Should the development and use of survivorship care plans still be encouraged?
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Yes. The elimination of a requirement to quantify survivorship care plans does not negate their importance.
The barriers to implementation of care plans have been well-documented, resulting in limited success implementing these plans in oncology practices despite the standard introduced in 2012.
However, the CoC mandate is changing, and change brings opportunity. It is time to examine what we have been trying to accomplish with the implementation of survivorship care plans and how we have been doing so in our clinical settings. There is no doubt that we should be providing high-quality follow-up/survivorship care, which is part of good cancer care.
The implementation of care plans into everyday practice has been viewed as an enormous burden and, in the process, institutions and providers have looked at different ways to meet the standard. In some cases, the plan has been developed by someone other than the patient’s health care team. However, as part of good cancer care, it should be done by the team delivering care to the patient, when providing that care.
Survivorship care plans can be developed in a number of ways to accomplish the same end — and perhaps by thinking out of the box. After reviewing the encounter notes of numerous oncology providers, it became evident that in most cases a summary of the patient’s treatment was included in the encounter note, as well as an itemized plan of care for the patient. Providers were essentially outlining a plan of care with every return visit, creating a care plan that was shared with the patient.
The CoC mandate was for the development of care plans for patients at completion of treatment; however, the growing population of people living with a long-term history of cancer also requires thorough assessments at every follow-up visit, including documentation of the plan of care. The risk for potential late effects of treatment increases as patients age and as comorbidities that may be hereditary or related to health behaviors begin to manifest. In addition, we have learned many things about the outcome of different cancer treatments that were not described in the more distant past.
The change in the CoC standard merely eliminates the perhaps too-prescribed structure of care plans and the much-too-difficult-to-achieve numeric bar that was set for accreditation. Rather than “throwing the baby out with the bathwater,” providers and institutions should recognize the ways in which implementation of care plans has changed practice and strive to continue the practice of creating treatment summaries and plans of care in a way that works best for them in the practice setting.
The survivorship care plan movement provided us with a long-overdue push into an era of recognizing the need to provide more specialized follow-up/survivorship care, and we cannot go back. Survivorship care plans in some form remain an important part of cancer care for patients and providers alike.
Linda A. Jacobs, PhD, CRNP, FAAN, is director of development of cancer survivorship clinical programs, research and education at the Abramson Cancer Center of University of Pennsylvania, and a clinical professor of nursing at Penn’s School of Nursing. She can be reached at linda.jacobs@pennmedicine.upenn.edu.
No. Only in appropriate cases, which should include patients with stage IV metastatic cancer.
An estimated 16.9 million people with a history of cancer lived in the U.S. in 2019. Low-risk cancer survivors with early-stage disease do not need a formal care plan, although it is important to remind them of healthy lifestyle choices and following standard screening for other cancers as they age. Adult survivors of pediatric cancers tend to ignore their risks and not follow screening recommendations as noncancer survivors do in the general population.
However, nearly two-thirds of cancer survivors are aged 65 years and older, and these survivors experience one or more geriatric syndromes than older adults without cancer. Due to the increased potential for multiple comorbidities, this population of older survivors of metastatic disease definitely needs a care plan to support their multiple needs.
Advances in treatment options have led to many more patients with stage IV disease living longer lives — they are a new type of cancer survivor living with the chronic disease of cancer in addition to other comorbidities. Patients with advanced cancer experience feelings of vulnerability and uncertainty. Providing a focused, written care plan to reinforce information they have received during their medical visits has been shown to be helpful for these patients. Coordination with their PCPs by using a focused survivorship care plan for management of comorbidities and minimization of duplicate procedures can help to improve efficiency and manage costs for this complicated population.
This may sound incongruent with the common definition of survivorship care, where most follow-up occurs after completion of treatment with curative intent. However, if we recognize the reality today that people with advanced cancer continue treatment to continue living, then coordination of care is essential. This unique population needs focused survivorship care plans that provide resources and planning to meet the individual needs related to their continued care.
As we struggle to develop models of care for cancer survivors based on risk stratification, we are aware of the importance of meeting the complicated needs of this population. The high-risk category reflects chemotherapy history, amounts of radiation received, existing comorbidities and risk for long-term and late effects of treatment, including for those who received adjuvant therapy. The leading issue for these high-risk survivors is lack of communication.
Cancer survival is impacted by cancer type, stage of disease at diagnosis, insurance status, age and coexisting health conditions, as well as financial resources. It is essential that we as health care providers coordinate follow-up care to meet the complicated needs of these survivors. A focused survivorship care plan with follow-up care allows for assessment and treatment of their individual needs, including emotional and social needs so often not met for cancer survivors in general.
References:
American Cancer Society. Cancer Treatment & Survivorship Facts & Figures 2019-2021. Atlanta: American Cancer Society. 2019.
Jacobs, LA and Shulman LN. Lancet Oncol. 2017;doi:10.1016/S1470-2045(16)30386-2.
Mayer, DK, et al. Support Care Cancer. 2015;doi:10.1007/s00520-014-2586-4.
Mohile, SG, et al. J Clin Oncol. 2011;doi:10.1200/JCO.2010.31.6695.
Nekhlyudov, L, et al. J Natl Cancer Inst. 2019;doi:10.1093/jnci/djz089.
Denice Economou, PhD, CNS, CHPN, is a senior research scientist in the department of nursing research and education at City of Hope. She also is the intervention nurse for an RO1 providing survivorship telehealth visits to survivors of stage I to stage III colorectal and lung cancer. She can be reached at deconomou@coh.org.
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