The Survivorship Care Plan - Assuring Quality of Care for Cancer Survivors

  • 02 Aug, 2020
  • By UHAPO
  • 413

A cancer survivor refers to any person who has been diagnosed with cancer. For the purposes of this topic, we will focus on the post-treatment period of survivorship. The follow-up of cancer survivors can be shared among the primary care provider (PCP), medical oncologist, and other cancer specialists, and is often transitioned to the PCP after the period of highest risk for disease recurrence(often five years, but sometimes longer).


Following the completion of initial treatment, more than 60 percent of adults diagnosed with cancer are expected to become long-term cancer survivors, living five years or more following their cancer diagnosis. At present, it is estimated that there are close to 30 million globally.[1]


These gains in survival are not without cost, and cancer survivors are at risk for a broad array of potential long-term and late effects of treatment. These include recurrent and new malignancies; increased morbidity and mortality from cardiovascular, skeletal, and other diseases; myriad physical effects such as peripheral neuropathy and lymphedema; and psychosocial distress that may impact work and social relationships.


One-third of cancer survivors have persisting symptoms that are similar to those they suffered during active treatment; fatigue, pain, depression, and sleep disruption are the most common across different malignancies.

There are four essential components of survivorship care for patients who have completed primary therapy:[3]

  • Prevention of recurrent and new cancers, and of other late effects

  • Surveillance for cancer spread, recurrence, and secondary cancers; assessment of  medical and psychosocial late effects

  • Intervention for consequences of cancer and its treatment

  • Coordination between primary and specialty care


Recommendations to improve the quality of survivorship care from experts state that each patient should receive a cancer treatment summary and follow-up care plan, collectively called the survivorship care plan (SCP), to facilitate care transitions and guide the content and coordination of care following acute treatment, and foster greater self-management of health by cancer survivors[3]. SCPs are intended to provide critical information regarding diagnoses, treatments, and potential late effects, as well as recommended surveillance, preventive strategies, and education and referrals for management of other medical and psychosocial needs.


The most common cancer types among female survivors include the following:[4]

  • Breast cancer (44 percent)

  • Cancer of the uterine corpus (9 percent)

  • Cancer of the colon or rectum (9 percent)

  • Thyroid cancer (8 percent)

  • Melanoma (8 percent)

Among male survivors, the most common cancers include the following:[4]

  • Prostate cancer (45 percent)

  • Cancer of the colon or rectum (10 percent)

  • Melanoma (8 percent)

  • Bladder cancer (8 percent)

  • Non-Hodgkin lymphomas (5 percent)



Components of Post Treatment Follow Up


The transition from active treatment to post-treatment care is critical to long-term health. A committee established at the Institute of Medicine (IOM) to examine the range of medical and psychosocial issues faced by cancer survivors defined the following components of survivorship care:[3]


  • Prevention of recurrent and new cancers, and of other late effects.

  • Surveillance for cancer spread, recurrence, or second cancers.

  • Assessment of medical and psychosocial late effects.

  • Intervention for consequences of cancer and its treatment, for example, medical problems such as lymphedema and sexual dysfunction; symptoms, including pain and fatigue; and psychological distress experienced by cancer survivors and their caregivers.

  • Evaluation of concerns related to employment, insurance, and disability.

  • Coordination between specialists and primary care providers to ensure that all of the survivor's health needs are met.


"Thus, a survivorship care plan is imperative for each and every patient to ensure good coordination between the specialist and the primary care provider."




  1. World estimated cancer prevalence, adult population: both sexes. http://globocan.iarc.fr.ezproxy.tmc.gov.in:2048/summary_table_pop_prev.asp?selection=225900&title=World&sex=0&window=1&sort=0&submit=%A0Execute%A0 (Accessed on February 13, 2013).


  1. Wu HS, Harden JK. Symptom burden and quality of life in survivorship: a review of the literature. Cancer Nurs 2015; 38:E29. https://pubmed.ncbi.nlm.nih.gov/24831042/

  2. Hewitt M, Greenfield S, Stovall E. From cancer patient to cancer survivor: lost in transition, The National Academies Press, Washington, DC2006.



  1. American Cancer Society. Cancer Treatment & Survivorship, Facts & Figures, 2016-2017. American Cancer Society; Atlanta, GA 2016.