Survivorship care planning - ACSC

Cancer survivors are increasing in number: in Australia, relative five-year survival rates for all cancers have increased from 41.3% in 1982–6 to around 58.4% in 1998–2004.

With growing numbers of survivors, and demands on an already stretched cancer workforce likely to be increased by advances in cancer treatment (e.g. wider use of chemotherapy and wider application of multidisciplinary care), more efficient ways of managing follow-up care of survivors are needed.

Survivorship care plans

Survivorship care plans (SCPs) are emerging as one element of an improved and more coordinated approach to survivor care.

SCPs are formal, written documents that provide details of a person’s cancer diagnosis and treatment, potential late and long-term effects arising from the cancer and its treatment, recommended follow-up, and strategies to remain well.

The Institute of Medicine (IOM), in its report From Cancer Patient to Cancer Survivor: Lost in Transition, recommends that each person who completes primary treatment for cancer receive a comprehensive care summary and follow-up plan. This needs to be clearly and effectively explained to the survivor.

The IOM has prepared a useful
fact sheet on cancer survivorship care planning.


  • See the example from the Australian Cancer Survivorship Centre at the Peter MacCallum Cancer Centre (If you require a Survivorship Care Plan in Word format please complete the Evaluation and Feedback form)

SCP content

The plan should include information about:
  • the cancer for which the survivor received treatment, and the type of treatments they received
  • short-term and long-term effects of treatment: what to be alert for and how frequently to visit the doctor for check-ups and screening (including information about psychosocial effects)
  • how the survivor’s follow-up care will be coordinated between the oncology specialist, GP, nurse specialists, etc., and who to contact in between follow-up appointments
  • lifestyle changes needed to reduce the risk and severity of treatment side effects, prevent comorbid conditions and promote better health (including information about diet, smoking, alcohol, obesity and overweight, exercise and sun protection)
  • useful community resources should the survivor encounter employment and insurance issues.

The relative novelty of SCPs means there is limited evidence of the ideal content of an SCP.

How SCPs are used

The SCP is discussed with the survivor (and their family if appropriate) and a copy given to the survivor. Copies go to all other health care professionals involved in the survivor’s care.

As an example of how SCPs are used in Australia, in the Peter MacCallum Cancer Centre late effects clinic, each survivor receiving treatment has an individualised SCP. The plan includes details of medical history, treatments received, potential for late effects, requirements for follow-up appointments, tests and reasons for them. The care plan focuses on health promotion and highlights the need for and how to adopt healthy behaviours. It also addresses psychosocial issues, how to identify them and where to get help. A copy is sent to the survivor’s primary care physician so they are kept up to date with information essential to monitoring the health of a cancer survivor and to providing the survivor with a knowledgeable source of support and advice close to home.

Who should prepare the plan?

The IOM recommends that the plan be written by the principal specialist(s) who provided the cancer treatment. However, there has been some variation in opinion regarding ideal content of the SCP, who might prepare it, and how it might be discussed and utilised.

The survivor needs to be involved in the development of the SCP.

Oncologists have significant time constraints that complicate preparation of individual SCPs and discussion and explanation with the patient. A US review suggests electronic records management systems could be adopted within institutions to allow doctors to communicate across specialties.

Links for SCP templates.

Evidence and support

SCPs are recommended as an important tool to facilitate communication and allocation of responsibility during the transition from active treatment to survivorship.

An Australian report of a study into the use of SCPs among bowel cancer survivors revealed strong support for the development and use of SCPs.

A/Prof Michael Jefford, Director of the ACSC, cautions that ‘While the use of care plans might make intuitive sense (have good face validity), their impact has not been formally evaluated. There are a number of challenges to their routine use, most obviously who will produce the document, how can it be easily tailored to an individual person, who will discuss the document and how should it be used to enhance outcomes for survivors? … We await further evaluation and publication.’

Useful links and resources

This overview was prepared with reference to:
  • Rosenbaum E et al. 2007. Everyone’s Guide to Cancer Survivorship. Missouri: Andrews McMeel Publishing.

  • From cancer patient to cancer survivor: lost in transition: an American Society of Clinical Oncology and Institute of Medicine Symposium (2006) (free PDF)
  • The 2005 IOM Committee on Cancer Survivorship report

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