Survivorship Care Plan (Post-Treatment)

Document Title: Survivorship Care Plan (Post-Treatment) — [Cancer type/site]

Date Created: [Date]

Authoring Clinician: [Name], [Role], [Service] — [Clinic phone] — [Clinic address]

Distribution: [List recipients with method (portal / printed / faxed) and date sent] (If PCP is unknown, state: "PCP: Unknown—patient asked to identify PCP for distribution.")

Purpose and Scope

This Survivorship Care Plan summarizes the patient's cancer diagnosis and treatment, outlines recommended surveillance for recurrence and monitoring for potential late and long-term effects, and delineates shared follow-up responsibilities between oncology and primary care. It is not a complete medical record; recommendations may evolve with new information and updated guidelines. Patients should bring this document to all medical appointments and promptly report any new, unusual, or persistent symptoms.

Patient Information

Name: [Patient full name]

Date of Birth: [DOB]

MRN: [Medical record number]

Preferred Language: [Language] (Note interpreter needs if applicable.)

Contact: [Phone, email, address]

Emergency Contact: [Name, relationship, phone]

Care Team

Role	Name	Organization	Phone	Notes
Medical Oncologist	[Name / Not applicable]	[Organization]	[Phone]	[Notes]
Radiation Oncologist	[Name / Not applicable]	[Organization]	[Phone]	[Notes]
Surgical Oncologist	[Name / Not applicable]	[Organization]	[Phone]	[Notes]
Primary Care Provider	[Name / Unknown]	[Organization]	[Phone]	(If unknown, note that patient was asked to identify PCP.)
[Additional specialist role]	[Name]	[Organization]	[Phone]	[Notes]

(Include additional rows for specialists involved in survivorship care such as cardiology, endocrinology, genetics, or behavioral health. Enter "Not applicable" for oncology subspecialties the patient did not see; omit specialist rows that do not apply.)

Cancer Diagnosis Summary

(Repeat this block for each primary cancer if multiple primaries.)

Cancer Site/Type: [Site/Type]

Histology/Subtype: [Histology/Subtype]

Date of Diagnosis: [Date]

Stage at Diagnosis: [Stage and staging system] (If unknown, state "Unknown—outside records requested" and add to Pending Items.)

Grade: [Grade / Unknown]

Key Biomarkers/Molecular Findings: [Findings impacting follow-up or risk stratification] (If none or unknown, state accordingly.)

Treatment Intent: [Curative / Adjuvant / Neoadjuvant / Definitive]

Hereditary/Genetic Risk: [Genetic counseling status, results, cascade testing recommendations] (If pending or unknown, note and add to Pending Items.)

Treatment Summary

Treatment Completion

Date of Treatment Completion: [Date]

Response/Status at End of Treatment: [Complete remission / No evidence of disease / Partial response / Other]

Surgery

[Procedure name], [Anatomic site], [Date (YYYY or YYYY-MM)], margin status: [status], nodal findings: [findings], complications with ongoing implications: [complications] (If surgery not received, state "Not received.")

Systemic Therapy

(List each agent individually. If systemic therapy not received, state "Not received.")

• [Agent name]: [Start date]–[End date], cumulative dose: [dose if relevant to late effects], significant toxicities: [toxicities with ongoing implications]

Ongoing adjuvant/endocrine therapy: [Agent, dose, planned duration, monitoring considerations / None]

Radiation Therapy

[Anatomic fields treated with laterality], end date: [YYYY], dose/fractionation: [dose or "Unknown—records requested"] (If radiation not received, state "Not received.")

Other Treatments

[Transplant type / Cellular therapy / Other modality], date: [Date], conditioning regimen: [regimen if applicable], major complications: [complications relevant to long-term monitoring] (If none, state "Not received.")

Current Status

Cancer Status: [Current disease status] — based on [date and findings of last imaging or oncology evaluation]

Active Symptoms/Toxicities: [Treatment-related effects requiring ongoing management] (If none, state "No ongoing treatment-related toxicities reported.")

Key Survivorship Medications: [Ongoing adjuvant/endocrine therapy with duration; supportive medications affecting health maintenance]

Surveillance for Recurrence

(Document only tests explicitly planned by oncology or per referenced guidelines. Do not infer surveillance tests.)

Test/Modality	Frequency	Duration	Responsible Clinician	Notes
Oncology follow-up visit	[Interval]	[Duration then long-term cadence]	[Oncologist]	[Notes]
[Imaging modality]	[Frequency]	[Duration]	[Clinician who orders and interprets]	[Notes]
[Laboratory / tumor markers]	[Frequency]	[Duration]	[Clinician]	[Notes]
[Endoscopy / procedure]	[Frequency]	[Duration]	[Clinician]	[Notes]

Symptom-triggered evaluation: Contact your provider for earlier assessment if new or concerning symptoms arise outside the scheduled surveillance, including: [cancer-specific symptoms warranting prompt evaluation].

(If the surveillance plan is pending finalization, note the expected date and provide an interim plan.)

Second Primary Cancer Screening

Enhanced Screening Due to Cancer History or Treatment

(Include screening that differs from general population recommendations based on treatment exposures or cancer history.)

Cancer Type	Recommendation	Start Date/Age	Frequency	Responsible Clinician
[Cancer type]	[Enhanced screening recommendation]	[Start date or age]	[Frequency]	[Clinician]

Routine Age-Appropriate Screening: Continue routine cancer screening with primary care per general population guidelines, except as modified above.

Late Effects Monitoring

(Include only domains relevant to this patient's treatment exposures and current symptoms. Omit domains that do not apply.)

Domain	Risk Factor	Monitoring	Interval	Responsible Clinician	Notes
[Cardiovascular]	[Anthracyclines / Chest radiation / Targeted therapy]	[Symptoms and/or tests to monitor]	[Frequency and start timing]	[Oncology / PCP / Cardiology]	[Action thresholds; patient warning symptoms]
[Additional domain]	[Treatment exposure]	[Monitoring approach]	[Interval]	[Responsible clinician]	[Referral triggers; patient warnings]

(Common domains to consider based on exposures: cardiovascular, pulmonary, endocrine/metabolic, bone health, renal/genitourinary, neurologic/cognitive, hearing/vision, gastrointestinal/hepatic, sexual health and fertility, lymphedema/musculoskeletal, immune/infection risk, psychological health.)

Health Maintenance

Lifestyle

[Physical activity, nutrition, weight management, tobacco cessation, and alcohol moderation recommendations with actionable targets tailored to patient limitations]

Immunizations

Continue routine adult vaccinations per primary care. [Additional recommendations for immunocompromised states, post-transplant status, or therapy-specific considerations as applicable.]

Chronic Disease Management

[Comorbidities requiring primary care ownership] — confirmed handoff to PCP for ongoing management.

Care Coordination

(Explicitly assign responsibilities to prevent gaps during transition.)

Care Task	Details	Frequency	Responsible Clinician	Notes
Recurrence surveillance	[Tests and visit cadence]	[Frequency]	[Oncology / PCP]	[Notes]
Second primary screening modifications	[Enhanced screening details]	[Frequency]	[PCP / Specialist]	[Notes]
Late-effects monitoring	[Domain-specific monitoring]	[Frequency]	[Oncology / PCP / Specialist]	[Referral triggers]
Ongoing adjuvant/endocrine therapy	[Medication management, labs, adherence]	[Frequency]	[Oncology / PCP]	[Notes]
Routine preventive care	[Preventive measures and immunizations]	[Per guidelines]	[PCP]	[Notes]
Cardiovascular and metabolic risk	[BP, lipids, diabetes screening, lifestyle]	[Per guidelines]	[PCP]	[Notes]
Bone health	[DXA, calcium/vitamin D, bone agents]	[Frequency]	[PCP / Specialist]	[Notes]
Psychosocial screening	[Depression, anxiety, distress, sleep]	[Frequency]	[PCP / Behavioral Health]	[Referral resources]
Triggers for re-referral to oncology	[Clinical scenarios warranting oncology review]	[As needed]	[PCP → Oncology]	[Contact pathway]

Oncology Point of Contact: [Name, role, phone, secure message instructions]

Communication Plan: [How PCP should contact oncology for abnormal findings; urgent vs routine pathways; when to direct patient to emergency care]

Red Flags and Return Precautions

Report any new, unusual, or persistent symptoms to your provider promptly, especially:

• [Cancer-specific or treatment-specific warning sign]
• [Cancer-specific or treatment-specific warning sign]
• [Cancer-specific or treatment-specific warning sign]

Supportive Resources

(Include if needs are identified or resources are being provided. If no specific resources apply, state "Support services are available upon request." This section may be omitted if not applicable.)

• [Resource type]: [Access information]

Pending Items

(Include if data gaps exist in the diagnosis or treatment summary. This section may be omitted if no pending items.)

Item	Owner	Target Date	Status
[Missing item description]	[Name/Role]	[Date]	[Requested / In progress / Completed]

Review and Attestation

This care plan was reviewed with the patient [and caregiver name/relationship if present]. Questions were addressed. Copies were provided to the patient and distributed to the care team as listed above. Interpreter used: [Yes, language / No].