Journey Forward Survivorship Care Plan


Most cancer experts agree that cancer Survivorship Care Plans are an essential part of quality care after active treatment. "Too many cancer survivors are lost in transition once they finish treatment. They move from an orderly system of care to a ‘non-system’ in which there are few guidelines to see them through the next stage of their life or help them overcome the medical and psychosocial problems that may arise… Every cancer survivor should have a comprehensive care plan once they complete primary treatment to improve their health and quality of life.” (From Cancer Patient to Cancer Survivor: Lost in Transition, Institute of Medicine 2005 report)

What is a cancer Survivorship Care Plan?

A Survivorship Care Plan is:

  • a coordinated, post-treatment plan
  • for the cancer survivor, oncology team, primary care physician and other healthcare providers
  • created by the oncology provider and survivor in partnership

Survivorship Care Plans created with Journey Forward tools include:

  1. contact information for the patient's care team
  2. a brief summary of the cancer diagnosis and treatment
  3. schedule for follow-up tests and surveillance
  4. psycho-social assessment
  5. information on managing ongoing symptoms and what to expect after treatment

Survivorship Care Plans are typically created by an oncology nurse or nurse navigator. But they may also be completed by an oncologist, nurse practitioner, physician's assistant, nurse or lay navigator, or even registry technician.

Survivorship Care Plans are shared with:

  • the cancer survivor
  • the oncology provider
  • the primary care provider
  • other specialists

Survivorship care begins once active treatment ends. However, patients and providers can begin the conversation and survivorship care planning process at the beginning of treatment.

Publication Year: 
2013-01-01 00:00:00
Resource(s) on...: 
Cancer - General
Publishing Organization(s): 
Other - Organizations
Publisher Location(s): 
California (CA)
Target Location(s): 
Target Population(s):