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Assuring quality of care for cancer survivors: The survivorship care plan

Assuring quality of care for cancer survivors: The survivorship care plan
Author:
Carrie Tompkins Stricker, PhD, RN
Section Editor:
Patricia A Ganz, MD
Deputy Editor:
Sonali Shah, MD
Literature review current through: Jun 2022. | This topic last updated: Jun 29, 2022.

INTRODUCTION — The term "cancer survivor" has been used variably in the literature; most commonly, a cancer survivor refers to any person who has been diagnosed with cancer for the balance of their life. Therefore, survivorship begins at the time of diagnosis and includes the periods of initial treatment with intent to cure, cancer-free survival, chronic or intermittent disease, and palliative care [1]. For the purposes of this topic, we will focus on the post-treatment period of survivorship.

There are over 18 million cancer survivors living in the United States [2]. Worldwide, over 19 million individuals are diagnosed with cancer annually [3]. Following cancer treatment, the roles and responsibilities for survivorship care should be well delineated for both patients and their providers, particularly during transitions. The follow-up of cancer survivors can be shared among the primary care provider (PCP), medical oncologist, and other cancer specialists, and is often recommended to be transitioned to the PCP after the period of highest risk for disease recurrence (often five years, but sometimes longer). For survivors, the transition from oncology to primary care settings should be guided by the survivorship care plan (SCP), which is developed by the oncology team at the completion of treatment and is meant to be shared with the patient and his or her providers, including the PCP. It includes a summary of the patient's treatment, along with recommendations for follow-up care [4,5].

This topic will address the evidence supporting SCPs in cancer survivors, implementation, barriers to implementation, and how standards focused on implementation of SCPs have evolved over time to represent a broader view of survivorship care delivery. An overview of cancer survivorship care for primary care and oncology providers, adolescents and young adults, and patients with specific malignancies, is discussed separately.

(See "Overview of cancer survivorship care for primary care and oncology providers".)

(See "Overview of cancer survivorship in adolescents and young adults".)

(See "Overview of care for adult survivors of non-Hodgkin lymphoma".)

(See "Overview of approach to lung cancer survivors".)

(See "Approach to the patient following treatment for breast cancer".)

(See "Long-term care of the adult hematopoietic cell transplantation survivor".)

OVERVIEW OF SURVIVORSHIP EPIDEMIOLOGY

Epidemiology — Following completion of initial treatment, more than 60 percent of adults diagnosed with cancer are expected to become long-term cancer survivors, living five years or more following their cancer diagnosis [6]. It was estimated that over 18 million cancer survivors are living in the United States [2]. This number is expected to grow due to improvements in cancer screening [7], increases in life expectancy following definitive cancer treatment [2,7], and the aging of the population [8]. By 2024, it is anticipated that there will be an estimated 19 million cancer survivors in the United States [9]. (See "Overview of cancer survivorship care for primary care and oncology providers", section on 'Epidemiology'.)

Challenges of cancer survivorship — These gains in survival are not without cost, and cancer survivors are at risk for a broad array of potential long-term and late effects of treatment. These include [5,10]:

Recurrent and new malignancies

Increased morbidity and mortality from cardiovascular, skeletal, and other diseases

Myriad of physical effects such as peripheral neuropathy and lymphedema

Psychosocial distress that may impact work and social relationships

Expecting life to be better after cancer treatment may not be a correct assumption for all cancer survivors. One-third of cancer survivors have persisting symptoms that are similar to those they suffered during active treatment; fatigue, pain, depression, and sleep disruption are the most common across different malignancies [11]. An increased number of symptoms and poorer quality of life have been found with younger age, lower socioeconomic status, and a higher number of comorbidities [12]. (See "Cancer-related fatigue: Prevalence, screening, and clinical assessment".)

Cancer survivors are a widely heterogeneous group in terms of sociodemographic and health characteristics such as comorbidities, as well as specific cancer diagnoses and treatment modalities, which may range from surgery alone to complex combination therapy with radiation, chemotherapy, hormonal therapy, and/or targeted therapies. Thus, the issues, risks, and corresponding care needs of cancer survivors are both complex and widely variable, contributing to myriad challenges to quality care for this burgeoning population. (See "Overview of cancer survivorship care for primary care and oncology providers", section on 'General issues'.)

Meeting the challenge — The growing numbers of cancer survivors are outstripping the capacity of cancer care systems to keep pace with demand. As a result, cancer survivors are increasingly being referred back to their communities, especially if they have remained free of disease after three to five years. Unfortunately, primary care providers (PCPs) are already overburdened by an aging and increasingly complex client base. As a result, PCPs may not be adequately prepared to care for these survivors due to perceived knowledge gaps about the individualized needs, risks, and surveillance plans for cancer survivors [13-18]. In addition, for most PCPs and oncology professionals, there is a lack of clarity about who is responsible for survivorship care delivery and less-than-optimal interprofessional communication between various providers. Coupled with other system-based issues, coordination of care for cancer survivors is often impaired, and most patients do not benefit from a carefully coordinated transition from active cancer treatment to cancer survivorship care [19-25]. (See "Overview of cancer survivorship care for primary care and oncology providers", section on 'Coordination of care'.)

In 2006, the Institute of Medicine (IOM) met to explore ways to improve the quality of survivorship care, resulting in the publication that year of the IOM report "From Cancer Patient to Cancer Survivor: Lost in Transition" [5]. Chief among their recommendations was that each patient should receive a cancer treatment summary and follow-up care plan, collectively called the survivorship care plan (SCP), to facilitate care transitions and guide the content and coordination of care following acute treatment, and foster greater self-management of health by cancer survivors [5].

Other efforts have further expanded this recommendation to incorporate treatment care planning from the time of diagnosis [26]. Subsequently, standards and quality metrics, including the SCP standard by the American College of Surgeons' Commission on Cancer (CoC), began to require cancer programs to deliver SCPs, catalyzing efforts to implement SCPs across the United States and internationally. This organically created more focus on the SCP recommendation than on other recommendations within the IOM report.

Despite these efforts, the majority of cancer survivors in practice have yet to receive a formal SCP, in part due to myriad barriers to their development and delivery. Overall adoption rates of SCPs are still low, ranging from 12 to 43 percent in some evaluations [27,28]. (See 'Barriers to implementation' below.).

In part due to the recognition of the burden SCP delivery creates for cancer programs, as well as due to a growing recognition that a broader approach to survivorship care is warranted, the CoC updated its standard in September 2019 to no longer require a certain percentage of SCPs to be delivered, although it still "encourages their continued use," including "for partial compliance with the new standard" [29]. (See 'Quality standards' below.)

DEFINING AND MEASURING QUALITY SURVIVORSHIP CARE — As cancer survivors move beyond active treatment, they tend to underutilize cancer-related surveillance, despite the availability of published guidelines [5,20-23]. (See "Overview of cancer survivorship care for primary care and oncology providers", section on 'Components of posttreatment follow-up'.)

Survivors have also been found to visit emergency departments and be hospitalized more frequently than expected [30]. This situation is at least in part related to reduced frequency of contact with the primary oncologist when the patient's care is transferred back to the primary care provider (PCP), the lack of relevant care guidelines, and a continued lack of communication among providers [17,31,32]. Survivors also experience enduring problems with psychosocial distress and physical symptoms that often go under-recognized and under-managed [33].

Essential components of survivorship care — The seminal report from the Institute of Medicine (IOM), "From Cancer Patient to Cancer Survivor: Lost in Transition," identified four essential components of survivorship care for patients who have completed primary therapy [5]:

Prevention of recurrent and new cancers, and of other late effects

Surveillance for cancer spread, recurrence, and secondary cancers; assessment of medical and psychosocial late effects

Intervention for consequences of cancer and its treatment

Coordination between primary and specialty care

The IOM recommended that a survivorship care plan (SCP), consisting of a treatment summary and follow-up care plan, be developed and used as a tool to deliver patient-centered care by enhancing communication between the oncology team and the patient as well as communication and coordination of care between the oncology team and the PCP.

Quality standards — In the United States, the delivery of SCPs has been endorsed or required as a quality metric and/or accreditation standard by accrediting and organizing bodies, including, among others [34,35]:

American College of Surgeons (ACS)'s Commission on Cancer (CoC)

National Comprehensive Cancer Network (NCCN) [36]

American Society of Clinical Oncology (ASCO)'s Quality Oncology Practice Initiative (QOPI) [37]

National Accreditation Program for Breast Centers (NAPBC) [38]

SCPs, as outlined by an Institute of Medicine report, are also a required element of care for centers participating in the Center for Medicare and Medicaid Innovation (CMMI)'s value-based cancer payment model, the Oncology Care Model [39,40]. The original CoC standard specifically mandated that both a treatment summary and follow-up care plan be prepared by the principal oncology provider and delivered to patients upon completion of treatment, and it noted that SCP content should comply with the minimum standards as defined by the IOM [41]. The ACS CoC standard has the greatest potential impact on shaping SCP and survivorship care delivery within cancer centers, given that 70 percent of all cancer patients in the United States are cared for in an ACS CoC-accredited institution.

However, the struggles of centers to meet the SCP standard in general, and the details of SCP content in particular, have been widely articulated and documented [30,42], leading to sequential revisions in the quality standards for SCPs. Both the ACS CoC and ASCO have revisited their standards for SCP content and delivery as follows:

In September 2014, the ACS CoC published clarifications for their Survivorship Care Plan standard 3.3. The clarification describes the extent of information required to be included in a treatment summary and SCP and specifies which health care provider(s) should be responsible for gathering and delivering care plans. The clarification outlined a five-year phase-in plan to help ease the burden on cancer centers trying to deliver care plans to cancer survivors. Starting January 1, 2015, centers were required to deliver care plans to 10 percent of patients who were treated with curative intent upon the completion of active treatment. The percent increases annually such that by January 2017, at least half of all survivors must receive SCPs, and all survivors by January 2019.

A 2014 publication summarized results from the September 2013 ASCO multi-stakeholder consensus conference on SCPs. The resulting ASCO Clinical Expert Statement on Cancer Survivorship Care Planning outlined the minimum essential elements of SCPs and assumptions around their delivery [30]. Given the limited evidence to support efficacy of SCPs and the concerns of survivors that SCPs are "necessary but not sufficient" to meet their needs [43,44], ASCO (and others) emphasizes that SCPs are intended to be an adjunct to, not a replacement for, quality survivorship care processes such as discussions between oncology teams and survivors about a follow-up plan of care. The minimal essential elements of an SCP as suggested by ASCO are further discussed below. (See 'Content' below.)

In response to recognition of the burden borne by cancer centers in attempting to implement SCPs, in 2016, the CoC updated its standards to reduce the portion of individuals with cancer required to receive an SCP posttreatment to at least 50 percent of eligible patients.

In September 2019, the CoC released updated language of the new survivorship standard, which will be included in the 2020 CoC standards manual; however, cancer programs will not be required to demonstrate compliance until January 1, 2021. In releasing this language, the CoC noted that extensive input was gathered from member organizations, CoC surveyors, and various advocacy and professional society meetings and constituents. They announced that the existing Standard 3.3 (Survivorship Care Plans) will be replaced with a new Standard 4.8: "Survivorship Program." This new standard reflects a shift in emphasis to a broader and more programmatic approach to survivorship care, rather than simply focusing on the discretely measured delivery of SCPs to a specific proportion of survivors.

In the letter announcing this change, the CoC noted the following, giving insight for the rationale for the change:

"We realize that the requirement to deliver survivorship care plans (SCP) presented significant challenges to our accredited programs. The new Standard 4.8 builds on the value of SCPs and encourages their continued use. Notably, the delivery of SCPs can be used for partial compliance with the new standard. The new standard allows cancer programs to determine what services will best meet the needs of their patients."

SURVIVORSHIP CARE PLANS

Evidence for benefit — Despite the widespread endorsement of SCPs that has characterized much of this past decade, evidence for the effectiveness of survivorship care plans (SCPs) remains limited. Support for their implementation has historically been largely driven by claims of face validity [5,45], studies showing high stakeholder endorsement [15,17,43,46-51], and positive perceptions of use, including as a health management tool [52,53].

An integrative review of 42 studies of SCPs, published between 2006 and 2013, found that only 14 of these studies focused on patient and provider outcomes, and only four were randomized clinical trials (RCTs) [54]. A more extensive review of 13 available RCTs showed inconsistent results [55]. Single studies showed positive effects on more proximal outcomes, including evidence-based surveillance testing and satisfaction with care, particularly when SCPs were accompanied by additional counseling. However, there were not consistent improvements in commonly studied outcomes, such as physical, functional, and psychosocial wellbeing. Heterogeneity in study designs and the low likelihood that SCP delivery alone would influence distal outcomes are likely reasons for this finding.

Subsequent RCTs have been published, again showing mixed effects. As examples, one RCT of web-based SCPs in 165 breast cancer survivors revealed significantly greater declines in unmet needs and fear of recurrence over time in the SCP group, as well as greater rises in quality of life [56]. By contrast, a separate RCT examining the effects of an online SCP delivered to young (ages 18 to 50) breast cancer survivors failed to show significant improvement in at least one self-identified issue of concern, the primary outcome of interest [57].

Some key nonrandomized studies that support the benefits of SCPs include evidence for the following outcomes:

Improved knowledge – In a single-arm pre/post-test study of 344 breast and colorectal cancer survivors who had their treatment summaries (TSs) mailed to them, provision of this information improved their knowledge about their disease and treatment details [58]. Subsequent studies have shown improvements in knowledge and informational needs as well [52,59].

Improved surveillance – Another smaller study mailed a brief SCP focused on guidelines for cardiac and breast cancer surveillance to 72 Hodgkin disease survivors and their primary care providers (PCPs), and found improved adherence to recommended echocardiograms and mammograms [60]. A subsequent study corroborated these findings [61]. (See 'Strategies to improve the efficacy of SCPs' below.)

Improved quality and coordination of care – Several pilot studies have explored the feasibility and outcomes of "end-of-treatment" visits that include the delivery of several types of SCPs [45,62,63]. These studies concluded that such visits resulted in high rates of patient satisfaction [45,62,63], were associated with lower patient concerns and unmet needs [62-64], and improved preparedness to manage healthcare [63]. A recent multi-center, single-arm study at seven academic and community cancer centers found that breast cancer survivors' perceptions of care coordination and quality improved from baseline to post-test following SCP delivery [65].

Strategies to improve the efficacy of SCPs — Most studies of SCPs have focused on the delivery of an SCP at a single point in time, yet evolving evidence indicates that this approach is likely insufficient to show benefit. At face value, the provision of an SCP at one point seems inadequate, given that survivors often need continued support posttreatment [66]. Many researchers and authors have called for more comprehensive and longitudinal SCP interventions [27,67].

Several studies have shown positive benefits when SCPs are delivered in combination with enduring support and resource provision. As an example, in one four-site cluster RCT in which 42 physicians (MDs) and 198 lymphoma survivors were randomly assigned to an intervention (MD communication skills training plus SCP provision) versus a wellness-focused control arm, the intervention arm resulted in improved knowledge and adherence to certain MD recommendations (ie, influenza vaccinations and colonoscopy) in the SCP arm [61]. Another phase II RCT in 60 lymphoma survivors compared unmet needs, distress, and empowerment in 30 receiving an SCP, intervention consisting of three face-to-face appointments plus delivery of an SCP and tailored resources, compared with 30 controls. While findings were not statistically significant, all outcomes improved in the intervention group [68]. A nonrandomized study evaluated 30 survivors exposed to a toolkit that combined SCP delivery with 12 weeks of continued follow-up and support via bi-weekly patient portal messages, goal-setting and management, and provision of online resources specific to survivors in the transition phase [69]. Over three months from baseline to follow-up, physical symptom burden declined, and quality of life (specifically, physical wellbeing) improved significantly. However, given the lack of a control group, it is unknown if this simply reflected normal recovery from treatment, and further, mental health and wellbeing did not improve.

Standards for implementation

Content — Broadly speaking, the content of SCPs should be designed to comport with the Institute of Medicine (IOM)'s four broad goals and components of survivorship care, with sections devoted to prevention and detection, surveillance, education and intervention for consequences of cancer and its treatment, and coordination of care [5]. At present, all SCP elements are consensus-based rather than evidence-based, as there is yet no published evidence that links particular elements with desired outcomes. A checklist to evaluate concordance of breast cancer SCP content with IOM recommendations is available to assist centers, and has demonstrated excellent inter-rater reliability [70].

The SCP standard (from the American College of Surgeons' Commission on Cancer [ACS CoC], the Survivorship Care Plan standard 3.3, based on the IOM report [5] and the American Society of Clinical Oncology [ASCO] consensus statement) describes the extent of information required to be included in a treatment summary and SCP and specifies which health care provider(s) should be responsible for gathering and delivering care plans (table 1A-B). Centers that deliver SCPs as a component of meeting the new Survivorship Program Standard 4.8 can be guided by these documents as well. (See 'Defining and measuring quality survivorship care' above.)

Emerging evidence indicates that SCP content should be tailored to reflect the needs and concerns of the individual survivor [71], and the ASCO Clinical Expert Statement emphasized the need to tailor the posttreatment surveillance plan and the discussion of late effects to the individual survivor [30]. As an example, content of SCPs regarding the risk of late and long-term effects varies widely depending on the population under consideration, given differential risk across different populations of cancer survivors. Therefore, SCP sections detailing risk for late effects can be customized according to the cancer diagnosis and treatment.

Finally, different versions of the SCP may need to be produced for distribution to PCPs and survivors [35,43]:

PCPs desire information on treatments received and surveillance recommendations, but in a concise summary written in lay language and providing clear direction as to what should be their responsibility in delivering this care [15,18,43,46,47,50,72].

By contrast, survivors appear to desire more information on resources and referrals for symptoms and late effects experienced, as well as clear direction about what symptoms and concerns to report and to whom [15,17,43,47,49,62,73,74].

More research is needed to define and evaluate the optimal depth, breadth, and specifics for SCP content, and it is unlikely that a "one size fits all" approach will be viable. Substantial individualization of content will likely be necessary to serve the needs of diverse survivor populations.

Timing — There is no consensus as to the optimal time-point for distribution of SCPs. Intuitively, it might be optimal to distribute SCPs around the time of completion of active treatment, as recommended within the ACS CoC standards. The National Accreditation Program for Breast Cancers (NAPBC) Survivorship Care standard specifies that care plans be delivered within six months of completing active therapy.

These recommendations are in keeping with the results of a qualitative study in which patients expressed their desire to receive an SCP from their oncologist just before or soon after treatment completion [43]. If SCPs are provided by the patient's primary oncology provider(s) as the ACS CoC advises, distribution at this time-point would ensure that the largest number of survivors receive SCPs, given that some survivors are lost to oncology follow-up after the completion of active cancer treatment [5]. Additionally, much of the information contained in SCPs would intuitively be useful to patients at this juncture, since a primary goal of these documents is to provide a framework for follow-up care, including recommended surveillance and preventive strategies [75]. A preliminary report of a single-arm study reported that the greatest effect of SCPs was observed proximal to the time of treatment completion [76]. Patients have even voiced that a similar document containing a treatment plan instead of a summary would have been even more helpful if provided from the start of treatment [43], as has been described for implementation in a community practice setting [33].

Models for delivering SCPs — The delivery of SCPs is dependent on the models of care and the resources available locally. From the existing literature on SCP implementation, SCPs most often appear to be disseminated within a formalized survivorship care program or clinic rather than integrated into routine oncology follow-up care [33,42,46,77-80], although this practice has begun to evolve [81]. Integrated across all models of care, nurses, including advanced practice nurses such as nurse practitioners, are increasingly critical to the implementation of survivorship care and care planning efforts [42,82], which require education and skills in patient education, symptom assessment and management, and care planning [5,82-86]. One study of a real-world survivorship program describes a model of risk-adapted visits (RAV) facilitated by an oncology nurse, during which an SCP is provided and discussed [87], and it provides evidence that this approach helps survivors guide future self-care behavior.

Research is underway to evaluate outcomes of a variety of models of SCP delivery, including a number of nurse-led models of care. One center pairs nurse practitioners with social workers to deliver the SCP but saves costs and time by employing registered health information technicians to prepare the SCP documents ahead of the clinical survivorship visit [88]. As previously discussed, novel approaches to survivorship care delivery, including telephone, internet, mail-based, and peer-led interventions, are being explored [60]. Results from both research and clinical endeavors will hold great significance for informing the development and dissemination of optimal models of survivorship care planning. Other models of nurse and advanced practice nurse (APN)-led survivorship care and SCP delivery have been described [89].

SCP templates — A number of SCP templates have been created and are available for application to practice. Options include web-based documents created by professional and advocacy-based cancer organizations such as the American Society of Clinical Oncology, Journey Forward, and LIVESTRONG, as well as commercially available platforms.

Although a number of templates are available, the time burden of preparation is similar for all non-commercial templates, and almost universally a barrier to implementation [42]. Updates to the ASCO template has been associated with lower time burden [30]. (see 'Barriers to implementation' below).

Is there a preferred SCP? — There is no single SCP that is universally considered the standard tool. While there is a rich body of literature describing stakeholder preferences for SCPs, there is a dearth of robust efficacy data to inform the content and delivery of SCPs. (See 'Content' above.)

In the only study that directly compared five different non-commercial SCP templates, both patients and PCPs strongly preferred a modified version of one SCP, called Journey Forward, adapted to include local resources [43,90]. Independent of the specific care plan template, survivors described helpful features an ideal SCP should have, including easy-to-read format, understandable language, contact information for all providers, and clear direction on who to contact, for what concerns, and when. PCPs desired similar features, and also wanted information on what late effects might occur, as well as a clear description of recommendations for follow-up care and surveillance, including who was responsible for which components of the follow-up plan. Survivors also wanted a clear description of what a recurrence might look like, including what symptoms to report and which ones about which they should not worry [43].

Dissemination of SCPs — A growing number of studies have examined the implementation of SCPs in practice and have demonstrated modest uptake, reach, and concordance with IOM guidelines.

To patients — Data suggest that SCPs are being delivered to less than half of cancer survivors [27,28], and few are meeting the IOM recommendations for quality SCPs [34,42,72,83,91,92]. As examples:

One study examined the content, process, and reach of SCPs within 13 community and academic centers participating in the LIVESTRONG Survivorship Centers of Excellence (COE) Network. As a requirement of participation, each center had to deliver SCPs to breast cancer survivors [42]. At the majority of these institutions, less than 10 percent of breast cancer survivors received an SCP, and even for those who did, only about half of the IOM content recommendations were addressed within reviewed documents.

Another study examined the delivery of SCPs at over 50 National Cancer Institute (NCI)-designated cancer centers [91]. Only 43 percent of centers provided care plans to either breast or colorectal cancer survivors. No center's SCP met all of the IOM's recommendations, and most addressed only a small subset.

Data taken from centers participating in ASCO's Quality of Oncology Practice Initiative (QOPI) in 2012 revealed that only 30 percent of participating practices are routinely providing TSs to their patients [92]. The number of centers providing SCPs does not seem to be increasing over time, prompting an examination of barriers to implementation.

To other providers — PCPs consistently verbalize the desire for specific direction about which tests should be done and who should be responsible for ordering and following these. Unlike the literature evaluating the dissemination of SCPs to patients, there are limited data looking at the impact SCPs have on inter-professional communication and coordination of care between providers, despite these being main goals of SCP delivery. In qualitative studies, PCPs consistently endorse the potential value of SCPs for improving communication [15,18,43,50,93]. One small qualitative study interviewed 15 PCPs who had actually received at least one SCP for a patient under their care, 10 of whom had read that SCP prior to the interview. Each of the 10 PCPs stated that the SCP improved their knowledge about the patient's cancer history and recommendations and follow-up care, and eight reported a resulting change in patient care [50]. All stated their willingness to either share or take primary responsibility for the care of cancer survivors, particularly if they were provided with an SCP for such patients. More study is needed.

BARRIERS TO IMPLEMENTATION — Many studies have described barriers to the provision of survivorship care plans (SCPs), including patient, provider, and system variables, including one randomized trial [67]. Barriers appear particularly difficult to overcome in community settings [82,83]. The three major obstacles to delivery of SCPs are the time required to complete and deliver, the level of detail required in the care plans, and the lack of reimbursement for their preparation and delivery [30].

Patient barriers — Patient barriers include lack of awareness that the transition back to primary care providers (PCPs) is an option. In addition, patients may be reluctant to leave their oncology providers. This is being addressed by integrated models of survivorship care, where survivorship care is incorporated into services provided by the primary oncology team [77,94].

Provider barriers — The preparation of detailed treatment summaries (TSs) and individualized follow-up care plans is often a time-consuming process, taking on average 60 to 90 minutes per patient in one analysis within 13 centers [42] and more than two hours per SCP in a national survey of 395 providers [95]. Time burden is especially high when patients are treated in many different areas, given the lack of data sharing between electronic medical record (EMR) systems [41]. Other barriers also include a perceived lack of institutional commitment (which may influence whether clinicians participate in mandates to provide or refer for SCPs), and the lack of time available to review the SCP with survivors can be substantial [42]. Lack of role clarity about who is to complete, maintain, prepare, and deliver care plans complicates matters [30]. One nationwide survey in the United States showed that much of the responsibility for SCP implementation falls on nurse navigators (48 to 58 percent of each stage of implementation), but such a narrow base of responsibility is a barrier within itself [95].

Finally, there is a paucity of evidence-based guidelines, which is a major barrier to providing specific care recommendations within SCPs [92]. Although research is greatly needed, consensus-based guidelines and society-specific guidance statements (American Society of Clinical Oncology [ASCO], American Cancer Society, National Comprehensive Cancer Network [NCCN]) are available [36,92,96].

System barriers — Despite the time required to communicate the SCP to patients, no specific mechanism for reimbursement of survivorship care planning is available [82]. Among the various activities that comprise preparation and delivery/communication of the SCP, less than one-third is reimbursed by third-party payers [95]. In addition, the scope of work required to create SCPs specific for each cancer is substantial because the Institute of Medicine (IOM) recommendations for content are both comprehensive and detailed, including a summary of diagnostic and treatment details; recommendations for surveillance, follow-up and preventive care; and identification of resources in a variety of domains (physical, psychosocial, financial), as well as implications for family members [5].

An available checklist to evaluate SCP content consists of 92 items by which SCPs could be evaluated for concordance with IOM recommendations [70]. Research is clearly needed to define the most important elements of SCPs and link particular elements to outcomes of interest. This will allow evidence-based refinement of the IOM framework and has the potential to improve both the feasibility and effectiveness of survivorship care planning efforts [42].

Even resource-rich institutions struggle with developing and maintaining SCP content, and personalizing it for individual patients is yet another time-consuming challenge. As technology solutions grow that auto-populate disease and treatment data from the EMR or cancer registry, and personalize care plans based on patient data, the efficiency and adoption of SCPs should increase [30].

Overcoming barriers — A variety of approaches may be used to overcome these financial, time, and staffing constraints. Grant and philanthropic funding has been instrumental to the development and implementation of survivorship clinics at some centers [84,97], but this strategy is unlikely to be sustainable in the long term.

Failure of current EMR systems to provide efficient solutions is a substantial barrier, although this is being actively addressed [98], both within individual institutions as well as via the efforts of third-party vendors and solutions that are integrated with EMRs. Indeed, harnessing the ability of EMR systems is one strategy for improving the efficiency of preparing cancer SCPs [41,99]; however, obstacles to this approach include an inability of many EMRs to easily translate cancer diagnostic and treatment data into an SCP template. However, case examples of successful EMR applications are growing [84,85].

Another approach, which has been demonstrated to be cost-effective, is the preparation of the TS by registered health information technicians [88]. Novel strategies, such as group-based survivorship care planning visits and mailed and patient portal-delivered SCPs, are being explored as approaches to improve efficiency and decrease resource intensity of survivorship care planning [58,60,69,100], as is the longitudinal development and delivery of SCPs over a series of clinical visits rather than at a single clinical encounter [33].

Some studies suggest several opportunities for improving SCP implementation, including broadening responsibility for delivery (eg, not restricting preparation and delivery to one discipline), optimizing modes of communication, decreasing the time required to create plans, and increasing both funding and reimbursement for SCP delivery. Limiting variation in SCP implementation both across and within cancer programs should improve efficiency as well [95]. These recommendations augment earlier qualitative findings showing that providers and systems that were most successful implementing SCPs had active leaders and champions and used strategies such as proactively addressing care plan requirements, leveraging requirements to improve survivorship care to gain institutional buy-in, setting internal targets, utilizing automated implementation, and tasking specific and appropriate employees with implementing SCPs [81].

A number of issues must be taken into account when planning for the implementation of SCPs, including structure, process, and timing of delivery. Nurse and advanced practice clinician-led models of care have proliferated and have been shown to be feasible and cost-effective in many settings [89]. However, limited evidence is available to guide decision-making about best practice approaches, since research determining best approaches has not fully matured. Further, standards are now evolving to reflect a much broader programmatic approach to survivorship care beyond provision of SCPs alone [29]. (See 'Standards for implementation' above.)

Thus, clinical factors primarily influence the selected approach. Factors influencing decision-making include characteristics of both the patient population and the setting for care plan delivery (eg, the availability of institutional resources), as well as determination of the intended audience for the SCP. Some experts propose a number of reflective questions that should be considered when implementing survivorship programs, including the delivery of SCPs [82]. Others cast an even broader vision, proposing a systems-engineering approach to population health management of cancer survivors that extends beyond static survivorship care plans [101].

SUMMARY

Following completion of initial treatment, more than 60 percent of individuals diagnosed with cancer will become long-term cancer survivors, living five years or more following their cancer diagnosis. (See 'Introduction' above and 'Overview of survivorship epidemiology' above.)

Recommendations from the Institute of Medicine (IOM) state that each patient should receive a cancer treatment summary and follow-up care plan, collectively called the survivorship care plan (SCP). The SCP improves the quality of survivorship care by facilitating care transitions, guiding the content and coordination of care following acute treatment, and fostering greater self-management of health by cancer survivors. (See 'Meeting the challenge' above.)

SCPs are intended to provide critical information regarding diagnoses, treatments, and potential late effects, as well as recommended surveillance, preventive strategies, and education and referrals for management of other medical and psychosocial needs. The SCP should assist with coordination of care by outlining which providers are responsible for particular aspects of care and by recommending resources and individual referrals for ongoing issues related to cancer and its treatment. (See 'Defining and measuring quality survivorship care' above.)

In the United States, the delivery of SCPs has been endorsed or required by a growing number of accrediting and organizing bodies. In the case of the American College of Surgeons (ACS)'s Commission on Cancer (CoC), these standards have evolved to require a broader scope of SCP development and care delivery, within which SCPs can be one of several services delivered. Although this change reflects the emerging benefits of more comprehensive survivorship interventions and programs rather than SCP delivery alone, more research is needed. (See 'Quality standards' above and 'Evidence for benefit' above.)

The key components of the treatment summary and follow-up care plan as defined by a multi-stakeholder consensus conference held by the American Society of Clinical Oncology (ASCO) (table 1A-B) have been endorsed by the American College of Surgeons' (ACS) CoC's accreditation committee, with emphasis on the importance of tailoring and communicating the follow-up plan of care. (See 'Content' above.)

For patients living after cancer, a number of SCP templates have been created and are available for application to practice. An ideal SCP should be easy to read with understandable language, include contact information for all providers, and provide clear direction on who to contact, for what concerns, and when. However, the actual content of SCPs varies widely in practice, and there is no single gold standard or "one size fits all" approach. (See 'SCP templates' above.)

Primary care providers (PCPs) and survivors alike believe that SCPs would help improve the quality and coordination of survivorship care, provided that they are tailored to individual needs, concerns, and risks, and clearly articulate what is expected of the survivor as well as those providers involved in the survivor's care. To address barriers to delivery, novel information technology efforts may ease the resource burden of preparing and delivering SCPs. (See 'Strategies to improve the efficacy of SCPs' above and 'Barriers to implementation' above.)

  1. Hewitt M, Greenfield S, Stovall E, et al. From cancer patient to cancer survivor: Lost in transition. National Academies Press, Washington DC, 2006. https://canceradvocacy.org/wp-content/uploads/2013/01/From-Cancer-Patient-to-Cancer-Survivor-Lost-in-Transition-Summary-.pdf (Accessed on June 02, 2021).
  2. Miller KD, Nogueira L, Devasia T, et al. Cancer treatment and survivorship statistics, 2022. CA Cancer J Clin 2022.
  3. Global Cancer Observatory. International Agency for Research on Cancer. World Health Organization. Available at: https://gco.iarc.fr/ (Accessed on June 06, 2021).
  4. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/survivorship-care-plan (Accessed on November 13, 2018).
  5. Institute of Medicine and National Research Council. From Cancer Patient to Cancer Survivor: Lost in Transition, Hewitt M, Greenfield S, Stovall E (Eds), The National Academies Press, Washington, DC 2006.
  6. DeSantis CE, Lin CC, Mariotto AB, et al. Cancer treatment and survivorship statistics, 2014. CA Cancer J Clin 2014; 64:252.
  7. Berry DA, Cronin KA, Plevritis SK, et al. Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med 2005; 353:1784.
  8. Smith BD, Smith GL, Hurria A, et al. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol 2009; 27:2758.
  9. http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-042801.pdf (Accessed on June 10, 2015).
  10. Stricker CT, Jacobs LA. Physical late effects in adult cancer survivors. Oncology (Williston Park) 2008; 22:33.
  11. Wu HS, Harden JK. Symptom burden and quality of life in survivorship: a review of the literature. Cancer Nurs 2015; 38:E29.
  12. Harrington CB, Hansen JA, Moskowitz M, et al. It's not over when it's over: long-term symptoms in cancer survivors--a systematic review. Int J Psychiatry Med 2010; 40:163.
  13. Nekhlyudov L, Aziz N, Lerro CC, Virgo KS. Oncologists' and primary care providers' awareness of late effects of cancer treatment: Implications for survivorship care [abstract 6008]. J Clin Oncol 2012; Suppl:6008.
  14. Hudson SV, Miller SM, Hemler J, et al. Adult cancer survivors discuss follow-up in primary care: 'not what i want, but maybe what i need'. Ann Fam Med 2012; 10:418.
  15. Kantsiper M, McDonald EL, Geller G, et al. Transitioning to breast cancer survivorship: perspectives of patients, cancer specialists, and primary care providers. J Gen Intern Med 2009; 24 Suppl 2:S459.
  16. Nissen MJ, Beran MS, Lee MW, et al. Views of primary care providers on follow-up care of cancer patients. Fam Med 2007; 39:477.
  17. Smith SL, Wai ES, Alexander C, Singh-Carlson S. Caring for survivors of breast cancer: perspective of the primary care physician. Curr Oncol 2011; 18:e218.
  18. Watson EK, Sugden EM, Rose PW. Views of primary care physicians and oncologists on cancer follow-up initiatives in primary care: an online survey. J Cancer Surviv 2010; 4:159.
  19. Cheung WY, Neville BA, Cameron DB, et al. Comparisons of patient and physician expectations for cancer survivorship care. J Clin Oncol 2009; 27:2489.
  20. Snyder CF, Earle CC, Herbert RJ, et al. Preventive care for colorectal cancer survivors: a 5-year longitudinal study. J Clin Oncol 2008; 26:1073.
  21. Snyder CF, Earle CC, Herbert RJ, et al. Trends in follow-up and preventive care for colorectal cancer survivors. J Gen Intern Med 2008; 23:254.
  22. Earle CC, Burstein HJ, Winer EP, Weeks JC. Quality of non-breast cancer health maintenance among elderly breast cancer survivors. J Clin Oncol 2003; 21:1447.
  23. Earle CC, Neville BA. Under use of necessary care among cancer survivors. Cancer 2004; 101:1712.
  24. Beckjord EB, Reynolds KA, van Londen GJ, et al. Population-level trends in posttreatment cancer survivors' concerns and associated receipt of care: results from the 2006 and 2010 LIVESTRONG surveys. J Psychosoc Oncol 2014; 32:125.
  25. Potosky AL, Han PK, Rowland J, et al. Differences between primary care physicians' and oncologists' knowledge, attitudes and practices regarding the care of cancer survivors. J Gen Intern Med 2011; 26:1403.
  26. Balogh EP, Ganz PA, Murphy SB, et al. Patient-centered cancer treatment planning: improving the quality of oncology care. Summary of an Institute of Medicine workshop. Oncologist 2011; 16:1800.
  27. Long-Term Survivorship Care After Cancer Treatment: Proceedings of a Workshop, National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Health Care Services, National Cancer Policy Forum (Eds), National Academies Press (US), Washington, DC 2018.
  28. Birken SA, Mayer DK. Survivorship Care Planning: Why Is It Taking So Long? J Natl Compr Canc Netw 2017; 15:1165.
  29. Commission on Cancer (CoC) letter. 2019. http://www.magnetmail.net/actions/email_web_version.cfm?ep=wUrsG5KYDhFDpJTF1siv9YMb6QMB5BujyQNsnaDX5cnoH0NsNz8WJZQapT4JXPcfRvHuK18z7bADU295SnlRe_X1ALCivRWxk32pTqQ5rOTRcSf8f6CK4SAr0bhElcrA (Accessed on October 07, 2019).
  30. Mayer DK, Nekhlyudov L, Snyder CF, et al. American Society of Clinical Oncology clinical expert statement on cancer survivorship care planning. J Oncol Pract 2014; 10:345.
  31. Mao JJ, Bowman MA, Stricker CT, et al. Delivery of survivorship care by primary care physicians: the perspective of breast cancer patients. J Clin Oncol 2009; 27:933.
  32. Pollack CE, Frick KD, Herbert RJ, et al. It's who you know: patient-sharing, quality, and costs of cancer survivorship care. J Cancer Surviv 2014; 8:156.
  33. O'Brien M, Stricker CT, Foster JD, et al. Navigating the seasons of survivorship in community oncology. Clin J Oncol Nurs 2014; 18 Suppl:9.
  34. Birken SA, Deal AM, Mayer DK, Weiner BJ. Following through: the consistency of survivorship care plan use in United States cancer programs. J Cancer Educ 2014; 29:689.
  35. Stricker CT, O'Brien M. Implementing the commission on cancer standards for survivorship care plans. Clin J Oncol Nurs 2014; 18 Suppl:15.
  36. https://www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf (Accessed on May 02, 2019).
  37. American Society of Clinical Oncology (ASCO)'s Quality Oncology Practice Initiative. https://practice.asco.org/quality-improvement/quality-programs/quality-oncology-practice-initiative (Accessed on October 21, 2020).
  38. National Accreditation Program for Breast Centers (NAPBC) Standards and Resources. https://www.facs.org/quality-programs/napbc/standards (Accessed on October 21, 2020).
  39. Oncology Care Model Press Release. Accessed online at http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-02-12.html (Accessed on May 30, 2015).
  40. Levit L, Balogh E, Nass S, Ganz P. Institute of Medicine Report. Delivering High-Quality Care: Charting a New Course for a System in Crisis. 2013.
  41. Houlihan NG. Transitioning to cancer survivorship: plans of care. Oncology (Williston Park) 2009; 23:42.
  42. Stricker CT, Jacobs LA, Risendal B, et al. Survivorship care planning after the institute of medicine recommendations: how are we faring? J Cancer Surviv 2011; 5:358.
  43. Mayer DK, Gerstel A, Leak AN, Smith SK. Patient and provider preferences for survivorship care plans. J Oncol Pract 2012; 8:e80.
  44. Mayer DK. Survivorship care plans: necessary but not sufficient? Clin J Oncol Nurs 2014; 18 Suppl:7.
  45. Sprague BL, Dittus KL, Pace CM, et al. Patient satisfaction with breast and colorectal cancer survivorship care plans. Clin J Oncol Nurs 2013; 17:266.
  46. Salz T, Oeffinger KC, McCabe MS, et al. Survivorship care plans in research and practice. CA Cancer J Clin 2012; 62:101.
  47. Baravelli C, Krishnasamy M, Pezaro C, et al. The views of bowel cancer survivors and health care professionals regarding survivorship care plans and post treatment follow up. J Cancer Surviv 2009; 3:99.
  48. Hewitt ME, Bamundo A, Day R, Harvey C. Perspectives on post-treatment cancer care: qualitative research with survivors, nurses, and physicians. J Clin Oncol 2007; 25:2270.
  49. Marbach TJ, Griffie J. Patient preferences concerning treatment plans, survivorship care plans, education, and support services. Oncol Nurs Forum 2011; 38:335.
  50. Shalom MM, Hahn EE, Casillas J, Ganz PA. Do survivorship care plans make a difference? A primary care provider perspective. J Oncol Pract 2011; 7:314.
  51. Nicolaije KA, Ezendam NP, Vos MC, et al. Oncology providers' evaluation of the use of an automatically generated cancer survivorship care plan: longitudinal results from the ROGY Care trial. J Cancer Surviv 2014; 8:248.
  52. Antalis EP, Doucette R, Kuhn G, et al. Patient Perceptions of Survivorship Care Plans: A Mixed-Methods Evaluation. Oncol Nurs Forum 2019; 46:493.
  53. Benci JL, Vachani CC, Bach C, et al. Identifying barriers to cancer survivors sharing their survivorship care plans with their healthcare provider. J Cancer Surviv 2018; 12:632.
  54. Mayer DK, Birken SA, Check DK, Chen RC. Summing it up: an integrative review of studies of cancer survivorship care plans (2006-2013). Cancer 2015; 121:978.
  55. Jacobsen PB, DeRosa AP, Henderson TO, et al. Systematic Review of the Impact of Cancer Survivorship Care Plans on Health Outcomes and Health Care Delivery. J Clin Oncol 2018; 36:2088.
  56. Fang SY, Wang YL, Lu WH, et al. Long-term effectiveness of an E-based survivorship care plan for breast cancer survivors: A quasi-experimental study. Patient Educ Couns 2020; 103:549.
  57. Irene Su H, Stark S, Kwan B, et al. Efficacy of a web-based women's health survivorship care plan for young breast cancer survivors: a randomized controlled trial. Breast Cancer Res Treat 2019; 176:579.
  58. Nissen MJ, Tsai ML, Blaes AH, et al. Effectiveness of treatment summaries in increasing breast and colorectal cancer survivors' knowledge about their diagnosis and treatment. J Cancer Surviv 2013; 7:211.
  59. Shay LA, Parsons HM, Vernon SW. Survivorship Care Planning and Unmet Information and Service Needs Among Adolescent and Young Adult Cancer Survivors. J Adolesc Young Adult Oncol 2017; 6:327.
  60. Oeffinger KC, Hudson MM, Mertens AC, et al. Increasing rates of breast cancer and cardiac surveillance among high-risk survivors of childhood Hodgkin lymphoma following a mailed, one-page survivorship care plan. Pediatr Blood Cancer 2011; 56:818.
  61. Parker PA, Banerjee SC, Matasar MJ, et al. Efficacy of a survivorship-focused consultation versus a time-controlled rehabilitation consultation in patients with lymphoma: A cluster randomized controlled trial. Cancer 2018; 124:4567.
  62. Jefford M, Lotfi-Jam K, Baravelli C, et al. Development and pilot testing of a nurse-led posttreatment support package for bowel cancer survivors. Cancer Nurs 2011; 34:E1.
  63. Jagielski C, Crowley S, Dunn R, et al. Impact of a transition visit on addressing health-related patient concerns among breast cancer survivors. Paper presented at: 5th Biennial Cancer Survivorship Research Conference; June 2010; Washington, DC.
  64. Stricker, C.T., et al., Breast cancer survivors’ outcomes and satisfaction following delivery of a survivorship care plan: Results of a multicenter trial. Poster presented at 2013 San Antonio Breast Cancer Symposium. San Antonio, TX Dec 12, 2013.
  65. Palmer SC, Stricker CT, Panzer SL, et al. Outcomes and satisfaction after delivery of a breast cancer survivorship care plan: results of a multicenter trial. J Oncol Pract 2015; 11:e222.
  66. Gosain R, Miller K. Symptoms and symptom management in long-term cancer survivors. Cancer J 2013; 19:405.
  67. Tevaarwerk AJ, Hocking WG, Buhr KA, et al. A randomized trial of immediate versus delayed survivorship care plan receipt on patient satisfaction and knowledge of diagnosis and treatment. Cancer 2019; 125:1000.
  68. Taylor K, Chivers P, Bulsara C, et al. Care After Lymphoma (CALy) trial: A phase II pilot pragmatic randomised controlled trial of a nurse-led model of survivorship care. Eur J Oncol Nurs 2019; 40:53.
  69. Nahm ES, Miller K, McQuaige M, et al. Testing the Impact of a Cancer Survivorship Patient Engagement Toolkit on Selected Health Outcomes. Oncol Nurs Forum 2019; 46:572.
  70. Palmer SC, Jacobs LA, DeMichele A, et al. Metrics to evaluate treatment summaries and survivorship care plans: a scorecard. Support Care Cancer 2014; 22:1475.
  71. Boyajian RN, Grose A, Grenon N, et al. Desired elements and timing of cancer survivorship care: one approach may not fit all. J Oncol Pract 2014; 10:e293.
  72. Merport A, Lemon SC, Nyambose J, Prout MN. The use of cancer treatment summaries and care plans among Massachusetts physicians. Support Care Cancer 2012; 20:1579.
  73. Smith SL, Singh-Carlson S, Downie L, et al. Survivors of breast cancer: patient perspectives on survivorship care planning. J Cancer Surviv 2011; 5:337.
  74. Ashing-Giwa K, Tapp C, Brown S, et al. Are survivorship care plans responsive to African-American breast cancer survivors?: voices of survivors and advocates. J Cancer Surviv 2013; 7:283.
  75. Mao JJ, Torradas JR, Xie SX, et al. Assessing cancer knowledge and self-efficacy: the potential of treatment summaries in optimizing breast cancer survivorship. Paper presented at: 2010 Biennial Cancer Survivorship Research Conference; June 19, 2010; Washington, DC.
  76. Palmer SC, Jacobs LA, Panzer SL, Stricker CT. Survivorship care planning: When is intervention most effective? Poster presented at the San Antonio Breast Cancer Symposium. Abstract #1211, December 12, 2013.
  77. Landier W. Survivorship care: essential components and models of delivery. Oncology (Williston Park) 2009; 23:46.
  78. Oeffinger KC, McCabe MS. Models for delivering survivorship care. J Clin Oncol 2006; 24:5117.
  79. Dulko D, Pace CM, Dittus KL, et al. Barriers and facilitators to implementing cancer survivorship care plans. Oncol Nurs Forum 2013; 40:575.
  80. Ganz PA, Casillas J, Hahn EE. Ensuring quality care for cancer survivors: implementing the survivorship care plan. Semin Oncol Nurs 2008; 24:208.
  81. Birken SA, Clary AS, Bernstein S, et al. Strategies for Successful Survivorship Care Plan Implementation: Results From a Qualitative Study. J Oncol Pract 2018; 14:e462.
  82. Grant M, Economou D, Ferrell BR. Oncology nurse participation in survivorship care. Clin J Oncol Nurs 2010; 14:709.
  83. Irwin M, Klemp JR, Glennon C, Frazier LM. Oncology nurses' perspectives on the state of cancer survivorship care: current practice and barriers to implementation. Oncol Nurs Forum 2011; 38:E11.
  84. Rosenberg CA. Living in the Future Cancer Survivorship Program. Oncology Issues. 2008; Supplement: ACCC's Comprehensive Survivorship Services: A Practical Guide:S12.
  85. Patton A. M D Anderson Breast Cancer Survivor Clinic. Oncology Issues 2010; May/June:44.
  86. McCabe MS, Jacobs L. Survivorship care: models and programs. Semin Oncol Nurs 2008; 24:202.
  87. Rosenberg CA, Flanagan C, Brockstein B, et al. Promotion of self-management for post treatment cancer survivors: evaluation of a risk-adapted visit. J Cancer Surviv 2016; 10:206.
  88. Rosales AR, Byrne D, Burnham C, et al. Comprehensive survivorship care with cost and revenue analysis. J Oncol Pract 2014; 10:e81.
  89. Rosenzweig MQ, Kota K, van Londen G. Interprofessional Management of Cancer Survivorship: New Models of Care. Semin Oncol Nurs 2017; 33:449.
  90. Journey Forward. Survivorship Care Plan Builder 5.0. http://www.journeyforward.org/professionals/survivorship-care-plan-builder (Accessed on March 31, 2014).
  91. Salz T, Oeffinger KC, McCabe MS, Layne TM, Bach PB. Survivorship care plans for cancer survivors: Works in Progress. Under review.
  92. McCabe MS, Bhatia S, Oeffinger KC, et al. American Society of Clinical Oncology statement: achieving high-quality cancer survivorship care. J Clin Oncol 2013; 31:631.
  93. Salz T, Oeffinger KC, Lewis PR, et al. Primary care providers' needs and preferences for information about colorectal cancer survivorship care. J Am Board Fam Med 2012; 25:635.
  94. Survivorship: Integrated care model aims to cut costs, alleviate workload. The Oncology Watch: News in Review. February 2009.
  95. Birken SA, Raskin S, Zhang Y, et al. Survivorship Care Plan Implementation in US Cancer Programs: a National Survey of Cancer Care Providers. J Cancer Educ 2019; 34:614.
  96. Cowens-Alvarado R, Sharpe K, Pratt-Chapman M, et al. Advancing survivorship care through the National Cancer Survivorship Resource Center: developing American Cancer Society guidelines for primary care providers. CA Cancer J Clin 2013; 63:147.
  97. Shapiro CL, McCabe MS, Syrjala KL, et al. The LIVESTRONG Survivorship Center of Excellence Network. J Cancer Surviv 2009; 3:4.
  98. Tevaarwerk AJ, Wisinski KB, Buhr KA, et al. Leveraging electronic health record systems to create and provide electronic cancer survivorship care plans: a pilot study. J Oncol Pract 2014; 10:e150.
  99. Jacobs LA, Palmer SC, Schwartz LA, et al. Adult cancer survivorship: evolution, research, and planning care. CA Cancer J Clin 2009; 59:391.
  100. Trotter K, Frazier A, Hendricks CK, Scarsella H. Innovation in survivor care: group visits. Clin J Oncol Nurs 2011; 15:E24.
  101. Tevaarwerk AJ, Klemp JR, van Londen GJ, et al. Moving beyond static survivorship care plans: A systems engineering approach to population health management for cancer survivors. Cancer 2018; 124:4292.
Topic 17020 Version 24.0

References