Implementing Survivorship Care Plans for Colon Cancer Survivors

Deborah K. Mayer

Adrian Gerstel

AnnMarie Walton

Tammy Triglianos

Teresa E. Sadiq

Nikki A. Hawkins

Janine M. Davies

survivorship care plans, colon cancer, communication, transitions, survivorship
ONF 2014, 41(3), 266-273. DOI: 10.1188/14.ONF.266-273

Purpose/Objectives: To evaluate the feasibility, usability, and satisfaction of a survivorship care plan (SCP) and identify the optimum time for its delivery during the first 12 months after diagnosis.

Design: Prospective, descriptive, single-arm study.

Setting: A National Cancer Institute-designated cancer center in the southeastern United States.

Sample: 28 nonmetastatic colon cancer survivors within the first year of diagnosis and their primary care physicians (PCPs).

Methods: Regular screening identified potential participants who were followed until treatment ended. An oncology certified nurse developed the JourneyForward™ SCP, which then was delivered to the patient by the oncology nurse practitioner (NP) during a routine follow-up visit and mailed to the PCP.

Main Research Variables: Time to complete, time to deliver, usability, and satisfaction with the SCP.

Findings: During one year, 75 patients were screened for eligibility, 34 SCPs were delivered, and 28 survivors and 15 PCPs participated in the study. It took an average of 49 minutes to complete a surgery SCP and 90 minutes to complete a surgery plus chemotherapy SCP. Most survivors identified that before treatment ended or within the first three months was the preferred time to receive an SCP.

Conclusions: The SCPs were well received by the survivors and their PCPs, but were too time and labor intensive to track and complete.

Implications for Nursing: More work needs to be done to streamline processes that identify eligible patients and to develop and implement SCPs. Measuring outcomes will be needed to demonstrate whether SCPs are useful or not.

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    American College of Surgeons. (2012). Cancer Program Standards 2012: Ensuring patient-centered care. Retrieved from
    Baravelli, C., Krishnasamy, M., Pezaro, C., Schofield, P., Lotfi-Jam, K., Rogers, M., … Jefford, M. (2009). The views of bowel cancer survivors and health care professionals regarding survivorship care plans and post treatment follow up. Journal of Cancer Survivorship: Research and Practice, 3, 99-108. doi:10.1007/s11764-009-0086-1
    Benson, A.B., Arnoletti, J.P., Bekaii-Saab, T., Chan, E., Chen, Y.J., Choti, M.A., … Willett, C. (2011). Colon cancer. Journal of the National Comprehensive Cancer Network, 9, 1238-1290.
    Birken, S.A., Mayer, D.K., & Weiner, B.J. (2013). Survivorship care plans: Prevalence and barriers to use. Journal of Cancer Education, 28, 290-296. doi:10.1007/s13187-013-0469-x
    Brooke, J. (1996). SUS: A ‘quick and dirty’ usabilty scale. In P.W. Jordan, B. Thomas, B. Weerdmeester, & A. McClelland (Eds.), Usability evaluation in industry (pp. 189-194). London, UK: Taylor and Francis.
    Cheung, W.Y., Neville, B.A., Cameron, D.B., Cook, E.F., & Earle, C.C. (2009). Comparisons of patient and physician expectations for cancer survivorship care. Journal of Clinical Oncology, 27, 2489-2495. doi:10.1200/JCO.2008.20.3232
    Cheung, W.Y., Neville, B.A., & Earle, C.C. (2010). Associations among cancer survivorship discussions, patient and physician expectations, and receipt of follow-up care. Journal of Clinical Oncology, 28, 2577-2583. doi:10.1200/JCO.2009.26.4549
    Chubak, J., Tuzzio, L., Hsu, C., Alfano, C.M., Rabin, B.A., Hornbrook, M.C., … Nekhlyudov, L. (2012). Providing care for cancer survivors in integrated health care delivery systems: Practices, challenges, and research opportunities. Journal of Oncology Practice, 8, 184-189.
    Cooper, G.S., & Doug Kou, T. (2008). Underuse of colorectal cancer screening in a cohort of Medicare beneficiaries. Cancer, 112, 293-299. doi:10.1002/cncr.23176
    Davies, J.M., Batuyong, E., Lupichuk, S., Hilsden, R.J., Eliasiw, M., & Easaw, J. (2012). Cohort study evaluating the impact of a discharge letter (DL) compared with usual care on adherence to surveillance following treatment for stage II/III colorectal cancer (CRC) [Abstract]. Poster presentation at the 2012 Gastrointestinal Cancers Symposium. San Francisco, CA.
    Desch, C.E., Benson, A.B., Somerfield, M.R., Flynn, P.J., Krause, C., Loprinzi, C.L., … Petrelli, N.J. (2005). Colorectal cancer surveillance: 2005 update of an American Society of Clinical Oncology practice guideline. Journal of Clinical Oncology, 23, 8512-8519.
    Earle, C.C. (2007). Long term care planning for cancer survivors: A health services research agenda. Journal of Cancer Survivorship: Research and Practice, 1, 64-74. doi:10.1007/s11764-006-0003-9
    Earle, C.C., & Neville, B.A. (2004). Under use of necessary care among cancer survivors. Cancer, 101, 1712-1719. doi:10.1002/cncr.20560
    Edwards, B.K., Howe, H.L., Ries, L.A., Thun, M.J., Rosenberg, H.M., Yancik, R., … Fiegal, E.G. (2002). Annual report to the nation on the status of cancer, 1973-1999, featuring implications of age and aging on U.S. cancer burden. Cancer, 94, 2766-2792.
    Faul, L.A., Rivers, B., Shibata, D., Townsend, I., Cabrera, P., Quinn, G.P., Jacobsen, P.B. (2012). Survivorship care planning in colorectal cancer: Feedback from survivors and providers. Journal of Psychosocial Oncology, 30, 198-216. doi:10.1080/07347332.2011.651260
    Faul, L.A., Shibata, D., Townsend, I., & Jacobsen, P.B. (2010). Improving survivorship care for patients with colorectal cancer. Cancer Control, 17, 35-43.
    Figueredo, A., Rumble, R.B., Maroun, J., Earle, C.C., Cummings, B., McLeod, R., … Zwaal, C. (2003). Follow-up of patients with curatively resected colorectal cancer: A practice guideline. BMC Cancer, 3, 26. doi:10.1186/1471-2407-3-26
    Ganz, P.A. (2009). Survivorship: Adult cancer survivors. Primary Care, 36, 721-741. doi:10.1016/j.pop.2009.08.001
    Grunfeld, E., & Earle, C.C. (2010). The interface between primary and oncology specialty care: Treatment through survivorship. Journal of the National Cancer Institute. Monographs, 2010(40), 25-30. doi:10.1093/jncimonographs/lgq002
    Grunfeld, E., Julian, J.A., Pond, G., Maunsell, E., Coyle, D., Folkes, A., … Levine, M.N. (2011). Evaluating survivorship care plans: Results of a randomized, clinical trial of patients with breast cancer. Journal of Clinical Oncology, 29, 4755-4762. doi:10.1200/JCO.2011.36.8373
    Haq, R., Heus, L., Baker, N.A., Dastur, D., Leung, F.H., Leung, E., … Parsons, J.A. (2013). Designing a multifaceted survivorship care plan to meet the information and communication needs of breast cancer patients and their family physicians: Results of a qualitative pilot study. BMC, 13, 76. doi:10.1186/1472-6947-13-76
    Hargraves, J.L., Hays, R.D., & Cleary, P.D. (2003). Psychometric properties of the consumer assessment of health plans study (CAHPS) 2.0 adult core survey. Health Services Research, 38, 1509-1527.
    Hershman, D.L., Greenlee, H., Awad, D., Kalinsky, K., Maurer, M., Kranwinkel, G., … Crew, K.D. (2013). Randomized controlled trial of a clinic-based survivorship intervention following adjuvant therapy in breast cancer survivors. Breast Cancer Research and Treatment, 138, 795-806. doi:10.1007/s10549-013-2486-1
    Hewitt, M., & Ganz, P. (2007). Implementing cancer survivorship care planning: Workshop summary. Washington, DC: National Academies Press.
    Hewitt, M., Greenfield, S., & Stovall, E. (Eds.). (2005). From cancer patient to cancer survivor: Lost in transition. Washington, DC: National Academies Press.
    Hewitt, M., & Rowland, J.H. (2002). Mental health service use among adult cancer survivors: Analyses of the national health interview survey. Journal of Clinical Oncology, 20, 4581-4590.
    Hewitt, M.E., Bamundo, A., Day, R., & Harvey, C. (2007). Perspectives on post-treatment cancer care: Qualitative research with survivors, nurses, and physicians. Journal of Clinical Oncology, 25, 2270-2273. doi:10.1200/JCO.2006.10.0826
    Hill-Kayser, C.E., Vachani, C., Hampshire, M.K., Jacobs, L.A., & Metz, J.M. (2009). Utilization of Internet-based survivorship care plans by lung cancer survivors. Clinical Lung Cancer, 10, 347-352.
    Hill-Kayser, C.E., Vachani, C.C., Hampshire, M.K., Di Lullo, G., Jacobs, L.A., & Metz, J.M. (2013). Impact of Internet-based cancer survivorship care plans on health care and lifestyle behaviors. Cancer, 119, 3854-3860. doi:10.1002/cncr.28286; 10.1002/cncr.28286
    Howell, D., Hack, T.F., Oliver, T.K., Chulak, T., Mayo, S., Aubin, M., … Sinclair, S. (2012). Models of care for post-treatment follow-up of adult cancer survivors: A systematic review and quality appraisal of the evidence. Journal of Cancer Survivorship: Research and Practice, 6, 359-371. doi:10.1007/s11764-012-0232-z
    Jacobs, L.A., Palmer, S.C., Schwartz, L.A., DeMichele, A., Mao, J.J., Carver, J., … Meadows, A.T. (2009). Adult cancer survivorship: Evolution, research, and planning care. CA: A Cancer Journal for Clinicians, 59, 391-410. doi:10.3322/caac.20040
    Kantsiper, M., McDonald, E.L., Geller, G., Shockney, L., Snyder, C., & Wolff, A.C. (2009). Transitioning to breast cancer survivorship: Perspectives of patients, cancer specialists, and primary care providers. Journal of General Internal Medicine, 24(Suppl. 2), S459-S466. doi:10.1007/s11606-009-1000-2
    Lawler, S., Spathonis, K., Masters, J., Adams, J., & Eakin, E. (2011). Follow-up care after breast cancer treatment: Experiences and perceptions of service provision and provider interactions in rural Australian women. Supportive Care in Cancer, 19, 1975-1982. doi:10.1007/s00520-010-1041-4
    Lewis, R.A., Neal, R.D., Hendry, M., France, B., Williams, N.H., Russell, D., … Wilkinson, C. (2009). Patients' and healthcare professionals' views of cancer follow-up: Systematic review. British Journal of General Practice, 59, e248-e259. doi:10.3399/bjgp09X453576
    Mayer, D.K., Gerstel, A., Leak, A.N., & Smith, S.K. (2012). Patient and provider preferences for survivorship care plans. Journal of Oncology Practice, 8, e80-e86. doi:10.1200/JOP.2011.000401
    McCabe, M.S., & Jacobs, L. (2008). Survivorship care: Models and programs. Seminars in Oncology Nursing, 24, 202-207.
    Merport, A., Lemon, S.C., Nyambose, J., & Prout, M.N. (2012). The use of cancer treatment summaries and care plans among Massachusetts physicians. Supportive Care in Cancer, 20, 1579-1583. doi:10.1007/s00520-012-1458-z
    National Cancer Institute. (2014). SEER Stat Fact Sheets: Colon and rectum cancer. Retrieved from
    Nissen, M.J., Beran, M.S., Lee, M.W., Mehta, S.R., Pine, D.A., & Swenson, K.K. (2007). Views of primary care providers on follow-up care of cancer patients. Family Medicine, 39, 477-482.
    Nissen, M.J., Tsai, M.L., Blaes, A.H., Swenson, K.K., & Koering, S. (2013). Effectiveness of treatment summaries in increasing breast and colorectal cancer survivors' knowledge about their diagnosis and treatment. Journal of Cancer Survivorship: Research and Practice, 7, 211-218. doi:10.1007/s11764-012-0261-7
    O'Malley, A.S., & Cunningham, P.J. (2009). Patient experiences with coordination of care: The benefit of continuity and primary care physician as referral source. Journal of General Internal Medicine, 24, 170-177. doi:10.1007/s11606-008-0885-5
    Parry, C., Kent, E.E., Forsythe, L.P., Alfano, C.M., & Rowland, J.H. (2013). Can't see the forest for the care plan: A call to revisit the context of care planning. Journal of Clinical Oncology, 31, 2651-2653. doi:10.1200/JCO.2012.48.4618
    Potosky, A.L., Han, P.K., Rowland, J., Klabunde, C.N., Smith, T., Aziz, N., … Stefanek, M. (2011). Differences between primary care physicians' and oncologists' knowledge, attitudes and practices regarding the care of cancer survivors. Journal of General Internal Medicine, 26, 1403-1410. doi:10.1007/s11606-011-1808-4
    Rowland, J.H. (2008). What are cancer survivors telling us? Cancer Journal, 14, 361-368. doi:10.1097/PPO.0b013e31818ec48e
    Salz, T., Oeffinger, K.C., Lewis, P.R., Williams, R.L., Rhyne, R.L., & Yeazel, M.W. (2012). Primary care providers' needs and preferences for information about colorectal cancer survivorship care. Journal of the American Board of Family Medicine, 25, 635-651. doi:10.3122/jabfm.2012.05.120083
    Salz, T., Oeffinger, K.C., McCabe, M.S., Layne, T.M., & Bach, P.B. (2012). Survivorship care plans in research and practice. CA: A Cancer Journal for Clinicians, 62, 101-117. doi:10.3322/caac.20142
    Sauro, J. (2011). A practical guide to the system usability scale: Background, benchmarks, and best practices. Denver, CO: Measuring Usability.
    Schlairet, M., Heddon, M.A., & Griffis, M. (2010). Piloting a needs assessment to guide development of a survivorship program for a community cancer center. Oncology Nursing Forum, 37, 501-508. doi:10.1188/10.ONF.501-508
    Schrag, D. (2006). The cancer treatment summary: Changing the culture of documentation to facilitate high quality cancer care. Retrieved from
    Skolarus, T.A., Holmes-Rovner, M., Northouse, L.L., Fagerlin, A., Garlinghouse, C., Demers, R.Y., … Wei, J.T. (2011). Primary care perspectives on prostate cancer survivorship: Implications for improving quality of care. Urologic Oncology, 31, 727-732. doi:10.1016/j.urolonc.2011.06.002
    Snyder, C.F., Earle, C.C., Herbert, R.J., Neville, B.A., Blackford, A.L., & Frick, K.D. (2008a). Preventive care for colorectal cancer survivors: A 5-year longitudinal study. Journal of Clinical Oncology, 26, 1073-1079. doi:10.1200/JCO.2007.11.9859
    Snyder, C.F., Earle, C.C., Herbert, R.J., Neville, B.A., Blackford, A.L., & Frick, K.D. (2008b). Trends in follow-up and preventive care for colorectal cancer survivors. Journal of General Internal Medicine, 23, 254-259. doi:10.1007/s11606-007-0497-5
    Stricker, C.T., Jacobs, L.A., & Palmer, S.C. (2012). Survivorship care plans: An argument for evidence over common sense. Journal of Clinical Oncology, 30, 1392-1393. doi:10.1200/JCO.2011.40.7940
    Stricker, C.T., Jacobs, L.A., Risendal, B., Jones, A., Panzer, S., Ganz, P.A., … Palmer, S.C. (2011). Survivorship care planning after the Institute of Medicine recommendations: How are we faring? Journal of Cancer Survivorship: Research and Practice, 5, 358-370. doi:10.1007/s11764-011-0196-4
    Watson, E.K., Sugden, E.M., & Rose, P.W. (2010). Views of primary care physicians and oncologists on cancer follow-up initiatives in primary care: An online survey. Journal of Cancer Survivorship: Research and Practice, 4, 159-166. doi:10.1007/s11764-010-0117-y
    Wolin, K.Y., Colditz, G.A., & Proctor, E.K. (2011). Maximizing benefits for effective cancer survivorship programming: Defining a dissemination and implementation plan. Oncologist, 16, 1189-1196. doi:10.1634/theoncologist.2011-0054