The American Society of Clinical Oncology (ASCO) and organizations such as Livestrong also have developed templates for survivorship care plans (SCPs). But there has been limited success in implementing SCPs. 7,8 The American College of Surgeons Commission on Cancer (CoC) Standard 3.3 is scheduled to be implemented in 2015.9 The standard is expected to require that a cancer care committee develop and implement a process to disseminate a comprehensive care summary and follow-up plan for cancer survivors. 9 To address this need, ASCO has formed a joint work group for improving cancer survivorship and a new version of an SCP template. This group recommended including contact information for the oncology providers who administered the treatment; basic diagnostic and staging information; and information on surgery, radiation therapy, systemic therapy (both chemotherapy and biologic therapy), and ongoing significant toxicities, including dates (Table 1). 10
The ASCO also developed a follow-up care plan that includes a surveillance plan to detect recurrence and late AEs; interventions to manage ongoing problems resulting from cancer and its treatment; and age- and sex-appropriate health care, including cancer screening and general health promotion. It also recommended that the follow-up care plan should include a schedule of clinic visits in a table format, surveillance care testing to detect recurrence and second primary cancers, such as early breast cancer screening for women who underwent chest radiation for Hodgkin lymphoma. The person responsible for ordering these screening test should be included in the follow-up care plan. 10 In addition, ASCO developed a cancer survivorship compendium, which included not only tools and resources, but also different models for cancer survivorship care. 11 In addition, ASCO developed a Quality Oncology Practice Initiative (QOPI) to assess the quality of survivorship programs. 9
The Central Arkansas Veterans Healthcare System (CAVHS) adopted National Comprehensive Cancer Network (NCCN), ASCO, and National Cancer Institute (NCI) guidelines and developed a template for a cancer treatment summary that includes the cancer type; grade; staging; and date of diagnosis and duration of treatment, including chemotherapy, surgery, and radiation with a disease-specific follow-up care plan for each type of cancer. The treatment summary is a useful tool to communicate a patient’s treatment and disease status to PCPs and patients.
Models of Care
Eight models for delivering survivorship care have been developed by ASCO 11:
- Oncologist Specialist Care: Care occurs as a continuation in the oncology setting
- Multidisciplinary Survivor Clinic: Different specialists provide care
- General Survivorship Clinic: Care is provided by a physician or advanced care provider (APN) and implemented at a cancer center or private practice
- Consultative Survivorship Clinic: Initial follow-up is provided in an oncology setting with an eventual transition to a PCP; patients may be directed to the cancer center for needed services
- Integrated Survivorship Clinic: Care is provided by a physician or APN, and the care is coordinated with the PCP and other specialists as needed
- Community Generalist Model: The PCP, APN, or internist within the community provides care
- Shared-Care of Survivor: Care is coordinated and provided by any combination of specialists, PCPs, and nurses and is patient directed
