Development of Phase-Specific Breast Cancer Survivorship Care Plans

Phase-specific survivorship care plans (SCPs) have the potential to be powerful tools in providing individualized, comprehensive survivorship care, particularly in terms of care coordination and transition, if used as dynamic documents. We designed an initial follow-up care plan (FCP) to be used at the conclusion of curative therapy, as well as distinct, phase-specific FCPs for periodic use at 5-year and 10-year time points in the survivorship course. These FCPs incorporate the 4 essential components of survivorship care outlined by the Institute of Medicine: prevention, surveillance, intervention for consequences of cancer treatment, and coordination among health care providers. Phase-specific SCPs were designed by a multidisciplinary team with expertise in breast health, survivorship, and cancer care delivery across diverse practice settings. The FCPs were formulated to align with national guidelines and emergent, peer-reviewed literature, and reflect evolving recommendations regarding the duration of adjuvant hormone therapy. The SCPs were pilot-tested and successfully integrated into the existing work flow of the electronic medical records at each practice site. Phase-specific SCPs were developed to incorporate new knowledge about evolving treatment recommendations, screening guidelines, and updated genetic information to encourage timely discussions relevant to the specific stage of survivorship. Survivorship care plans (SCPs) have the potential to be powerful tools in providing individualized, comprehensive survivorship care over time, particularly if these documents are used in a dynamic fashion and updated throughout the survivorship course. We propose the addition of the phase-specific SCP at key care junctures to capture time-specific risks and updates, as well as to prepare for transitions of care. We detail the development and integration of the phase-specific SCP into the electronic medical record and clinical work flow at two, diverse practice settings.