By Cindy C. Parman, CPC, CPC-H, RCC
The goals of cancer treatment include curing the cancer (when possible), prolonging patient survival, and providing the highest possible quality of life both during and after treatment. In cancer, survivorship focuses on the health and life of a person with cancer post-treatment - beyond the diagnosis and treatment phases - until the end of life. Survivorship means different things to different patients, but it generally describes the process of living with, through, and beyond cancer. Current projections estimate that there will be more than 18 million cancer survivors in the United States by 2024. These increasing numbers of cancer survivors have directed a greater focus to the care of cancer patients after treatment.
According to Cancer Treatment & Survivorship Facts & Figures 2016-2017, there are at least three phases of cancer survival:
- The time from diagnosis to the end of initial treatment;
- The transition from treatment to extended survival; and
- Long-term survival.
In addition, survivorship encompasses a range of cancer experiences and trajectories, including:
- Living cancer-free after treatment for the remainder of life.
- Living cancer-free after treatment for many years, but experiencing one or more serious, late complications of treatment.
- Living cancer-free after treatment for many years, but dying after a late recurrence.
- Living cancer-free after the first cancer is treated, but developing a second cancer.
- Living with intermittent periods of active disease requirement treatment.
- Living with cancer continuously, with or without treatment, without a disease-free period.
After the active treatment phase is complete, patients may need to continue supportive therapies, surveillance testing, and monitoring for treatment-related sequelae. According to the American Cancer Society, studies indicate that survivorship care plans (SCP) help survivors feel more informed, make healthier diet and exercise choices, and increase the likelihood that patients will share this information with their healthcare team members.
An SCP is a detailed plan provided to a patient when active treatment ends, based on the specific type of cancer and the actual treatment received. According to the American Cancer Society, the Institute of Medicine issued a report in 2006 recommending that every cancer patient receive an individualized survivorship care plan that includes guidelines for monitoring and maintaining their health. In general, an SCP:
- Documents a concise history of the patient's cancer treatment (all modalities, including surgery, chemotherapy, immunotherapy and radiotherapy);
- Provides a platform for patient dialog with all members of the care team, specifically regarding surveillance for recurrence and/or cancer spread (e.g., primary care, medical oncology, surgeon, radiation oncologist, other medical specialists);
- Establishes follow-up care management services [e.g., what tests will be performed, which provider(s) will continue to evaluate the patient, the timing of diagnostic and follow-up services];
- Discusses anticipated course of recovery, existing or potential short-term and long-term side effects, and how to manage them or when to contact the healthcare provider (quality of life changes);
- Provides tools and directions for patient self-care, including physical, emotional and practical issues (e.g., legal and financial needs, psychosocial issues, access to healthcare, referral to supportive care providers, nutrition, physical therapy, lifestyle behavior modification counseling, support groups, and other cancer information resources)'
- Defines goals for achieving wellness.
The American College of Surgeons Commission on Cancer (CoC) issued a mandate that accredited cancer programs provide SCPs for all curative cancer patients by 2019 to maintain accreditation. These CoC requirements may necessitate changes for radiation oncologists and accredited cancer centers; a March 2014 survey of ASTRO members indicates that only 40 percent of radiation oncologists provided SCPs for curative treatment, and only 19 percent provided an SCP for palliative patients. In addition, ASTRO published a survivorship template in 2015 to help standardize and streamline the creation of patient-focused plans for long-term cancer survivor care following radiation therapy.
While radiation oncologists have traditionally created a radiotherapy treatment summary, a survivorship care plan goes beyond the data in this document. Treatment completion notes were generally created for review by other physicians, with emphasis on the technical details of radiotherapy. The audience for the SCP is the patient and caregiver(s); as a result, there is more emphasis on future care needs.
In summary, a survivorship care plan is intended to educate cancer survivors, improve communication between oncologists and primary care providers, and facilitate coordinated post-treatment health care. In addition, delivery of an SCP to a patient provides an opportunity for the patient to indicate additional areas of concern beyond treatment and toxicity, which can generate necessary referrals and support. Given the significant treatment role and unique toxicities of radiotherapy, a need exists to include this information in a comprehensive survivorship care plan. In the words of Karen Karls, a Minnesota cancer survivor, "A survivor care plan is for the future - an empowering reminder that you still have control of your life. Cancer happened to you, but it does not have to define who you are."