Guidelines and Recommendations 

Several organizations have models of care and professional organizations have evidence-based guidelines for survivorship care, including the National Comprehensive Cancer Network, American Society of Clinical Oncology, and American Cancer Society. The American College of Surgeons Commission on Cancer (CoC) included survivorship programs as an accreditation standard and critical component for cancer programs as part of its Optimal Resources for Cancer Care.

Structure  

Developing a cancer survivorship program requires an interprofessional approach, including physicians, APRNs, nurses, allied health professionals, cancer registry, information technology, marketing, and administration. To create a strategic plan and programmatic goals, assess patient and caregiver needs, barriers to care, and institutional resources and consider the role, participation, and integration of primary care with survivorship care. The CoC survivorship program standards may be a starting point, with future goals to grow survivorship services and programs.  

Individualized survivorship care plans (SCP) are often part of survivorship services. For patients with curative intent, the tool provides a roadmap for future care and services and can be shared with primary care for ongoing surveillance and wellness strategies. SCP guidelines are evolving: CoC no longer requires them to meet the standard, although they are still strongly recommended. SCPs have value, but practice barriers such as time needed to complete the care plan, delineation of which patients should receive a care plan, and questionable follow through on care plan recommendations and patient outcomes have hindered implementation.  

APRN Leadership 

APRNs are the backbone of many survivorship programs, serving as program coordinators, care providers, and liaisons to primary care. In survivorship care, APRNs provide an approach that encompasses previous treatment considerations, surveillance plans, and long-term or late effects of treatment.  

Some practices may recommend a one-time survivorship visit, whereas others have patients return for annual visits. APRNs are able to stratify risk based on the type of cancer, treatment, and long-term complications and recommend personalized, evidence-based, and cost-effective care. In addition, APRNs contribute to the evaluation of clinical outcomes and safety for ongoing quality improvement and survivorship research. 

COC Survivorship Program Standard Requirements 

• Develop a comprehensive survivorship program to meet the needs of patients treated with curative intent. 

• Document policies and procedures, and evaluate compliance annually.  

• Create an interprofessional survivorship team, led by a coordinator and including physicians, advanced practice providers, nurses, social workers, nutritionists, physical therapists, and other allied health professionals. 

• Document at least three services and programs that address the needs of cancer survivors, and report estimated number of participants in those services annually. Examples include:  

  o   Survivorship care plans 

  o   Screening programs 

  o   Rehabilitation, nutrition, psychological support, or financial support services 

  o   Formalized interprofessional referrals 

  o   Support groups and services 

  o   Physical activity programs 

Survivorship care plans are recommended but not required and may be used as one of the three services.