from cancer treatment, including treatment of recurrences, every patient should be given a record of all care received and important disease characteristics. This should include, at a minimum:

  1. Diagnostic tests performed and results.

  2. Tumor characteristics (e.g., site[s], stage and grade, hormone receptor status, marker information).

  3. Dates of treatment initiation and completion.

  4. Surgery, chemotherapy, radiotherapy, transplant, hormonal therapy, or gene or other therapies provided, including agents used, treatment regimen, total dosage, identifying number and title of clinical trials (if any), indicators of treatment response, and toxicities experienced during treatment.

  5. Psychosocial, nutritional, and other supportive services provided.

  6. Full contact information on treating institutions and key individual providers.

  7. Identification of a key point of contact and coordinator of continuing care.

Upon discharge from cancer treatment, every patient and his/her primary health care provider should receive a written follow-up care plan incorporating available evidence-based standards of care. This should include, at a minimum:

  1. The likely course of recovery from treatment toxicities, as well as the need for ongoing health maintenance/adjuvant therapy.

  2. A description of recommended cancer screening and other periodic testing and examinations, and the schedule on which they should be performed (and who should provide them).

  3. Information on possible late and long-term effects of treatment and symptoms of such effects.

  4. Information on possible signs of recurrence and second tumors.

  5. Information on the possible effects of cancer on marital/partner relationship, sexual functioning, work, and parenting, and the potential future need for psychosocial support.

  6. Information on the potential insurance, employment, and financial consequences of cancer and, as necessary, referral to counseling, legal aid, and financial assistance.

  7. Specific recommendations for healthy behaviors (e.g., diet, exercise, healthy weight, sunscreen use, immunizations, smoking cessation, osteoporosis prevention). When appropriate, recommendations that first-degree relatives be informed about their increased risk and the need for cancer screening (e.g., breast cancer, colorectal cancer, prostate cancer).

  8. As appropriate, information on genetic counseling and testing to identify high-risk individuals who could benefit from more comprehensive cancer surveillance, chemoprevention, or risk-reducing surgery.

  9. As appropriate, information on known effective chemoprevention strategies for secondary prevention (e.g., tamoxifen in women at high risk for breast cancer; aspirin for colorectal cancer prevention).

  10. Referrals to specific follow-up care providers (e.g., rehabilitation, fertility, psychology), support groups, and/or the patient’s primary care provider.

  11. A listing of cancer-related resources and information (e.g., Internet-based sources and telephone listings for major cancer support organizations).

SOURCE: Adapted from the President’s Cancer Panel (2004).



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