The Cancer Survivorship Care Plan: An Idea Whose Time Is Overdue

58 Background: More than 15.5 million cancer survivors live in the United States. This number is expected to be over 20 million by 2026. Cancer survivors have increased risk of morbidity; therefore, preventive and on-going medical treatment requires close monitoring and coordination. The Institute of Medicine’s (IOM) 2005 report, Cancer Patient to Cancer Survivor: Lost in Transition, recommended health providers raise awareness of cancer survivors’ needs and establish cancer survivorship as a distinct phase of care. The IOM also recommended patients who complete primary treatment are provided a comprehensive summary and plan that is effectively explained. A survivorship care plan maps out and improves care related to accessibility of past diagnosis and treatment history, surveillance guidelines, and potential long term side effects. In 2012, the Commission on Cancer (CoC) added Standard 3.3 Survivorship Care Planto the program standards. This met the IOM’s objective of addressing potential patients that get “lost” as they transition from care they received during treatment through phases of their life or disease. Methods: The Cancer Committee within a CoC certified organization developed multiple strategies to address the IOM and CoC standards. Strategies included a process to disseminate a comprehensive care summary for cancer patients who are completing primary treatment, adoption of the American Society of Clinical Oncology’s Treatment Summary and Survivorship Care Plan template, and adding a survivorship nurse navigator to the interprofessional treatment team. The survivorship nurse navigator monitors and reviews survivorship care plans with patients, advises when to seek treatment for symptoms, discusses surveillance guidelines, navigates patients through therapies, and educates on prevention and screening. Results: Evaluation for quality of life and compliance with individualized surveillance guidelines is ongoing. Conclusions: The oncology nurse navigator role is uniquely positioned to lead care coordination and improve outcomes through the continuum of care. Providing patients with a summary of their treatment and a plan moving forward may decrease stress related to the transition from active treatment to survivorship.

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Development and validation of an individualized survivorship care plan (ISCP) for women with endometrial cancer during the transition of the end of active treatment to the cancer survivorship

Canadian Oncology Nursing Journal ◽

10.5737/236880762713342 ◽

2017 ◽

Vol 27 (1) ◽

pp. 33-42

Author(s):

Johanne Hébert ◽

Lise Fillion

Keyword(s):

Endometrial Cancer ◽

Cancer Survivorship ◽

Active Treatment ◽

Care Plan ◽

Survivorship Care Plan ◽

Survivorship Care ◽

Development And Validation

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Improving patient participation in a breast cancer survivorship program at a safety net hospital.

Journal of Clinical Oncology ◽

10.1200/jco.2016.34.3_suppl.60 ◽

2016 ◽

Vol 34 (3_suppl) ◽

pp. 60-60

Author(s):

Shakuntala Shrestha ◽

Pam Khosla ◽

Janos Molnar ◽

Maria Eugenia Corona ◽

Sofia M Garcia

Keyword(s):

Breast Cancer ◽

Cancer Survivors ◽

Cancer Survivorship ◽

Breast Cancer Survivors ◽

Safety Net ◽

Care Plan ◽

Survivorship Care Plan ◽

Survivorship Care ◽

Breast Cancer Survivorship ◽

Safety Net Hospital

60 Background: To provide comprehensive services and meet Commission on Cancer (CoC) accreditation requirements, we developed and evaluated a customized breast cancer SCP template and delivery model. Objective: To implement and pilot test survivorship care plan (SCP) delivery for breast cancer survivors. Methods: Clinicians at a safety net hospital partnered with investigators at an academic institution to start a breast cancer survivorship care program. We developed an SCP template that is CoC-complaint and responsive to input gathered in 2 focus groups with breast cancer survivors (n = 12) and interviews with staff (n = 8). Oncologists and nurses identified and referred English-speaking women who had completed breast cancer treatment. Participants completed baseline measures prior to receiving individualized SCPs in a survivorship consultation visit with a dedicated APN. In response to high no-show rates, we expanded clinic scheduling to harmonize with participants' other medical appointments. Interim feasibility results for our ongoing study are presented here. Results: A total of 154 patients were screened to reach target enrollment (n= 80) within 20 months. Participant median age was 60 ± 11; 71% were African American, 14% Hispanic; 11% Non-Hispanic White and 92% had household incomes < $20,000. Average times were: 30 ± 13.4 minutes for abstracting patient clinical information in preparation for the survivorship visit; 25 ± 16 minutes for completing individual SCPs; 22±7.65 minutes to review / deliver the SCPs with patients. The difference in no-show rate between first 3-month recruitment period (clinic limited to one day/week) and next 17 months (clinic appointment expanded to accommodate patients' schedule) was statistically significant, p = 0.028. Conclusions: Tailoring SCP templates and delivery models to the needs of a safety net hospital aided the sustainability of a new survivorship clinic. Patient non-adherence to scheduled visits was significantly improved by expanding clinic hours. Significant clinician time was spent preparing SCPs and a level 4 visit (25 minutes) does not adequately reflect this effort. This study is funded by the American Cancer Society, Illinois Division (Grant# 254698).

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Integrating cancer survivorship care into allogeneic BMT recovery.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.5_suppl.39 ◽

2017 ◽

Vol 35 (5_suppl) ◽

pp. 39-39 ◽

Cited By ~ 1

Author(s):

Kelly Bugos ◽

Sarah Stenger ◽

Andrea Segura Smith ◽

Laura Johnston ◽

Morgan Gross ◽

...

Keyword(s):

Cancer Survivorship ◽

Late Effects ◽

Cellular Therapy ◽

Recovery Period ◽

Symptom Assessment ◽

Care Plan ◽

Survivorship Care Plan ◽

Survivorship Care ◽

Long Term Effects ◽

Post Transplant

39 Background: AlloBMT patients are at risk for chronic morbidity and late effects. Prior to 2015, the Stanford BMT program conducted group classes at three months post-transplant to prepare alloBMT patients and their families for the transition to survivorship, but no formal cancer survivorship program existed. Cancer survivorship care is required by the Foundation for the Accreditation of Cellular Therapy ( FACT). In order to fill this gap, we developed a standardized pathway to survivorship care for alloBMT survivors. Aim: To implement an initial cancer survivorship care consultation with comprehensive symptom assessment, late effects monitoring, and development of a survivorship care plan (SCP) three to six months after alloBMT. Methods: Standard work was implemented including patient introduction to survivorship by the BMT nurses and Advanced Practice Providers [APP] and during group ‘moving home’ class; responsibility for referral to survivorship; metric tracking, and administration of patient survey. The survivorship visit included an evaluation by the patient’s BMT social worker, introduction to post-BMT nurse coordinator and consult with cancer survivorship APP. Eligible patients were alloBMT recipients receiving care in the outpatient setting. Results: From July 28, 2015 to January 25, 2016, 90% (66/72) of eligible alloBMT patients were referred to cancer survivorship by day 100, 66% (42/66) of referred patient s were seen in survivorship clinic by day 180, 33% (22/66) deferred the visit or were unreachable, 1% (2/66) died. Of the 42 patients who received a cancer survivorship visit, 38% (13/42) responded to a post-visit survey. Responses indicated the patients believed their health goals and needs were addressed, and a SCP in the context of a comprehensive visit was valuable. Conclusions: Integrating standardized cancer survivorship care into the alloBMT recovery period is feasible, satisfactory to patients, and adds a structured approach for long-term effects monitoring and treatment. Early experience and patient surveys demonstrate value in an individual visits 3-6 months after alloBMT with a focus on returning to life and goal oriented post-transplant care.

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Perceived value of cancer survivorship care among Asians and Native Hawaiian/Pacific Islanders.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.e22522 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. e22522-e22522

Author(s):

Jared David Acoba ◽

Sharon Tamashiro ◽

Marci Chock

Keyword(s):

Cancer Survivors ◽

Racial Differences ◽

Cancer Survivorship ◽

Native Hawaiian ◽

Care Plan ◽

Survivorship Care Plan ◽

Survivorship Care Plans ◽

Survivorship Care ◽

Care Plans

e22522 Background: Numerous studies have evaluated the impact of cancer survivorship care. However, no study to date has focused on Asian or Native Hawaiian/Pacific Islander (NH/PI) cancer survivors. It has been well documented that Asian and NH/PI patients often suffer from inferior cancer outcomes compared to White patients, and differences in their experience with cancer survivorship care could contribute to this disparity. Methods: Surveys were sent to 1410 cancer survivors who were treated at a community cancer center with curative intent and who had received survivorship care plans between Jan 2014 and June 2018. The 26-item questionnaire evaluated patients’ perception of various aspects of their survivorship care plan and follow-up physician visits. All responses were anonymous. Results: Of the 360 patients who responded, 24% were White, 54% Asian, and 13% NH/PI. Compared to Whites, Asian and NH/PI patients were younger (p = 0.004), less educated (p = 0.004), and reported a lower income (p < 0.0005). Among all patients, 62% reported that the survivorship care plan was “very helpful” and 86% rated their satisfaction with physician follow-up visits as “very good” to “excellent.” There were no racial differences in satisfaction with either survivorship care plan or physician follow-up. In a multivariate binary logistic regression, Asians and NH/PI patients were significantly more likely to rate ongoing survivorship care as helpful compared to Whites, OR 4.08 (95%CI, 2.13-7.82). Conclusions: There were no racial differences in patient satisfaction with their survivorship care plans and follow-up care. However, Asian and NH/PI patients valued ongoing cancer survivorship care follow-up significantly more than White patients. Whether more extensive survivorship care would lead to improved outcomes among Asian and NH/PI cancer patients should be investigated further.

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