In an interview with GWCI’s Mandi Pratt-Chapman, MA, Director, GWCI; Anne Willis, MA, Director of the Division of Cancer Survivorship; and Elisabeth A. Reed, MPA, Project Manager, Health Care Professional Education, they emphasized the importance of creating a process to develop and deliver the care plan. They suggest considering who your patients are and which patients will receive a survivorship care plan, which care delivery model might be appropriate, when it will be delivered, and how it will be delivered. In addition, decide who will be responsible for which activities.

Stricker suggested that providing information to patients on cancer survivorship, including what treatments they received and what effects those treatments may cause in the future should be an iterative process. Ideally, the survivorship care plan would not be the first time patients see this information.

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The time it takes to gather the treatment summary is one of the top barriers to implementing survivorship care plans. Existing plans have been criticized for taking too long to complete. The GWCI team acknowledged that, despite the growth of electronic medical records, pulling the necessary information can be difficult. “One way to simplify the process is to document a treatment plan from the beginning of treatment, and update the plan as treatment progresses,” they suggest. “Staff from your institution’s registry and IT departments might also be able to help create a more efficient system of gathering this information.”

“We miss the boat when we spend so much time pulling together granular information on treatment and make this a laborious process,” said Stricker. “Survivors need an understanding of what was received. It doesn’t need to be the exact dose. You need to know basic information about radiation, chemotherapy, etc, in order to know what to look for.”

Stricker explained that she pulls together a treatment summary using a template she created. Her method involves copying and pasting information from the progress notes and clarifying it a bit. She also provides a one-page version of the American Society of Clinical Oncology (ASCO) follow-up guidelines that she converts to a letter and individualizes to the patient. If time allows, she completes the LIVESTRONG care plan in the room with the patient; if not, she gives them the Web site link and instructs them to read it.

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The GWCI team added that many institutions create their own survivorship care plan that aligns with the recommendations in the IOM report. The report states that the care plan should summarize critical information needed for the survivor’s long-term care, including cancer type, treatments received, and potential consequences; specifics on the timing and content of recommended follow-up; recommendations on preventive services and maintaining health and well-being; information on legal protections regarding employment and access to health insurance; and availability of psychosocial services in the community.8

Reimbursement is another perceived barrier to implementing survivorship care plans and other components of the clinical survivorship program. The GWCI team said, “Many providers are successfully getting reimbursed for these services through existing billing codes. Providers can talk with their billing specialist to determine different coding options.”


Determining who does what is critical when implementing a survivorship care plan. Tasks include completing the plan, delivering it to the patient, referring the patient to resources or specialists, coordinating with the primary care provider, and following up with the survivor. “We need to give clear guidance on who’s doing what, where, and for whom,” explains Stricker.

“Survivors express the need to know what is important to them as an individual, including what risks they face, what particular care and behavioral recommendations they should follow, and what resources are available for their particular needs,” said Stricker.

The survivorship care plan needs to be discussed with, as well as given to, the patient. The GWCI team explain that patients need to understand potential risks and the plan for follow-up care. The clinician should also send the survivorship care plan to the patient’s primary care provider (PCP), or help the patient identify one if they need to transition their care from the oncologist to a PCP.

“Primary care physicians have consistently expressed the need to know what they should be monitoring, how often, and for whom, and which aspects of follow-up care are their responsibility. Further, they want this information in a concise document of no more than two pages,” Stricker said.