Although they’ve conquered cancer, survivors may develop late or long-term physical, psychosocial, practical, or spiritual effects from the disease or its treatment. For example, patients with breast cancer who have completed surgery, radiation, or chemotherapy should be monitored for recurrence, lymphedema, osteoporosis, and cardiac, hormone-related, and sexual issues.

In 2006, the Institute of Medicine (IOM) released the report From Cancer Patient to Cancer Survivor: Lost in Transition to guide patients and providers as they shift from cancer treatment to posttreatment survivorship. Historically, both consensus on who should manage that follow-up care and guidelines or evidence to support that care are lacking. Primary care providers (PCPs) often manage patients’ survivorship care, and oncology APRNs have an opportunity to lead the improvement of care coordination and collaboration during those transitions.

Care Plans Connect the Survivorship Team

One of IOM’s major recommendations is to provide patients with a cancer survivorship care plan to help keep a patient’s survivorship team on track by listing a complete treatment summary, the oncology provider’s contact information, a detailed surveillance plan, types of tests needed, and possible late or long-term side effects. However, less than 15% of patients receive a survivorship care plan at the end of therapy. Some of the barriers include lack of time, lack of reimbursement for time it takes to complete a care plan, and lack of training to complete treatment summaries. 

Survivorship care plan templates are available as free downloads from the American Society of Clinical Oncology (ASCO) for individual, noncommercial use. ASCO provides both a generic template and specific templates for breast, cervical, colorectal, lung, ovarian, prostate, and uterine cancers and lymphoma.

Some electronic health records have an option to create a treatment summary directly in the system. Alternatively, the plan can be detailed in the patient’s progress note at the end of therapy and provided to the PCP and the patient to empower them to be their own advocate.

Oncology APRNs Can Lead the Transition

Engaging PCPs during cancer therapy may facilitate the transition to surveillance and monitoring after completion of therapy, and oncology providers can also educate PCPs about cancer-related surveillance and management, especially for less common malignancies. APRNs and other members of the cancer care or survivorship teams can collaborate via individual phone calls, emails, consultation letters, progress notes, and treatment summaries.

By communicating with PCPs, oncology APRNs are promoting collaboration and optimal monitoring for patients with cancer.