Managing Survivorship Care

---
name: managing-survivorship-care
description: Creates survivorship care plans with surveillance schedules, late effects monitoring, and wellness recommendations. Use when creating survivorship plans, scheduling cancer surveillance, or documenting long-term follow-up.
tags:
  - management
  - oncology
metadata:
  author: casemark
  practice_areas:
    - Medical Oncology
    - Hematology-Oncology
    - Radiation Oncology
  document_types:
    - Management Report
  skill_modes:
    - Management
    - Coordination
---

# Managing Survivorship Care

Creates survivorship care plans with surveillance schedules, late effects monitoring, and wellness recommendations.

## Why This Skill Exists

There are over 18 million cancer survivors in the United States. The transition from active treatment to survivorship is a high-risk period for lost follow-up, undetected recurrence, and unmanaged late effects. The Institute of Medicine landmark report "From Cancer Patient to Cancer Survivor: Lost in Transition" (2006) established that every cancer patient completing treatment should receive a survivorship care plan (SCP). CoC Standard 3.3 mandates SCPs for accredited cancer programs.

Late effects of cancer treatment — including secondary malignancies, cardiotoxicity, infertility, neurocognitive changes, and psychosocial distress — may emerge years after treatment completion. Without structured surveillance, these complications are detected late when intervention options are limited. ASCO, NCCN, and ACS have published cancer site-specific survivorship guidelines that define surveillance imaging schedules, lab monitoring, and screening for treatment-related complications.

---

## Checkpoint A: Pre-Draft Intake (Mandatory)

1. What cancer was treated (type, stage, histology, receptor status)? (Default: [VERIFY])
2. What treatments were administered (surgery, chemotherapy agents with cumulative doses, radiation fields and total dose, hormonal therapy, immunotherapy)? (Default: complete treatment summary)
3. What was the date of treatment completion? (Default: specify)
4. What is the patient's current disease status (NED, CR, stable residual)? (Default: NED)
5. Are there existing treatment-related toxicities or complications? (Default: assess)
6. What is the patient's age, sex, and baseline comorbidity profile? (Default: document)
7. Has genetic/hereditary cancer testing been performed? (Default: assess need)
8. Who will be the primary follow-up provider (oncologist, PCP, shared care)? (Default: shared care model)

### Documents to Request

- Complete treatment summary (ASCO Treatment Summary template)
- Operative reports from all cancer surgeries
- Chemotherapy administration records with cumulative doses (especially anthracyclines, bleomycin, cisplatin)
- Radiation therapy summary with fields, total dose, and fractionation
- Final restaging imaging and labs
- Pathology report with biomarker status
- Genetic testing results if performed
- Current medication list including maintenance/adjuvant hormonal therapy
- Psychosocial distress screening results

---

## Step 1: Create the Treatment Summary

The treatment summary is the foundation of the SCP. Document:

1. **Cancer diagnosis:** Primary site, histology, stage (AJCC 8th edition), biomarker status
2. **Surgery:** Type, date, findings, margin status, complications
3. **Systemic therapy:** Each agent, cumulative dose, number of cycles, dates, dose modifications, reason for completion or discontinuation
4. **Radiation therapy:** Target volume, technique (IMRT, 3D-CRT, proton), total dose in Gy, fractionation, dates
5. **Other treatments:** Hormonal therapy (agent, planned duration), targeted therapy, immunotherapy
6. **Treatment-related complications:** Documented toxicities during treatment and current status
7. **Genetic testing results:** Germline mutations identified, implications for surveillance

**Cumulative dose tracking for late-effects risk:**

| Agent | Threshold | Late Effect |
|-------|-----------|------------|
| Doxorubicin | >250 mg/m² | Cardiomyopathy risk increases; >550 mg/m² high risk |
| Bleomycin | >400 units total | Pulmonary fibrosis |
| Cisplatin | >300 mg/m² | Ototoxicity, nephrotoxicity, peripheral neuropathy |
| Cyclophosphamide | High cumulative dose | Secondary MDS/AML, infertility |

---

## Step 2: Define the Surveillance Schedule

Apply NCCN and ASCO survivorship guidelines for the specific cancer type:

**Breast cancer (example schedule):**
- History and physical: every 3–6 months for years 1–3, every 6–12 months for years 4–5, then annually
- Mammography: annually (first mammogram 6–12 months after completion of radiation)
- No routine tumor markers (CA 15-3, CA 27.29, CEA) or imaging (CT, PET, bone scan) for asymptomatic surveillance per ASCO guidelines
- If on tamoxifen: annual gynecologic assessment; report abnormal vaginal bleeding promptly
- If on aromatase inhibitor: baseline DEXA scan, repeat per osteoporosis guidelines

**Colorectal cancer (example schedule):**
- CEA every 3–6 months for years 1–2, then every 6 months for years 3–5
- CT chest/abdomen/pelvis annually for 5 years (for stage II–III)
- Colonoscopy at 1 year post-resection, then per findings
- History and physical every 3–6 months for years 1–2, then every 6 months for years 3–5

Adapt the schedule to the specific cancer type using current NCCN survivorship guidelines.

---

## Step 3: Screen for and Monitor Late Effects

**Cardiotoxicity monitoring:**
- Patients who received anthracyclines or trastuzumab: echocardiogram at baseline and periodic monitoring per exposure level
- Patients who received mediastinal radiation: cardiac screening starting 5–10 years post-treatment per NCCN guidelines
- Cardiovascular risk factor management (lipids, blood pressure, glucose) with lower thresholds for intervention

**Secondary malignancy screening:**
- Radiation field surveillance: breast MRI for women who received chest radiation before age 30 (beginning 8 years after radiation or at age 25, whichever is later)
- Skin examination in radiation fields annually
- Consider enhanced colorectal screening for survivors who received abdominal/pelvic radiation

**Endocrine and fertility:**
- Thyroid function testing for patients who received neck/mediastinal radiation
- Fertility counseling and gonadal function assessment for reproductive-age survivors
- Bone density monitoring for patients with treatment-induced premature menopause or androgen deprivation therapy

**Psychosocial and neurocognitive:**
- Screen for depression, anxiety, fear of recurrence at every visit using validated tools (PHQ-9, GAD-7)
- Cognitive function assessment for patients reporting "chemo brain" symptoms
- Refer to survivorship support programs, peer support, or psycho-oncology as indicated

---

## Step 4: Deliver the Survivorship Care Plan

The SCP must be:
1. Written in patient-accessible language (below 8th-grade reading level for patient copy)
2. Shared with the patient, primary care provider, and all follow-up specialists
3. Updated when surveillance findings change management
4. Inclusive of both cancer-directed surveillance and general preventive health recommendations

General health recommendations for all cancer survivors:
- Maintain healthy weight (BMI 18.5–25)
- Exercise: ≥150 minutes moderate-intensity or ≥75 minutes vigorous-intensity per week
- Limit alcohol to ≤1 drink/day (women) or ≤2 drinks/day (men)
- Smoking cessation (if applicable)
- Age-appropriate cancer screening for other malignancies
- Influenza and pneumococcal vaccination per CDC guidelines

---

## Checkpoint B: Post-Draft Alignment (Mandatory)

1. Does the treatment summary include all agents, cumulative doses, radiation fields, and surgical procedures?
2. Is the surveillance schedule specific to the cancer type and based on current NCCN/ASCO guidelines?
3. Are late effects screening recommendations matched to the specific treatments received?
4. Is the SCP written in patient-accessible language for the patient copy?
5. Have psychosocial distress screening and referral resources been included?

---

## Quality Audit

- [ ] Treatment summary includes all treatment modalities with dates and doses
- [ ] Cumulative anthracycline dose calculated and documented
- [ ] Surveillance schedule matches NCCN guideline for the specific cancer type and stage
- [ ] No inappropriate surveillance imaging ordered for asymptomatic patients (e.g., routine PET/CT for early-stage breast cancer)
- [ ] Late effects monitoring matched to specific agents and radiation fields received
- [ ] Cardiac surveillance planned for patients with anthracycline or trastuzumab exposure
- [ ] Secondary malignancy screening addressed based on treatment history
- [ ] Fertility and endocrine effects addressed for relevant patients
- [ ] Psychosocial screening included with validated instruments
- [ ] General health and wellness recommendations included
- [ ] SCP shared with patient, PCP, and relevant specialists
- [ ] Follow-up responsibility clearly delineated (oncologist vs. PCP vs. shared)
- [ ] Plan for transition from oncology to primary care follow-up documented

---

## Guidelines

- Every patient completing curative-intent treatment must receive a survivorship care plan — this is a CoC accreditation requirement
- Survivorship care plans should be delivered within 3 months of treatment completion
- Do not order surveillance testing beyond what guidelines recommend — overtesting causes harm through false positives, unnecessary biopsies, and patient anxiety
- Clearly delineate which provider is responsible for each component of follow-up to prevent both duplication and gaps
- Cancer survivors have elevated risk for cardiovascular disease, secondary cancers, and psychosocial distress — the SCP must address all three
- Reassess the SCP annually and update as guidelines change or new survivorship evidence emerges
- Include emergency contact information and "red flag" symptoms that should prompt urgent evaluation (new persistent pain, unexplained weight loss, new neurologic symptoms)
- Genetic counseling referral should be included in the SCP for patients who meet NCCN criteria but have not yet been tested