What to Do During Treatment

Survivorship care does not just begin at the completion of active therapy. Below are details of what may be done during active cancer treatment to transition the patient into the period of surveillance and long-term follow up care.

Survivorship care should begin at the moment of cancer diagnosis. Starting early allows the doctor and patient to plan for the post-treatment period, laying the groundwork for a better continuity of care for the patient. The 2005 IOM report, From Cancer Patient to Cancer Survivor: Lost in Transition, recommends that patients completing their first course of treatment be provided with a comprehensive care summary and follow-up care plan. Together, these two documents make up the Survivorship Care Plan (SCP). ASCO promotes the use of the SCP to enhance communication between the oncology team and patient, and to improve communication and coordination of care between the oncology team and primary care provider.

See also: ASCO’s Treatment Plan and Summary Resources

In addition to developing the treatment summary and care plan, oncology providers should have ongoing discussions with patients about possible late- and long-term effects of treatment.

Transitioning the Patient

Upon completion of treatment, survivors enter into the initial phase of long-term follow-up care. This phase focuses on surveillance and disease-specific care. Patients should transition from this initial phase into survivorship-focused care, concentrating on risk-based screening and health promotion. Determining when, where and which patients are followed will vary depending on individual patient need and the model of care delivery.

LIVESTRONG Cancer Transitions

Cancer Transitions is a six-week, evidence-based educational program to support and empower survivors as they transition from active treatment to post-treatment. Though mainly targeted to individuals who have completed their treatment within the last 24 months, the program may benefit survivors at any time in their survivorship. The program helps participants learn the benefits of exercise, nutrition, emotional support, and medical management, and is offered in face-to-face meetings.

Transition Checklist 

Below is a sample checklist to help determine if the appropriate steps have been completed to transition the patient to survivorship-focused care. You can also download a modifiable version of this checklist

  1. Does the patient have an established relationship with a PCP?
  2. Has the survivorship care plan (SCP) been transmitted to the PCP or provider in charge of long-term follow-up care?
  3. Have additional resources, such as guidelines, been provided to the PCP?
  4. Has patient received the SCP?
  5. Has the patient been given the opportunity to review the SCP with a member of the care team?
  6. Has the transition of care been clearly communicated to the patient so that s/he understands who will be the lead in coordination of care?