Survivorship Care Plan — Post-Treatment Roadmap

A survivorship care plan is an evidence-based clinical document designed to bridge the transition from active cancer treatment to post-treatment survivorship. Advocated by major international cancer organisations, the plan comprises two fundamental sections: an oncology treatment summary and a prospective follow-up care plan.

The treatment summary details tumour characteristics, cancer stage, surgical procedures, chemotherapy regimens with cumulative doses, and radiation therapy fields and dosages. The prospective plan delineates upcoming clinical visits, required blood tests, and imaging intervals. It also highlights potential long-term toxicities, flags signs of possible recurrence, identifies recommended healthy lifestyle modifications, and defines clear clinical responsibilities between oncologists and general practitioners.

Transitioning out of acute oncology care can be confusing and distressing. A survivorship care plan is vital because it establishes clear responsibilities between oncologists and general practitioners, preventing gaps in follow-up medical care. It provides patients with tangible knowledge regarding what tests are genuinely needed and when, reducing uncertainty and scan-related anxiety. Moreover, it empowers survivors to recognise delayed treatment complications, such as cardiac toxicity or peripheral neuropathy, prompting early intervention. Having a consolidated record of past treatments is invaluable whenever seeing new healthcare professionals in the future.

While a survivorship care plan is not a diagnostic test, it establishes an explicit timetable for future testing. It schedules biomarker evaluations, such as PSA or CEA monitoring, and schedules periodic imaging like mammograms or CT scans. It also specifies necessary functional screenings based on specific treatment exposures, such as serial echocardiograms to assess cardiac ejection fraction after anthracycline therapy or bone densitometry (DEXA scans) to detect osteoporosis following endocrine treatments.

Survivorship care plans are recommended for any patient finishing curative treatment, but are most widely implemented in adult breast, colorectal, prostate, and haematological cancers. They are also routinely created for head and neck cancer survivors, who face complex long-term functional challenges regarding speech and swallowing. Furthermore, they are critical in childhood and adolescent cancer survivorship, where young adults carry a high lifelong risk of delayed physical and psychological toxicities resulting from aggressive multimodal treatments.

An SCP does not outline primary curative therapies; rather, it directs ongoing adjuvant interventions and maintenance regimens. For example, it specifies the duration of adjuvant endocrine therapy for breast cancer or androgen deprivation therapy for prostate cancer. It also prescribes evidence-based rehabilitative treatments, such as physical therapy for lymphoedema, speech therapy for dysphagia, and lifestyle interventions covering nutrition and physical activity to lower recurrence risk and manage metabolic health.