The growing number of cancer survivors challenges healthcare organizations to develop programs that support survivors' transition from active treatments to survivorship care. Many individuals and families continue to face complicated care issues resulting from cancer diagnosis and side effects long after completion of their treatments. This article describes a model of a survivorship care plan, Cancer Treatment Summary and Follow-Up Care Plan, piloted in an outpatient clinical setting in a community hospital for patients with breast cancer. The plan can be expanded to include other cancer types. The intent of the survivorship care plan is to strengthen the care connections and coordination of services for survivors of breast cancer to ensure that continuing care needs are met during the survivorship phase of the cancer trajectory. The survivorship care plan is a unique opportunity for oncology nurses to be catalysts for the interdisciplinary interactions that are required to develop survivorship care plans and to implement a change in oncology nursing practice. The intervention shifts the paradigm of cancer survivorship care from an acute care medical model to a wellness model for cancer survivors in the clinical setting.
Ries, L. A. G., Melbert, D., Krapcho, M., Mariotto, A., Miller, B. A., Feuer, E. J., et al. (Eds). (n.d.). SEER cancer statistics review, 1975-2004. Bethesda, MD: National Cancer Institute. Retrieved May 6, 2008, from http://seer.cancer.gov/csr/1975_2004/ <a target="_blank" href='http://seer.cancer.gov/csr/1975_2004/'>http://seer.cancer.gov/csr/1975_2...
Rooney, M., & Wald, A. (2007). Interventions for the management of weight and body composition changes in women with breast cancer. <i>Clinical Journal of Oncology Nursing</i>, 11(1), 41-52.
Rowland, J., Hewitt, M., & Ganz, P. (2006). Cancer survivorship: A new challenge in quality cancer care. <i>Journal of Clinical Oncology</i>, 24(32), 5101-5104.
Rowland, J., & Yancik, R. (2006). Cancer survivorship: The interfacing of aging, comorbidity, and quality care. <i>Journal of the National Cancer Institute</i>, 98(8), 504-505.
Advisory Board. (2006). <i>Oncology roundtable: Disciplined growth strategy</i>. Washington, DC: Author.
American Cancer Society. (2006). <i>Cancer facts and figures 2006</i>. Atlanta, GA: Author.
Aziz, N. (2006). Foreword. <i>American Journal of Nursing</i>, 106(3), 3.
Boyle, D. (2006). Survivorship. <i>Clinical Journal of Oncology Nursing</i>, 10(3), 407-416.
Carroll-Johnson, R. (2001). Redefining interdisciplinary practice. <i>Oncology Nursing Forum</i>, 28(4), 619.
Centers for Disease Control and Prevention. (2004). Cancer survivorship—United States, 1971-2001. <i>Morbidity and Mortality Weekly Report</i>, 53(24), 526-529.
Cox, K., & Wilson, E. (2003). Follow-up for people with cancer: Nurse-led services and telephone interventions. <i>Journal of Advanced Nursing</i>, 43(1), 51-61.
Earle, C. C. (2006). Failing to plan is planning to fail: Improving the quality of care with survivorship care plans. <i>Journal of Clinical Oncology</i>, 24(32), 5112-5116.
Feifer, C., Ornstein, S., Nietert, P., & Jenkins, R. (2001). System supports for chronic illness care and their relationship to clinical outcomes. <i>Topics in Health Information Management</i>, 22(2), 65-72.
Ferrell, B., Virani, R., Smith, S., & Juarez, G. (2003). The role of oncology nursing to ensure quality care for cancer survivors: A report commissioned by the National Cancer Policy Board and Institute of Medicine [Online exclusive]. <i>Oncology Nursing Forum</i>, 30(1), E1-11. Retrieved December 10, 2006, from http://www.ons.org/publications/journals/ONF/Volume30/Issue1/pdf/32.pdf <a target="_blank" href='http://www.ons.org/publications/journals/ONF/Volume30/Issue1/pdf/32.pdf'...
Ganz, P. (2005). A teachable moment for oncologists: Cancer survivors, 10 million strong and growing! <i>Journal of Clinical Oncology</i>, 23(24), 5458-5460.
Ganz, P. (2006). Monitoring the physical health of cancer survivors: A survivorship-focused medical history. <i>Journal of Clinical Oncology</i>, 24(32), 5105-5111.
Gill, K., Mishel, M., Belyea, M., Germino, B., Porter, L., LaNey, I., et al. (2004). Triggers of uncertainty about recurrence and long-term treatment side effects in older African American and Caucasian breast cancer survivors. <i>Oncology Nursing Forum</i>, 31(3), 633-638.
Haylock, P. (2006). The shifting paradigm of cancer care: The many needs of cancer survivors are starting to attract attention. <i>American Journal of Nursing</i>, 106(3, Suppl.), 16-19.
Hillner, B. E., Ingle, J. N., Chlebowski, R. J., Gralow, J., Yee, G. C., Janjan, N. A, et al. (2003). American Society of Clinical Oncology 2003 update on the role of bisphosphonates and bone heath issues in women with breast cancer. <i>Journal of Clinical Oncology</i>, 21(21), 4042-4057.
Houldin, A., Curtiss, C., & Haylock, P. (2006). Executive summary: The state of science on nursing approaches to managing late and long-term sequelae of cancer and cancer treatment. <i>American Journal of Nursing</i>, 106(3, Suppl.), 6-11.
Institute of Medicine & National Research Council. (2006). <i>From cancer patient to cancer survivor: Lost in transition</i>. Washington, DC: National Academies Press.
Joint Commission. (2007). National patient safety goals. Retrieved February 10, 2007, from <a target="_blank" href='http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/...
Lewis, L. (2006). Discussion and recommendations: Addressing barriers in the management of cancer survivors. An invitational symposium identifies obstacles and ways to overcome them. <i>American Journal of Nursing</i>, 106(3), 91-95.
Mahon, S. (2007). <i>Site-specific cancer series: Breast cancer</i>. Pittsburgh, PA: Oncology Nursing Society.
Memorial Healthcare. (2006). <i>Cancer registry data</i>. Owosso, MI: Author.
National Cancer Institute. (n.d.). Understanding breast changes: A health guide for women. Retrieved January 5, 2007, from <a target="_blank" href='http://www.cancer.gov/cancertopics/understanding-breast-changes/allpages...
National Cancer Institute. (2007). Estimated U. S. cancer prevalence. Retrieved January 29, 2007, from <a target="_blank" href='http://cancercontrol.cancer.gov/ocs/prevalence/prevalence.html#survivor'...
National Cancer Institute. (2008). Cancer control and prevalence sciences: Estimated cancer survivors over time. Retrieved April 13, 2008, from <a target="_blank" href='http://cancercontrol.cancer.gov/ocs/prevalence/prevalence.html#survivor'...
National Comprehensive Cancer Network. (2006). <i>NCCN Clinical Practice Guidelines in Oncology<sup>™</sup>: Breast cancer guidelines</i> [v 2.2008]. Retrieved November 8, 2006, from <a target="_blank" href='http://www.nccn.org/professionals/physician_gls/PDF/breast.pdf'>http://w...
National Institutes of Health. (2006). <i>Cancer survivorship figures</i>. Retrieved January 12, 2007, from <a target="_blank" href='http://cancercontrol.cancer.go/ocs/ocs_factsheet.pdf'>http://cancercontr...
O'Hair, D., Villagran, M., Wittenberg, E., Brown, K., Ferguson, M., Hall, H., et al. (2003). Cancer survivorship and agency model: Implications for patient choice, decision making, and influence. <i>Health Communication</i>, 15(2), 193-202.
President's Cancer Panel. (2004). <i>Living beyond cancer: Finding the new balance</i>. Retrieved November 8, 2006, from <a target="_blank" href='http://deainfo.nci.nih.gov/advisory/pcp/pcp03-04rpt/Survivorship.pdf'>ht...
Sohn, R. (2007). Patient-centered cancer care. <i>Oncology Issues</i>, 22(1), 40-43.
Stille, C., Jerant, A., Bell, D., Meltzer, D., & Elmore, J. (2005). Coordinating care across diseases, settings, and clinicians: A key role for the generalist in practice. <i>Annals in Internal Medicine</i>, 142(8), 700-708.
Thewes, B., Butow, P., Girgis, A., & Pendlebury, S. (2004). The psychosocial needs of breast cancer survivors: A qualitative study of the shared and unique needs of younger versus older survivors. <i>Psycho-Oncology</i>, 13(3), 177-189.
Vivar, C., & McQueen, A. (2005). Informational and emotional needs of long-term survivors of breast cancer. <i>Journal of Advanced Nursing</i>, 51(5), 520-528.
Wilson, S., Anderson, M., & Meischke, H. (2000). Meeting the needs of rural breast cancer survivors: What still needs to be done? <i>Journal of Women's Health and Gender-Based Medicine</i>, 9(6), 667-677.