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Working with Survivors

Working with Survivors

Focusing on the long term for patient wellness.

Primary care providers are critical in delivering general and preventive follow-up care to cancer survivors. A 2005 Institute of Medicine (IOM) report emphasized the need to improve a patient’s transition from oncologist to primary care provider, as the IOM found that many survivors were “lost in transition.” The IOM noted that despite an increase in the number of cancer survivors, as well as an aging population of survivors, many primary care providers were not extremely familiar with the late-effects of cancer, nor do they often receive explicit guidance from oncologists for a patient’s follow-up care.

Follow-Up / Survivorship Care Plans

The IOM report established a number of recommendations to enhance survivors’ transition from cancer treatment to survivorship. Perhaps the most notable was use of a follow-up or survivorship care plan. Such plans should summarize information critical to a survivor’s follow-up and long-term care and include:

  • Patient’s diagnosis, treatment, and potential consequences
  • Timing and content of follow-up visits
  • Tips on maintaining a healthy lifestyle and preventing recurrent or new cancers
  • Legal rights affecting employment and insurance
  • Availability of psychological and support services

A number of cancer treatment facilities provide survivorship or follow-up care plans to patients at the completion of their treatment, including those that are accredited by the Commission on Cancer (CoC) or National Accreditation Program for Breast Cancers (NAPBC, breast cancer only). A copy of the survivorship care plan is provided to the survivor, who can then provide a copy to you.

If you work with cancer survivors, ask them for a copy of their care plan or treatment summary.

Survivors that do not receive a survivorship care plan from their oncology provider can use their treatment records to aid in creating their own plan using an online tool. These often require the assistance of a health care provider.

Resources:

Journey Forward’s My Care Plan

OncoLife Care Plan

Research study on need for care plans 

National Cancer Institute Follow-Up Care Planning

Caring for Cancer Survivors: A Primary Care Physician’s Perspective