Survivorship Care Plans: Providing A Blueprint for Health Care After Cancer

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Survivors can experience unmet needs that required a carefully designed support system to address.
Survivors can experience unmet needs that required a carefully designed support system to address.
The following article features coverage from the 2017 ONA Navigation Summit in Austin, Texas. Click here to read more of Oncology Nurse Advisor's conference coverage. 

AUSTIN, Tx — In addition to its mandate to provide cancer survivors with survivorship care plans (SCPs), the Commission on Cancer (CoC) has established required content for these plans that nurse navigators can follow to ensure their patients have the best chance to receive optimal posttreatment care, according to an oral presentation at the 2017 Oncology Nurse Advisor Navigation Summit.

The probability for a woman to develop cancer is 37.5% (an estimated 1 in 3); for men, 40.8% (an estimated 1 in 2) will develop cancer in their lifetime. The estimated probability of living at least 5 years after a cancer diagnosis is 67%.

After completing treatment, many survivors are lost in transition. They experience unmet needs in that coordination of care is missing, interaction with the oncology care team is now limited, and evidence-based approaches to survivorship care are lacking. Gaps in primary care physicians' knowledge of survivorship care and in survivors' knowledge of health practices can negatively impact survivors' overall health.

These issues are addressed in the Institute of Medicine (IOM) recommendation to provide survivorship care plans as part of the continuum of cancer care, which are now mandated by CoC.

Essential elements CoC requires of an SCP policy include who provides the SCP (must be a qualified clinician; lay navigators may not provide the SCP), the process for its delivery (may not be provided by mail or through any electronic or automated system without an in-person discussion with the patient), a strategy for identifying eligible patients who should receive the SCP (track and report the number of SCPs provided compared with the number of patients eligible to receive SCPs), and a sample document that describes treatment summary and follow-up care that includes the American Society of Clinical Oncology (ASCO) recommended content.

In addition to policy and procedure requirements, the Commission on Cancer established content requirements for SCPs. Cindy Stern, RN, MSN, CCRP, reviewed the requirements for survivorship care plans in her oral presentation.

The minimum information required in an SCP includes the institution and physician's contact information plus specific information on the patient's diagnosis (eg, site and histology), and stage at diagnosis. Information on the patient's treatment course must include date (year) of any surgical procedure, names and end date of chemotherapy regimens, and location and end date of radiation therapy. Posttreatment information such as ongoing toxicity and recovery expectation, as well as results of any testing to determine genetic risks are also part of the minimum information required in an SCP.

Survivorship care plans are also required to include follow-up care plans. These plans need to include any ongoing adjuvant treatments planned and expected toxicities, as well as any rare, but significant, late or long term effects related to the patient's diagnosis and treatment. Instructions regarding recommended follow-up visits plus surveillance for recurrence (what, when, where, and who), as well as instructions to see the physician for new, unusual, or persistent symptoms are also needed. These plans also must include a statement about the importance of healthy living habits, provide information regarding common psychosocial survivorship issues, and local and national resources for the patient. Finally, the care plan needs to provide information regarding screening for new primary cancers.

Although SCPs and follow-up care plans require culling a significant amount of information for patients, nurse navigators are not charged with remembering all the required information on their own. ASCO provides Survivorship Care Planning Tools that include SCP templates to ensure oncology care teams provide cancer survivors with comprehensive information on their past history and future care.

Read more of Oncology Nurse Advisor's coverage of the 2017 ONA Navigation Summit by visiting the conference page.

Reference

1. Stern C. Current challenges for navigators: the survivorship care plan mandate. Oral presentation at: 2017 Oncology Nurse Advisor Navigation Summit; June 15-17, 2017; Austin, TX.

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