SAN FRANCISCO, CA—An established transition plan with a shared nurse navigator can minimize anxiety experienced by patients who are childhood cancer survivors transitioning from pediatric care to adult care. These results of a survivorship program were presented at the 2016 Cancer Survivorship Symposium.1

Although the importance of transitioning survivors of childhood cancers from pediatric care to adult care is acknowledged in the literature, barriers such as patient and provider anxiety, complexity of the health care system, and lack of knowledge regarding late effects impede smooth transfers to adult care.

A work group of clinicians at Children’s Mercy (CM) and the University of Kansas Cancer Center (KUCC) collaborated to design a program that would reduce the barriers to transition for childhood cancer survivors.

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The group met and reviewed models and delivery of survivorship care, including the breast cancer survivorship clinic at KUCC, over 2 years to determine best practices.

They identified a shared nurse navigator as an essential component of a seamless patient transition. Philanthropic support was obtained, a job description was developed, and contracts were negotiated to allow the nurse navigator to be at both facilities. The Survivorship Transition Clinic (STC) at KUCC launched in July 2014.

In this program, the patient’s transition begins at CM, with the nurse navigator providing patient support. The same nurse navigator meets the patient at KUCC STC to initiate adult survivorship care at this facility. The nurse navigator provides treatment summaries, patient education, and orchestrates the survivorship referral services for the patient.

Since launch of the program, 16 of 16 survivors successfully transitioned from pediatric to adult survivorship care. Responses on patient satisfaction surveys provided positive feedback on the program. A common theme of patients’ responses was relief from anxiety due to having a contact person to help navigate the complex health care system.

The work group concludes the nurse navigator minimized anxiety about transition for patients and parents. The nurse established relationship the nurse navigator has with the patient provides continuity of care throughout the transition. In addition, the nurse navigator improved communication between the pediatric care team, adult primary care clinicians, and the subspecialists involved in the patients’ care.

“Overall, our transition process has been effective and is now serving as a model across both institutions,” concluded the work group.


1. Fulbright JM, McClellan W, Doolittle GC, et al. Nurse navigation: the key to a seamless transition. Poster presented at: 2016 Cancer Survivorship Symposium; January 15-16, 2016; San Francisco, CA. Abstract 84. Accessed January 15, 2016.