Models of survivorship care

Abstract

The official definition of a cancer survivor encompasses those experiencing the entire trajectory of cancer care, including diagnosis, treatment, and beyond treatment. For each of these three phases, survivors have different health care needs. A report issued in 2005 by the Institute of Medicine, entitled “From Cancer Patient to Cancer Survivor: Lost in Transition,” brought to light the problems that many cancer survivors face once they are past the phase of cancer treatment. Survivors reported they struggled to find health care services and providers in their communities to address their persistent or late-emerging health problems that were secondary to their former cancer diagnosis or effects of treatment. This chapter will describe the process within our institution for developing a multidisciplinary care delivery model, as well as the components of care in the model. The domains of health care that address known and anticipated “after cancer” health care needs of survivors are as follows: surveillance for possible late recurrence of the primary cancer; screening and early detection, as well as prevention, of additional primary cancers; monitoring for and management of persistent or late effects of treatment; and psychosocial health. Communication between the primary oncology teams and community physicians is very important for continuity of care. It is recommended that a summary document be prepared as a care plan for each survivor, detailing the following: type of treatments received; residual and possible future late effects or complications; indicated evaluations for health maintenance; and cancer surveillance/screening.