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Post-Treatment: Developing a Care Plan for Each Cancer Patient

October 01, 2020

By Deborah Walker, APRN
Hartford HealthCare Cancer Institute

Over a decade ago, the independent, nonprofit Institute of Medicine recommended every cancer patient receive a survivorship care plan that includes guidelines for monitoring and maintaining their health.

This recommendation was developed from a prominent report, “From Cancer Patient to Cancer Survivor: Lost in Transition,” on the unmet needs of cancer survivors. In response to that report, it was recommended that each cancer survivor receive a treatment summary and survivorship care plan (SCP). This SCP is provided to help improve the quality of care of survivors as they move beyond their cancer treatment.

Cancer survivorship has developed into a distinct phase of cancer care. After active treatment ends, patients are often at a loss for coping with this next phase of their care. This next phase can be complex and involve a variety of care needs.

Frequently, when therapy ends, patients experience a loss of a strong connection to their care team. As these treatment appointments end, cancer survivors may lack a clear plan for follow-up as well as who to contact for assistance in managing physical symptoms, emotional distress and economic issues.

The survivorship care plan can address these areas by capturing essential information as well as communicating key issues to patients and their healthcare providers.

Major areas of concern for cancer survivors include recurrence, secondary malignancies, long-term or late treatment effects as well as financial, work or psychosocial issues.

So the four essential components of survivorship care are:

• Prevention
• Surveillance
• Intervention
• Coordination of care.

Cancer care is complex, with multiple methods of therapy and multidisciplinary care providers. A survivorship treatment summary and care plan can assist patients with their care needs.

A personalized treatment summary and care plan includes:

•  Contact information of the treating institutions and providers.
•  Specific diagnosis (such as breast cancer), including histologic subtype (such as non-small cell lung cancer) when relevant.
•   Surgical procedure.
•   Chemotherapy with names of systemic therapy agents administered .
•   Radiation with anatomical area treated by radiation.
•   Ongoing toxicity or side-effects of all treatments received at the completion of treatment, and any information concerning the likely course of recovery from these toxicities.
•   For selected cancers, genetic/hereditary risk factor(s) and genetic testing results if performed.
•   Need for ongoing adjuvant therapy for cancer (including name, duration, and side effects).
•   Schedule of follow up related clinical visits (who will provide the care and how often).
•   Cancer surveillance tests for recurrence (frequency of tests and provider responsible for ordering tests),
•   Cancer screening for early detection of new primaries.
•   Possible symptoms of cancer recurrence.
•   A list of potential late- and/or long-term effects that a survivor may experience based on his or her individual diagnosis.
•   A list of areas in which survivors may have receive assistance with issues such as emotional or mental health, parenting, work/employment, financial issues, and insurance.
•  Information about the benefits of healthy diet, exercise, smoking cessation and alcohol use reduction.

At Hartford HealthCare, our goal is to provide quality care to all of our patients throughout cancer treatment, but also beyond the active treatment phase. A survivorship appointment to review your treatment summary and care plan is an important resource in meeting our goal of providing high-quality care to all our cancer patients.

The patient visit will consist of a focused evaluation with individualized recommendations and education. If you are interested in scheduling an appointment, please contact your oncology team.