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Survivorship Care

"An individual is considered a cancer survivor from the time of diagnosis, through the balance of his or her life. Family members, friends, and caregivers are also impacted by the survivorship experience and are therefore included in this definition."

- National Cancer Institute (NCI) Office of Cancer Survivorship (adapted from the National Coalition for Cancer Survivorship)

In 2006 the Institute of Medicine (IOM) influential report From Cancer Patient to Cancer Survivor: Lost in Transition focused attention on unmet needs of the nation's growing population of cancer survivors. Included in the report's call to action was the recommendation "that each cancer patient receive a 'survivorship care plan.' "

Since the report's publication, the population of cancer survivors in the U.S. has grown from 10 million to nearly 17 million. This number is expected to reach 22.1 million by 2030.1

In late 2019, the American College of Surgeons Commission on Cancer (CoC) released Optimal Resources for Cancer Care: 2020 Standards for cancer program accreditation. The newly revised standards went into effect in January 2020; however, many of the new standards are phased in, including Standard 4.8 Survivorship Program.2 This standard requires that the cancer program's cancer committee "oversee the development and implementation of a survivorship program directed at meeting the needs of cancer patients treated with curative intent." With this phased-in standard, the CoC calls for a coordinator of the survivorship program (Standard 2.1), and the development of a survivorship program team composed of multidisciplinary cancer care professionals (e.g., physicians, nurses, advanced practice providers, social workers, nutritionists, physical therapists, and other allied health professionals). This team is responsible for determining the services and programs - available on-site or by referral - required to meet the needs of cancer survivors. The CoC includes survivorship care plans as among the services a survivorship program may choose to include.

Although many cancer programs and practices have initiated integration of survivorship care plans into the continuum of care, multiple facets of the current healthcare delivery system can make the process of developing and delivering these plans an ongoing challenge.

Despite obstacles, survivorship care remains an important area of ongoing discussion not only because the population of survivors continues to grow, but also new treatment paradigms are emerging, requiring fresh perspectives on the post-treatment needs of patients. In 2018, the National Academy of Medicine (formerly the Institute of Medicine) published proceedings from its workshop on Long-Term Survivorship Care After Cancer Treatment.

ACCC is pleased to offer a resource that explores the new frontier of Survivorship Care Plans for Patients Receiving Immunotherapy. The publication describes processes for developing survivorship care plans (SCPs) for patients treated with immunotherapy, effective practices in SCP design, and considerations for SCP delivery for this patient population.
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Sources:

  1. American Cancer Society. Cancer Treatment & Survivorship: Facts & Figures 2019-2021. Atlanta: American Cancer Society; 2019. Last accessed January 8, 2020.
  2. American College of Surgeons. Commission on Cancer. Optimal Resources for Cancer Care: 2020 Standards. Last accessed January 10, 2020.

 

In 2007-2008 ACCC conducted an educational initiative to raise awareness about the importance of comprehensive survivorship programs. ACCC President (2007-2008) Richard B. Reiling, MD, FACS, selected survivorship as his president's theme, and ACCC developed Comprehensive Survivorship Services: A practical guide for community cancer centers. 

Publication and distribution of ACCC's Comprehensive Survivorship Services: A Practical Guide for Community Cancer Centers was made possible through a sponsorship funded by AstraZeneca and Abraxis Oncology. 

 

Survivorship Resources

Featured Programs

Elevating Survivorship
ACCC has partnered with the National Coalition for Cancer Survivorship (NCCS) on the Elevating Survivorship project. ACCC has launched a web-based survey to learn about gaps in survivorship care delivery, technical support needed to improve survivorship care, and unmet and evolving survivorship care needs of patients who have been treated with immunotherapy.
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Let’s Be Clear: Communicating to Improve the Patient Experience
With this education initiative ACCC seeks to help cancer programs across the country to improve survivorship programming through the application of the health literacy principles.
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ACCC Metastatic Breast Cancer Project
While breast cancer is a high-profile disease, receiving significant private and public research funding and focused awareness and prevention initiatives, patients with metastatic breast cancer face unique challenges. ACCC has identified these 6 effective principles for patient support.
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From the ACCCBuzz Blog

From Oncology Issues

  • Effective Approaches to Address Transitions
    Anna Weiss, Jocelyn Bushart, Kristina Galton, Carli Kotula, Crystal Regis, and Alissa Huston
    With more and more patients being diagnosed with breast cancer and an improved prognosis for those living with the disease, there’s a clear need to find ways to offset high patient volumes while maintaining high-quality care for longer-term survivors.
  • The Impact of the Living Well After Cancer Program on Multiple Indicators of Wellness and Quality of Life
    By Nouf Alhomaidhi, MPH, et al.
    This study evaluated the effects of regular physical activity on the physical health, psychosocial wellness, and quality of life of cancer survivors.
  • Collaborative Care: A Model for Embedding Counseling in Oncology and Palliative Care
    By Earon Lehning
    Embedding counseling services into oncology and palliative care across 6 clinic locations landed this program a 2023 ACCC Innovator Award. Learn how this model allows patients to receive psychosocial care from treatment through survivorship.
  • Views: The Impact and Importance of a Care Coordinator in Community Oncology
    By Wendy Collins
    The importance of care coordination in managing the adverse effects of cancer treatment and navigating patient challenges such as emotional distress, isolation, financial toxicity, and lower quality of life.
  • Therapeutic Art: Transforming Self-Awareness for Those Impacted by Cancer
    By Vicki Mackie, Xinyi Yang, MSPH, Alex Kaizer, PhD, and Carlin Callaway, DNP
    This Colorado-based nonprofit organization offers free therapeutic art sessions to patients with cancer, their caregivers, and long-time cancer survivors.
  • Supportive Oncology in Lung Cancer: Program Development for Patients and Care Partners
    By Dori Beeler, PhD, et al.
    This study at Atrium Health, Levine Cancer Institute, highlights the needs of patients with lung cancer and their care partners.
  • Addressing Social Determinants of Health through a Medical-Legal Partnership
    Allison L. Held and Molly Hunold
    Through a collaboration between legal and healthcare professionals, this Virginia based medical-legal partnership assists patients with cancer resolve social and environmental factors that contribute to health disparities.
  • Calm Minds and Grateful Hearts
    Chidi Ike
    An interview with Kathyrn Smolinski, MSW, JD on the development and implementation of the medical-legal partnership between Wayne State University Law School and the Karmanos Cancer Institute.
  • Views: Expressing Life’s Inexplicable Events Through Art
    By Susan Patricia Cooper, ATR-BC, LCAT
    Through art therapy, patients with cancer can cope with the adverse events they may experience during treatment or in their daily lives.
  • Population Health Navigators: An Innovative Approach for Supporting Underserved Patients
    Carla Strom, MLA
    A trailblazing Winston-Salem based cancer center successfully created and developed the role of a population health navigator to address the unique needs of various underserved communities.
  • Pre- and Post-treatment Clinic: Providing Psychosocial Care from Diagnosis to Survivorship
    Jennifer Hancock, PSYD, and Carrie Wines-Larch, BSN, RN, ONN-CG
    Charleston Area Medical Center Cancer Center is the largest cancer program in Southern West Virginia. The cancer center opened a new treatment clinic to offer pre- and post-treatment visits to better help patients navigate their cancer journey.
  • Improving Cancer Care Teamwork
    Elizabeth H. Lazzara, Joseph R. Keebler, Logan M. Gisick, Kimberly N. Williams, Stephanie Zajac, and Jillian Gunther
    The absence of an optimal cancer care coordination model coupled with the vast network of providers involved in cancer care, necessitates the implementation of key strategies to strengthen care coordination.
  • Living Well After Cancer
    By Gabrielle Riazi, Mike Alpert, Sarah Flores, Danielle Kline, Haley Allen, Aditi Vyas, Denise Johnson, and Jessica Clague DeHart
    This pilot study aimed to determine the efficacy of a community-based wellness program offered to patients outside of the clinical setting.
  • Views: Fertility Preservation for Women with Cancer
    James Grifo, MD, PHD
    Advancements in reproductive science has provided more options for women to take greater control of their reproductive future.
  • Views: Philanthropy Funding Oncology Supportive Care Services
    By Jamie Arens, MSW, CSW-PIP
    Philanthropy is a way to start supportive care programs and other needed services.
  • Filling the Gap APP Utilization to Meet Care Needs in Oncology
    By Ellen R. Miller, MSN, et al.
    Cancer prevalence is increasing, and there is a gap between the growing number of patients and the number of oncology providers. Effective use of advanced practice providers (APPs) can help bridge this care gap.
  • Patients with Cancer, Comorbidities, and No Primary Care Provider
    Debra Delaney, MSN, FNP-BC, et al.
    Embedding a primary care provider in oncology helps on program soar to new heights.
  • An Investigation of Self-Determined Work Motivation Among Young Adult Survivors of Central Nervous System Cancer
    Chelsea E. Greco, PhD, et al.
    This study looked at how work motivation can impact career readiness, core self-evaluation, and work personality.
  • A Digital Population Tracking System Helps Improve Colorectal Cancer Survivorship Services
    Raymond Liu, MD, et al.
    An integrated precision tracking program ensures proper follow-up care and surveillance for survivors of colorectal cancer.
  • Rapid Practice Change During COVID-19 Leads to Enduring Innovations and Expansion of Integrative Oncology Services
    Danielle Gentile, PhD, et al.
    This cancer program continues to meet patients’ psychosocial needs through enduring telehealth expansion, livestream groups and classes, and on-demand digital repositories.
  • A Focus on APPs
    Sibel Blau, MD
    While the number of oncology patients and survivors is increasing, the growth of medical oncologists has lagged behind, and advanced practice providers (APPs) play a critical role in filling this care gap.
  • A Framework for Defining High Quality Care for Patients with NSCLC
    Mark A. Socinski, MD, and Leigh M. Boehmer, PharmD, BCOP
    An expert ACCC Steering Committee shares 32 informed treatment and care delivery recommendations for the ideal care of patients with non-small cell lung cancer.
  • Views: Celebrating Cancer Survivors During COVID-19
    Amber Kapoor, MPH
    At Middlesex Health Cancer Center, we knew we could not let another year pass without an in-person celebration of all that our survivors and staff have endured. We were determined to bring people together again in a safe way.
  • Views: More Than Beauty: Meeting Patients’ Aesthetic Needs
    Mary Vorous and Debbie DeNitto
    As the manager of Wellspring, a cancer resource center located just two miles from Valley Health Cancer Center at Winchester Medical Center in Virginia, I understand the importance of providing holistic care that meets the body, mind, and spiritual needs of our patients.
  • Key Areas of Interest Going Into 2021
    Randall A. Oyer, MD
    With the enormous pressures of COVID-19, the ever-increasing complexity of oncology care, and the persistent social factors that lead to medical injustice, it is difficult to think about tackling even one more job. Yet, we must, we can, and we do. Today I want to mention four specific areas that all cancer programs need to be watching, thinking about, and preparing for.
  • Expanding Patient Access to Cancer Care Services
    Kelley D. Simpson, MBA; Stacy Melvin, MHA; and Sue Fletcher, RN
    Key results from a national survey show a range of new initiatives.
  • Empowering Cancer Patients Using Integrative Medicine: A Novel Model for Breast Cancer Risk Modification
    Christina M. Bowen, MD; Robin Hearne, MS, RN; Caroline Dixon; and Charles H. Shelton, MD
    As a CoC-accredited critical access hospital—one of only about a dozen nationwide—The Outter Banks Hospital has developed a quality program with a focus on removing rurally linked barriers to care.
  • Young Adult Parents Tap into Long Distance Support
    Laura Melton, PhD, ABPP
    We proposed creating an online video support group to enable patients with cancer who would otherwise have difficulty attending such groups to participate virtually.
  • "Prescribing" Exercise and Nutrition in Cancer Care
    Jessica Clague DeHart, PhD, MPH, et al.
    As more evidence is showing, all the activities encompassed under the wellness umbrella can be applied to cancer prevention and the cancer care continuum.
  • Guided Patient Support: Helping Patients Navigate the Clinical, Psychosocial, and Financial Aspects of Cancer Care
    Jessica Sima, MSN, RN, ACM, et al.
    This innovative program provides coordinated whole-person care, ensuring that patients receive the support they need through psychosocial counseling, social support, rehabilitation services, financial counseling, nurse navigation, nutritional intervention, transportation assistance, physical therapy, tertiary care referrals, and medication assistance. The GPS approach helps the cancer care team proactively identify patient needs and prepare patients for treatment.
  • Supporting Cancer Survivors in Making Healthful Lifestyle Changes
    Wendy Demark-Wahnefried, PhD, RD, et al.
    Evidence-based diet and exercise interventions and programs that can improve cancer survivors’ quality of life and physical and mental health.
  • Impact of a Community-Based Cancer Survivorship Program on Quality of Life
    Rrachel Funk-Lawler, PhD, et al.
    Despite the demonstrated need to implement evidence-based interventions that address the psychosocial and behavioral concerns of cancer survivors, few studies have evaluated the effectiveness of community-based survivorship programs. To address this need, the Fort Worth Program for Community Survivorship—a community-based cancer survivorship program at the University of Texas Southwestern Medical Center Moncrief Cancer Institute in Fort Worth, Tex.—conducted a study involving more than 200 post treatment cancer survivors to evaluate the effectiveness of the program’s services.
  • Implementing and Evaluating an Online Educational Resource for Veterans with Cancer
    Cheryl Booth, RN, MSN, NP-C, AOCNP, AND Gwendolyn Hooper, PhD, RN, FNP, APRN-BC
    One VA Center improved patient education by developing an online resource for veterans with cancer. Although several barriers emerged during this quality improvement process, the VA Center was able to meet its patients needs and decrease their anxiety.
  • Addressing Cancer-Related Cognitive Impairment in Cancer Survivorship
    Lynne S. Padgett, PHD, et al.
    Poor executive function, attention and concentration deficits, and impairment to short term memory are a few of the symptoms of cancer-related cognitive impairment that can impact patients during- and post-treatment. Find out how patients present these symptoms and how assessment and screening can help early interventions.
  • Partnering with Data Analytics to Promote Survivorship Care Plan Success
    Andrea Rowe, BS, RHIT, et al.
    Creating and maintaining a survivorship care plan is a complex process, but it is essential to creating a survivorship compliance report that informs clinical and management team decision-making.
  • Virtual Care After Treatment: How Telemedicine Can Expand Survivorship Programs
    Holly Bushart, MSN, ACNP-BC, AOCNP, et al.
    Though the importance of post-cancer care is widely acknowledged, cancer programs and practices continue to struggle with the optimal approach for conducting dedicated survivorship visits. As a result, many patients still go without survivorship care. Telemedicine—which has increased access to care in numerous specialties—may offer one solution to these challenges
  • An Artful Impact on Cancer Care
    By Julie Manning, MS, et al.
    In this article we describe how ArtsCare delivers services aimed at improving the experiences of all those who have been affected by cancer.
  • Integrating Yoga Therapy into Oncology Care
    By Gigi Robison, MSN, APRN-CNS, AOCN, et al.
    This article outlines the process for designing and implementing a yoga therapy program for patients with cancer.
  • Elevating Survivorship: Results from Two National Surveys
    In order to explore experiences and needs concerning cancer survivorship from both the provider and the patient perspectives, ACCC and NCCS partnered to field two online surveys to oncology providers and cancer survivors, respectively.
  • A More Personalized Approach to Survivorship Care?
    Jennie R. Crews, MD, MMM, FACP
    Since the 2005 publication of From Cancer Patient to Cancer Survivor: Lost in Transition by the Institute of Medicine (now the National Academy of Medicine), the healthcare community has become more aware of the needs of cancer survivors and responded by developing survivorship services and programs.
  • Providing Psycho-Education to Combat Fatigue
    By Shannon Morton, LMSW, MA; Alison Snow, PhD; Anthony H. Bui, MS3; and Manjeet Chadha, MD
    Exercise has been demonstrated to alleviate the effects of cancer-related fatigue, but patients with cancer may not understand the true scope of its benefits. Mount Sinai Downtown Cancer Centers created a quality improvement (QI) initiative to provide psycho-education on exercise during initial radiation treatments and throughout treatments.
  • Supportive Oncodermatology
    Stephanie Kao, BA, and Adam Friedman, MD
    Dermatologic adverse events can have a profound impact on the physical, emotional, financial, and psychosocial health of cancer patients. Discover how the emerging collaborative subspecialty of supportive oncodermatology aims to address cancer-related dermatologic events.
  • The SCOOP Program
    Christopher Koprowski, MD, MBA; Edith J. Johnson, PhD, MBA; Karen Sites, BSN, RN, OCN; and Nicholas Petrelli, MD
    The Helen F. Graham Cancer Center and Research Institute implemented the Supportive Care of Oncology Patients (SCOOP) Program, which developed and implemented a clinical pathway that improved the patient experience and reduced the cost of care in selective curative cases.
  • Development of Care Pathways to Standardize and Optimally Integrate Multidisciplinary Care for Head and Neck Cancer
    Assuntina G. Sacco, Charles S. Coffey, Parag Sanghvi, Gloria P. Rubio, et al.
    The complexity of head and neck cancer management demands greater attention in order to provide high-quality care. UC San Diego Moores Cancer Center developed a well-defined care pathway to enable predictability and consistency in both care delivery and cost.
  • Development of an Outpatient Cardio-oncology Program
    By Laurie Walton Fitzgerald, MSN, RN, and Peyton Neilson, MSN, RN, OCN
    At University of Maryland Upper Chesapeake Health, the Heart and Vascular Institute and the Kaufman Cancer Center have come together to create a cardio-oncology program that provides a patient-centered, multidisciplinary clinic for cancer patients during diagnosis, treatment, and survivorship.
  • Life with Cancer at Inova Schar Cancer Institute
    By Sage Bolte, PhD, MSW, OSW-C
    Learn how Inova Schar Cancer Institute’s Life with Cancer program, with more than 40 multidisciplinary staff members, comes together to offer psychosocial support and survivorship care.
  • New Horizons in Oncology Rehabilitation
    Christopher M. Wilson, PT, DPT, DScPT; Reyna Colombo, PT, MA; and Basil Hakmeh, MPH
    Beaumont Health in metropolitan Detroit is actively preparing its physical therapists (PTs) and occupational therapists (OTs) to provide patient-centered, diagnosis-specific, compassionate care to cancer patients through advanced training by development of an accredited clinical residency program in cancer rehabilitation.
  • A History of Cancer Survivorship Plans
    Sigrun Hallmeyer, MD, and Naveed Cheema, DO
    A generation ago cancer care consisted of diagnosis, active treatment, and resigned palliation. Today, advances in cancer care have increased the number of people surviving a cancer diagnosis leading to a new dimension of care—cancer survivorship.
  • An EMR-Driven Approach to Survivorship Care Plans
    Sigrun Hallmeyer, MD, and Naveed Cheema, DO
    In order to minimize the challenges of time and resource allocation, Oncology Specialists, SC, set out to create a survivorship care plan (SCP) using its electronic medical record (EMR) as a tool to ease the clinician’s workload and time commitment, while still delivering patient-centered care at the end of treatment.
  • Fox Chase Cancer Center Care Connect
    Kelly Filchner, MSN, RN, OCN, CCRC, and Alan Howald, BS
    Fox Chase Cancer Center, Philadelphia, Pa., committed resources to develop a program to improve communication and education between oncology and primary care, and improve overall survivorship care.
  • Peer Mentoring: A Volunteer-Run Program Benefits Breast Cancer Patients & Survivors
    Dona Hobart, MD, and Marcia McMullin, RN, BSN, MA
    With the understanding that one-to-one mentoring services have proven effective in improving both quality of life and survival rates, the Center for Breast Health at Carroll Hospital developed a volunteer-run peer mentor program, Embrace Peer, in April 2014.
  • Views: The Healthy Forks Survivorship Series: Fighting Cancer One Fork at a Time
    Jennifer Fitzgibbon, MS, RD, CSO, CDN
    Stony Brook Cancer Center created a nutritional program for cancer survivors and their families with the aim of providing resources to help understand the necessity of providing health meals at a reasonable cost, while incorporating stress reduction and physical activity in support of a health lifestyle.