Version May 2024
| Key component |
| Oncology team member contacts with location of the treatment facility (repeat if separate document) |
| Need for ongoing adjuvant therapy for cancer |
| Adjuvant therapy name Planned duration Expected adverse effects |
| Schedule of follow-up-related clinical visits (to be presented in table format to include who will provide follow-up visits and how often and where these will take place) |
| Cancer surveillance tests for recurrence (to be presented in table format to include who is responsible for ordering or carrying out the tests, the frequency of testing, and where these will take place) |
| Cancer screening for early detection of new primaries; to be included only if different from the general population (presented in table format to include who is responsible for carrying out tests, the frequency of testing, and where these will take place) |
| Other periodic testing and examinations (rather than outlining specific testing, the group suggested an inclusion of a general statement to "continue all standard non-cancer-related health care with your primary care provider, with the following exceptions: [if there are any]") |
| Possible symptoms of cancer recurrence (rather than including a list of possible symptoms, the group suggested inclusion of a general statement: "Any new, unusual, and/or persistent symptoms should be brought to the attention of your provider") |
| A list of likely or rare but clinically significant late and/or long-term effects that a survivor may experience based on his or her individual diagnosis and treatment if known (including symptoms that may indicate the presence of such conditions) |
| A list of items (eg, emotional or mental health, parenting, work/employment, financial issues, and insurance) should be covered with standard language stating that survivors have experienced issues in these areas and that the patient should speak with his or her oncologist and/or PCP if having related concerns; include a list of local and national resources to assist the patient in obtaining proper services |
| A general statement emphasizing the importance of healthy diet, exercise, smoking cessation, and alcohol use reduction may be included; statements may be tailored if particularly pertinent to the individual |
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