Disclosures: Dulko reports no relevant financial disclosures.
March 25, 2020
5 min read

Survivorship care plans, evidence- based practice and the ‘Triple Aim’

Disclosures: Dulko reports no relevant financial disclosures.
You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

We were unable to process your request. Please try again later. If you continue to have this issue please contact

Survivorship care delivered by oncology nurse practitioners has been associated with improved patient satisfaction, quality of care and cost-effectiveness.

Dorothy Dulko, PhD, ARNP-C, AOCNP, CCRP
Dorothy Dulko

Although care for cancer survivors is frequently fragmented, survivorship care plans (SCPs) may offer a unique opportunity for advanced practice nurses (APNs) to support fulfillment of evidence-based practice, quality care and the “Triple Aim,” which the Institute for Healthcare Improvement defines as a cohesive method to enhance health care quality.

Optimizing population health, reducing per capita cost and improving the patient experience are the three tenets that support achievement of the Triple Aim. Moreover, APNs can apply evidence-based practice to clinical decision-making in support of the Triple Aim.

Implementation of SCPs remains far from universal

More than 15.5 million Americans have a history of cancer, a number that is expected to rise to over 21 million by 2029. Although this represents progress in cancer prevention and therapy, many survivors experience health concerns as a result of their cancer treatment.

ASCO defines three phases of survivorship, including:

acute survivorship, which starts at diagnosis and continues to the end of initial treatment;

extended survivorship, which encompasses the time from completion of initial treatment through the months after. In this phase, the effects of cancer and treatment are emphasized; and

permanent survivorship, which covers the years after cancer treatment. Long-term effects of cancer are the focus during this phase.

Cancer survivors receive rigorous care from oncologists, oncology nurses and APNs during the initial two phases; however, long-term survivor care may be provided by nononcology primary care physicians, physician assistants (PAs) and nurse practitioners (NPs) who may lack the needed knowledge and confidence to adequately care for these survivors.

A SCP — which is, essentially, a written summary — includes details of the survivor’s cancer diagnosis, treatment and recommended surveillance plans. Research has shown that outcomes may improve when survivors and all follow-up care providers are provided with a SCP.

Although the advantages of SCPs might seem obvious, these plans are not always easily implemented nor sustained in practice. Since the Institute of Medicine (IOM) released its seminal report, From Cancer Patient to Cancer Survivor: Lost in Transition, in 2005, consistent implementation of SCPs has remained challenging. The Commission on Cancer (CoC) also issued its Standard 3.3, which required accredited cancer programs to develop a process for implementing SCPs (although this was relaxed in 2019). Many cancer centers have adopted a plan for SCPs; however, universal implementation has not been achieved.


Consistent with the IOM and CoC recommendations, all patients with cancer who have completed treatment should have a summary of the therapy they received along with a specified plan of ongoing care. The summary should provide a clear delineation of oncology and nononcology provider responsibilities. This “transition plan” also should include follow-up schedules for visits and diagnostic testing; recommended screening for early detection; and management of treatment-associated effects, comorbidities and other health problems.

Opportunities for APNs

Many cancer centers have implemented SCPs to meet accreditation requirements; however, research has shown that although the SCP may be developed, it is not always delivered to the survivor or follow-up care providers.

In many ways this defeats the purpose of the plan, as the PCP, NP or PA may not receive the information they need to feel confident in providing survivorship care, including identification and management of late and long-term effects of cancer treatment.

In not providing the SCP to the survivor, synergy with the basic tenets of patient-centered care are breached. The cancer survivor may lack needed information and resources found in the SCP to reduce stress and empower decision-making regarding their physical status, treatment, follow-up continuity and available resources.

Research has suggested that restricting SCP implementation to APNs, in whom the responsibility can be clearly entrusted as a part of their role, may mitigate one often-cited barrier to SCP delivery: a lack of defined resources. Automating SCP implementation through electronic health records also may be a facilitator.

APNs often are the providers of survivorship care planning, beginning with development and delivery of the plan. With consistent identification of this dedicated responsibility, known gaps in communication among oncologists, patients and follow-up care providers may be reduced, as ongoing communication is essential to the success of this endeavor.

As members of the interdisciplinary team and advocates for patient-centered, evidence-based care, APNs are integral to providing needed leadership in survivorship care. Although APNs may be the main providers of survivorship care planning, RNs can participate by compiling information and discussing care plans with APNs or physicians to confirm referral orders.

However, health care professionals, including APNs, need additional education to ensure evidence-based knowledge of cancer survivorship care.

Research suggests that primary care NPs lack awareness of the current American Cancer Society/ASCO cancer survivorship care guidelines, which may impede their ability to provide the best evidence-based care for cancer survivors. Although changes in nursing higher education curriculum are definitely a longer-term goal toward optimizing cancer survivorship care, educating professionals already in practice is a key short-term objective.


Pediatric oncology APN practice may be an exemplar in achieving this short-term goal. These APNs, dedicated to the care of children with cancer, have been influential in defining and evaluating survivorship education. Collaboration among adult and pediatric oncology clinicians, educators and researchers presents us with the opportunity to harness collective SCP implementation strategies and best practices to enhance survivor care across the lifespan.

Designing web-based learning opportunities, continuing education, mentorship, and liaison with professional organizations and nursing academia are all key. Fragmented survivorship care will continue without focused education is provided.

Many continuing education and survivorship resources are available to providers, such as the National Comprehensive Cancer Network’s Clinical Practice Guidelines in Oncology for Survivorship that cover eight areas related to survivorship, ASCO’s Treatment and Survivorship Care Plan Templates, and adult post-treatment tools provided by American Cancer Society for cancer survivors and their caregivers (see Table).

Efforts to achieve the Triple Aim within cancer survivorship are occurring in the context of a workforce that isn’t growing to meet the demand. Whereas the number of oncologists is expected to increase by 25% over the next 20 years, the demand for oncology services is expected to increase by 40%.

Sharing care among oncologic physicians, PCPs and APPs offers an opportunity for APNs to lead the way in achieving the second aim of improving the care of patients. Doing so is in the interest of cancer survivors and leads us down the pathway of achieving the Triple Aim.


ACS: Cancer Facts & Figures 2017. Available at: Accessed Feb. 24, 2020.

Birken SA, et al. J Oncol Pract. 2018;doi:10.1200/JOP.17.00054.

Bluethmann SM, et al. Cancer Epidemiol Biomarkers Prev. 2016;doi:10.1158/1055-9965.EPI-16-0133.

Dulko D, et al. Oncol Nurs Forum. 2013;doi:10.1188/13.ONF.575-580.

Harvey A, et al. J Cancer Educ. 2020;doi:10.1007/s13187-018-1453-2.

NCI Office of Cancer Survivorship. For health care professionals. Available at: Accessed Feb. 24, 2020.

Nevidjon B, et al. J Oncol Pract. 2010;doi:10.1200/JOP.091072.

NEJM Catal. 2017;doi:10.1056/CAT.17.0559.

Ruccione K. J Pediatr Oncol Nurs. 2009;doi:10.1177/1043454209343179.

Taplin SH. J Oncol Pract. 2014;doi:10.1200/JOP.2014.000869.

For more information:

Dorothy Dulko, PhD, ARNP-C, AOCNP, CCRP, is lead core faculty of the graduate program at College of Health Sciences, School of Nursing at Walden University. She can be reached at

Disclosure: Dulko reports no relevant financial disclosures.