Running head: SURVIVORSHIP CARE PLANNING

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Survivorship Care Planning: An Evidence Based Quality Improvement Project in Breast Cancer
Beth Segerholm
Arizona State University

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Abstract
Cancer survivors meet survivorship with uncertainty due to a lack of uniform information
provided post cancer treatment. The implementation of survivorship care plans (SCP) has been
recognized by key stakeholders as the solution to transitional uncertainties.
In fact, to achieve accreditation by the Commission on Cancer (CoC) cancer centers are required
to deliver SCPs to cancer survivors within a year of their treatment completion. Research
demonstrates SCP delivery results in significant improvement in patient satisfaction,
coordination of care, and survivorship care knowledge. In order to meet CoC standard 3.3 and
bring understanding to SCPs function in cancer survivorship care a quality improvement project
was initiated within an Arizona cancer center. SCPs were delivered at a survivorship visit to
adult breast cancer patients. SCPs affect on survivors’ confidence in cancer self-care knowledge
and care satisfaction was evaluated as well as the organization’s adherence to CoC standard 3.3
requirements. Identified survivors were scheduled for a survivorship visit where a SCP was
delivered by a oncology provider. Survivors perceived confidence in knowledge and satisfaction
was measured using the modified 16-item Confidence in Survivorship Information Questionnaire
(CSI). Questionnaires were completed pre and post survivorship visit. A paired t-test analysis
was used to evaluate SCP effectiveness. There was an increase in the delivery of SCPs from zero
to 57 with an 84 percent SCP delivery from August 2017 to January 2018. Survivors and
providers verbalize value in SCPs. No statistical significance was found in the comparison of
SCPs affect on survivors’ confidence in cancer self-care knowledge and care satisfaction to that
of standard follow-up care; however, when comparing the pre/post questionnaire averages an
improvement was noted across the board.The prospect of this project is to unveil the impact SCP
delivery at a survivorship visit has on the selected metrics. This project aids as a director for
organization wide implementation for CoC standard 3.3 requirement compliance.
Keywords: survivorship, care plan, survivorship care plan, cancer, neoplasm, breast
cancer, breast neoplasm, confidence, self-efficacy, satisfaction, health promotion, followup recommendations, and follow-up adherence

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Survivorship Care Planning
With medical advances in cancer treatment, detection, and supportive care the number of
cancer survivors has exponentially grown (Rowland & Yancik, 2006). Of those diagnosed with
cancer, two of three persons are expected to live at least five years past their diagnosis.
Currently, 14 million cancer survivors live in the United States. By 2024 this number is expected
to be more than 18 million (Centers for Disease Control and Prevention, 2016).
Problem
Reaching survivorship for cancer patients is a great triumph; however, the completion of
treatment marks the beginning of another battle. Several challenges have been found in the realm
of the continuation of post cancer treatment care. These challenges include the ambiguity of
follow-up care and long-term effects and health risks due to cancer diagnosis and treatment
which affect the physical, psychosocial, and emotional well-being of the survivor (Nolte et al.,
2016; Sprague et al., 2013). The uncertainty of follow-up care is due to oncologists’ inability to
continue as the predominant provider in survivorship care with the increase of their patient
population (Boeknout et al., 2014). This has placed survivorship care in the hands of primary
care providers (PCPs), who along with survivors are uncertain of follow-up care for appropriate
screening and surveillance (Jackson, Scheid, & Rolnick, 2013). This is due to the lack of care
coordination during the transition phase from a cancer patient to a survivor (Salz & Baxi, 2016).
Long-term physical, psychosocial, and emotional effects may include, but are not limited to:
pain, fatigue, and psychological distress. Also, cancer survivors are at a higher risk of acquiring
hypertension, diabetes, dyslipidemias, and becoming obese (Sisler, Chaput, Sussman, &
Ozokwelu, 2016). If the survivor is unaware of these effects and risks it is difficult for them to
optimize their own well-being and take the appropriate steps to prevent further health issues.

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With the continuing evolution of the cancer survivor population it is important for
survivors and providers to understand follow-up care and the unique physical, psychosocial, and
emotional effects and risks of survivorship (DeSantis et al., 2014). Lack of understanding
increases the survivors’ chances of acquiring and mismanaging long-term effects and chronic
health issues. Also, the survivor may neglect cancer surveillance recommendations that identify
cancer recurrence. Without proper survivorship care the survivor may not be able to make a
successful transition from a patient to a survivor (Bulloch et al., 2017).
Purpose and Rationale
In 2006, the Institute of Medicine (IOM) released the report From Cancer Patient to
Cancer Survivor: Lost in Transition that brought attention to the inadequacies of current
survivorship care. In an attempt to correct these inadequacies the IOM identified four essential
components of survivorship care (a) prevention and detection of cancers (new or recurrent), (b)
surveillance for cancer (spread, reassurance, or secondary), (c) interventions for long-term
effects of cancer diagnosis and treatment, and (d) care coordination between providers in order to
meet survivors specific needs (IOM & National Research Council [NRC], 2006). Alongside
these essential survivorship components the IOM proposed 10 recommendations to help improve
survivorship care, one of which stated that each cancer survivor should be given a SCP upon the
completion of their primary treatment (Klemanski, Browning, & Kue, 2015). This SCP includes
the survivors complete care summary (cancer diagnosis and treatment), possible long-term
effects, surveillance and lifestyle recommendations, and provider identification in regard to who
will be in charge of care (Bulloch et al., 2017). This specific recommendation has shown to be
important among many key cancer stakeholders such as the American Society of Clinical
Oncology (ASCO), American Cancer Society (ACS), National Comprehensive Cancer Network,

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National Cancer Institute’s Office of Cancer Survivorship, National Coalition for Cancer
Survivorship, Oncology Nursing Society, and LIVESTRONG. All have endorsed the IOM
recommendation for SCPs (Klemanski, Browning, & Kue, 2016). The CoC has taken this
recommendation a step further and is requiring that by 2018 at least 75 percent of cancer
survivors must receive a SCP at the time of the survivor’s initial cancer treatment completion in
order to be deemed a cancer center (Commission on Cancer, 2014). Despite key stakeholders
efforts many health care systems and cancer centers have shown inconsistency with the
implementation and deliverance of SCPs (Klemanski, Browning, & Kue, 2016). This paper
investigates the use of SCPs through a current literature review, reviews the positive potential of
SCPs, the challenges they present, and a review of the evidence surrounding them.
Background and Significance
The importance of SCPs has been unremittingly acknowledged in the cancer reform
agenda for over a decade. However, despite organizational support, some evidence, and face
validity, only a few cancer centers have implemented them within their practice routine (Nolte et
al., 2016). Fifty-six percent of cancer programs in the United States admit to not using SCPs
(Birken, Deal, Mayer, & Weiner, 2014). This has resulted in a lack of understanding as to how
they impact both patients and providers in the transition of survivorship care (Nolte et al., 2016).
Cancer survivors are uncertain as to what comes next in their transition from patient to survivor.
Survivors are both fearful and uncertain about their survivorship. Although they are relieved to
have completed treatment, they are unsure where this leaves them in relationship to their
providers, and who is responsible for follow-up care and surveillance (Haq et al., 2013).
Healthcare providers have conflicting perspectives on their roles in survivorship care, which is
detrimental to the survivor as it may result in excess testing or worse, the omission of

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recommended follow-up surveillance (Birken, Deal, Mayer, Weiner, 2014). SCPs are meant to
provide direction for survivors to improve health outcomes, clarify providers’ responsibilities,
and decrease gaps in survivorship care (IOM & NRC, 2006). These care plans further encourage
care coordination, communication between providers, improved survivorship care knowledge,
and the understanding of needs that a survivor may have in their future (Forsythe et al., 2013).
Survivors must be given information in order to be their own advocate. SCPs are intended to
provide this information to improve patient advocacy (Keesing, McNamara, & Rosenwax, 2015).
Although the amount of high-level evidence in the support of SCPs is limited, there have
been several studies that have found benefits in the areas of survivor and provider satisfaction,
improving knowledge related to the survivor’s diagnosis and treatment, and improved
communication between the survivor and their providers (Nolte et al., 2016). Haq et al (2013)
conducted a qualitative pilot study that found SCPs to effectively address survivorship follow-up
needs. Faul et al. (2014) reported that SCPs improved survivorship care knowledge within older
breast cancer survivors. Oancea & Cheruvu (2016) found that SCPs benefit survivor’s
psychological well-being. Bulloch et al. (2015) noted that 100 percent of breast cancer survivors
were interesting in getting a SCP. Two randomized control trials showed higher satisfaction rates
in follow-up care for breast cancer survivors after receiving a SCP (Brennan, Gormally, Butow,
Boyle, & Spillane, 2014). Blaauwbroek et al., (2012) found that adherence to follow-up
recommendations was higher in survivors who provided their PCP with a SCP. Providers are
shown to benefit from SCPs as well. Forsythe et al (2013) illustrated improved care coordination,
communication, and confidence in providers’ knowledge of survivorship care post SCP receipt.
In a multicenter trial participants were found to have improved satisfaction of care, survivorship
knowledge, and care coordination after the implementation of a SCP (Palmer et al., 2015).

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The current literature consistently calls for continued research. Barriers such as the
implementation process, reimbursement, institutional resources, and time constraints need to be
explored (Palmer et al., 2015). Tompkins and O’ Brien (2014) emphasized the importance of
defining who is responsible for the coordination of survivors’ follow-up care through further
research. Other authors focused on the facilitation, creation, and implementation process of SCPs
(Forsythe et al., 2013). In a systematic review of qualitative studies, Keesing, McNamara, &
Rosenwax (2015) found that although stakeholders agreed upon the importance of SCPs in
survivorship care there is a lack of consensus on SCP format and deliverance, inconsistency of
SCP reciprocation, and little high-level evidence to support the use of SCPs. Another area of
research that was suggested is which key cancer survivor populations should be focused on.
Forty percent of women cancer survivors are breast cancer survivors, it is recommended that
future studies should be focused on breast and colon cancer survivors due to the fact that they
make up most of the survivorship population to date (Salz & Baxi, 2016; Bulloch et al., 2015;
Miller, 2008).
SCPs effect on survivors’ confidence in self-care and health promotion are other
outcome metrics that require further research. Arora et al. (2011) reported 59 percent of
survivors stated limited to no health promotion or prevention aspects were addressed in their
follow-up care. Kvale et al. (2016) conducted a randomized control trial (RCT) and found that
survivors who received SCPs reported higher self health and efficacy. This study illustrated the
positive impact SCPs can have on survivors’ self-care and health promotion. Breast cancer
survivors reported higher understanding of their follow-up care and self-efficacy after receiving a
SCP compared to survivors who did not (Ezendam et al., 2014). Limited evidence exists in

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relation to SCPs and survivors health benefits, therefore, more studies should aim to identify this
relation (Mayer, Birken, Check, & Chen, 2015).
Internal Evidence and PICO
It has become evident to a cancer center in the metropolitan Phoenix area that there is
much need and opportunity for an evidence-based practice project within the realm of cancer
survivorship care. Currently, this cancer center is in the process of figuring out how to
implement survivorship care plans within two pilot groups, the breast and colon cancer
survivors. The process of implementation has not begun. This is an issue because of the looming
CoC requirement. If they do not meet the CoC standard 3.3 requirements, as previously outlined
in the purpose and rationale, they will no longer be deemed a cancer center. This illustrates the
importance of survivorship care planning and the impact that is has on its stakeholders.
This inquiry has lead to the clinically relevant PICO question, “In breast cancer
survivors, how does a survivorship care plan compared to standard follow-up care affect
survivors’ confidence in cancer self-care knowledge and care satisfaction?”
Search Strategy
An exhaustive search was conducted in order to answer this clinical inquiry. CINAHL
(Appendix A), PubMed (Appendix B), and PsychINFO (Appendix C) were the three databases
searched to retrieve valid, reliable, and applicable literature. Key search terms included:
survivorship, care plan, care plans, or care planning, survivorship care plan, survivorship care
plans, survivorship care planning, cancer survivorship, cancer, neoplasm, breast cancer, breast
neoplasm, survivor, breast cancer survivor, confidence, self-efficacy, satisfaction, health
promotion, follow-up recommendations, and follow-up adherence.

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CINAHL (Appendix A) was first searched using the Boolean connectors AND/OR.
Survivorship care plans and breast cancer or breast neoplasm yielded 38 articles. Using the term
cancer or neoplasm, which produced a yield of 44 articles, further expanded this search. The only
limiting factor included in this initial search was a published date between 2013-2107.
Additional searches were conducted for each outcome metric. The Boolean connector AND
connected survivorship care plan or survivorship care plans to: cancer or neoplasm, breast cancer
or breast neoplasm, survivor confidence, confidence, satisfaction, health promotion, follow-up
recommendations, and follow-up adherence. Sixty-seven articles in total generated after these
searches. No limitations, inclusion, or exclusion criteria were set on these searches due to the
limited yield of articles.
A similar search was conducted in the PubMed database (Appendix B). Terms
survivorship, care plan or care plans, and cancer or neoplasm were connected with the AND
connector. The initial yield included 281 articles. This search was further limited to 81 articles
by using the terms breast cancer or breast neoplasm instead of the general terms cancer or
neoplasm. Including the term care planning within this same search yielded three additional
articles. Outcome metrics were included within additional searches. Survivorship care plan or
survivorship care plans were connected using the Boolean connector AND to cancer or
neoplasm, breast cancer or breast neoplasm, confidence, satisfaction, health promotion, and
follow-up recommendations. In total these searches yielded 137 articles. The limiter applied was
that each term must be within the title or abstract of the article.
PsychINFO (Appendix C) was the final database searched. Initially 160 articles generated
from the connected search terms of cancer survivorship and care plan or care planning. This
search was condensed to 136 through the limiter of publication date from 2013-2017. Survivor or

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breast cancer survivor was connected to previously searched terms through the AND connector.
The limiter of publication date was removed. This search yielded 138 articles. In order to review
articles that were specific to the clinical question’s population, breast cancer or breast neoplasm
was connected to survivorship and care plan or care planning. Fifty-five articles were found to
relate to this search.
Saturation was met based upon the reoccurrence of articles within each database.
Between the three databases the final field was 259, however, many of these articles were
duplicates, were not peer reviewed studies, and included childhood cancers, therefore they were
discarded. Forty articles were further reviewed and appraised. Article exclusion continued if they
were published prior to 2013, examined provider preference only, had limited generalizability
due to modest sample diversity, had poorly structured descriptive and statistical data, and were
irrelevant to the clinical inquiry. Eleven articles remained and were selected for further
evaluation due to their quality and relevance to the clinical question (Appendix D).
Critical Appraisal & Synthesis
Eleven studies were retained after rapid critical appraisal. With regard to the level of
evidence, four were level one (systematic reviews [SRs]), three were level two (randomized
control trials [RCTs]), and four were level four: one cohort study, one feasibility study, and two
cross-sectional studies (MeInyk & Fineout-Overholt, 2015). The majority of studies were
conducted in the United States, and all were quantitative studies expect one. The quality of the
chosen studies was deemed to be high after thorough review (Appendix D).
Sample size among level II-IV evidence ranged from 79 to 1,615 participants. The
studies’ demographic information revealed moderate homogeneity, which could result in bias of
outcome data. No biases were specifically mentioned (Appendix D). All eleven studies involved

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adult cancer survivors with a variable mean age ranging from 37 to 75 years. All studies had
more female participants than male, and most participants were survivors of breast or colorectal
cancer (Jefford et al, 2016). Four studies evaluated breast cancer survivors; one study evaluated
colorectal cancer survivors, while the remaining studies evaluated a variation of breast,
colorectal, gynecological, and other non-specified malignancies.
The primary intervention, implementation of SCPs, was evaluated across all studies.
Three studies addressed SCPs along with treatment summaries (TS) as an intervention, while two
studies addressed SCP plus a survivorship visit (SCPSV) as an intervention. Content and
distribution of SCPs revealed heterogeneity. The outcomes of interest addressed across the
studies included: quality of life, satisfaction, survivorship care knowledge, coordination of care,
follow-up to recommended guideline adherence, survivor distress, and survivor self-efficacy
(Appendix E). Self-efficacy and follow-up guideline adherence were the two variables that had
the least representation, therefore, research efforts tat evaluate these variables are necessary
(Appendix E). This information demonstrates value in the development of a project with the
focus of improving survivorship care.
There is heterogeneity of measurement tools. Most measurement tools were reported as
being valid and reliable, however, it was difficult to assess because each study used distinct
questionnaires and surveys. Potential for bias is apparent for the studies using surveys due to
their subjective nature (MeInyk & Fineout-Overholt, 2015). Reliability and validity was
demonstrated in all studies. (Appendix D).
The overarching themes that were found, in relation to outcomes, were improved patient
satisfaction and coordination of care. These outcomes were significantly demonstrated in five of
the eleven appraised studies after SCP implementation. Another outcome that presented

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significant improvement across multiple studies was survivorship care knowledge. The SCP
intervention that included survivorship visits demonstrated the most significant outcome
evidence (Appendix E).
To date the results of SCP implementation have been inconclusive. It is unknown as to
what factors are playing into these results. Despite this, there have been significant benefits in
patient satisfaction, coordination of care, and survivorship care knowledge. Application of these
significant findings in research and evidence-based practice projects could result in more
significant data and SCP process improvement (Appendix D).
Purpose Statement
This evidence has lead to the initiation of an evidence-based quality improvement
project. Breast cancer survivors that meet CoC survivor eligibility are the population of choice.
This is based on evidence that breast cancer is the most prevalent cancer for those to survive and
the most prominent cancer type. Through the involvement of stakeholders such as: the cancer
center’s nursing research manager, nursing informatics, multidisciplinary oncology providers,
the cancer registry, and the chosen SCP vendor team, data was collected to evaluate the cancer
center’s compliance to CoC standard 3.3 requirements and breast cancer survivors’ confidence in
cancer self-care knowledge and care satisfaction pre/post the initiation of a specific survivorship
visit where a SCP was delivered. The prospect of this pilot project is to meet CoC standard 3.3
requirements and bring understanding to SCPs function in cancer survivorship care.
Models
The Mayo Clinic Nursing Evidence-Based Practice Model (MCNEBP) was selected to
guide the implementation of the proposed evidence-based SCP pilot intervention. This sevenstep model was developed to guide practice change within Mayo for the purpose of assuring the

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use of best practice for attaining the best patient outcomes (Mayo Clinic, 2017). The MCNEBP
Model is specific to the Mayo Clinic and its patients, therefore, appropriateness of setting and
population is apparent. The seven steps include: formulate a question, search for evidence,
appraise the evidence, compare and contrast, decision options, evaluate, and disseminate. An
aspect unique to this model that is specific to SCP implementation is step five. There are four
decision options to choose from after comparing and contrasting evidence. If strong evidence is
in support of a change then the implementation of a practice change can occur, and if the
evidence is inconclusive the options are to place the project on hold, implement a quality
improvement project, or a research study (Mayo Clinic, 2017). Although the evidence for SCP
implementation is inconclusive patient satisfaction, coordination of care, and cancer care
knowledge elicited improvement; therefore, through the guidance of this model a project will be
initiated using the significant data found for facility quality improvement. This model will
further guide this project through evaluation and dissemination. SCPs effectiveness will be
evaluated through a pre and post questionnaire, and findings will be disseminated through
internal and external presentations.
The Chronic Care Model (CCM) further guides SCP implementation within the cancer
center. This model came about to correct the deficits that were present in the management of
chronic disease. The goal of this model is to attain proactive disease management instead of
reactive, which has resulted in improved care and patient outcomes (Improving Chronic Illness
Care, 2017). In correlation to this project, the goal of SCPs is to improve the deficits that are
present in cancer survivorship care; therefore, the CCM was adopted to guide the content and
structure of SCP implementation. The six fundamental elements that make up this model
includes: the community, the health system, self-management support, delivery system design,

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decision support, and clinical information systems. Each element includes a change concept that
is necessary for element improvement. These change concepts include: to meet patients’ needs
through community resources, to create a health system that fosters safe and high quality care,
patient empowerment and preparation in regards to their health and the care they should receive,
effective and efficient care that supports self-management, promotion of care that is based off of
evidence and patient preference, and readily assessable patient/population data to attain care that
is efficient and effective. Evidence demonstrates that the products of combining these elements
and their change concepts include healthier patients, satisfied providers, fiscal savings, improved
patient-provider communication, improved patient participation in care, and enhanced utilization
of provided resources in respect to chronic disease care (Wagner, 1998). The creation of a
survivorship visit and the information that is included within the SCPs has been based upon these
elements and change concepts. All elements and concepts have been incorporated into a
personalized SCP. Breast cancer survivors will receive their SCP at a survivorship visit in the
hope to improve their survivorship care from that of their current standard follow-up care. Using
this model generates SCP component structure and connection, which in turn assists project
development, implementation, and potential practice change.
Methods
An evidence-based quality improvement project was initiated within an accredited cancer
center in Arizona. A SCP intervention was delivered at a survivorship visit to eligible adult
breast cancer patients. The CoC’s survivor eligibility criteria included breast cancer patients 18
and older that were treated with curative intent for an initial cancer occurrence. The CoC also
required SCPs to be delivered within one year of patients’ cancer treatment completion. CoC

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eligible breast cancer survivors included in the pilot were identified retrospectively by the
organization’s cancer registry.
Prior to the implementation of the intervention the organization’s breast cancer providers
received SCP and project workflow education. This multi-disciplinary education was conducted
for the purpose of optimizing the SCP delivery process. Starting in August 2017 identified
survivors were scheduled for a survivorship

visit. Prior to the visit SCPs were created by a

registered nurse care coordinator and then reviewed and finalized by an oncology provider. The
SCPs were reviewed and delivered by the oncology provider at a specified survivorship visit and
included four essential elements: description of specific cancer diagnosis, treatments received,
instruction for follow-up care, and health promotion recommendations. Survivors perceived
confidence in cancer self-care knowledge and care satisfaction was measured

using the

Confidence in Survivorship Information Questionnaire (CSI). This 13-item questionnaire
measures survivors’ confidence in their knowledge of cancer diagnosis, treatment,
prevention/treatment of late disease/treatment effects, disease prevention, accessibility to
resources, and family cancer risk (Palmer, Jacobs, Mao, & Stricker, 2012). With permission from
the creators of the CSI three items were added to the questionnaire to address survivor care
satisfaction. Although there is no known validity to date, the reliability of this instrument is set
upon two subscales. The first three items of the questionnaire address survivor knowledge of
their cancer diagnosis and treatment and have a Cronbach’s alpha of 0.77 (Palmer, Jacobs, Mao,
& Stricker, 2012). The last 10 items have a Cronbach’s alpha of 0.95. This information
demonstrates relevance to evaluation questions and reliability of the instrument. The CSI utilizes
a three-point Likert scale with numerical values ranging from 1 (not
confident), whereas

at all confident) to 3 (very

a 5-point Likert scale with numeric values ranging from 5 (very satisfied)

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to 1 (very dissatisfied) was utilized for the evaluation of patient care satisfaction. Questionnaires
were completed prior to receiving their SCP at the survivorship visit. Post CSI questionnaires
were completed by phone in February 2018. The doctorate of nursing practice student contacted
initial survey project participants by phone and followed an Institute of Review Board (IRB)
script. A paired T-test analysis, alpha 0.5, was used to evaluate SCP effectiveness. Throughout
the pilot the organization’s adherence to CoC standard 3.3 requirements was evaluated by
tracking the number of survivors identified as needing a SCP, number of SCPs delivered,
percentage of the two, and percentage of the correct SCP sent to health information
management systems (HIMS) per provider.
Project IRB approval was obtained by ensuring the protection of survivors’ privacy and
rights through data being stored in encrypted servers/files, which were locked in cabinets. Also, a
username and password protected encrypted access. All protected health information complied
with HIPPA rules. The only individuals granted access to material were those who participated
in the project or provided direct care to the patient. Data was stored for the duration of pilot
project, and expires 24 months from project initiation.
Results
Data demonstrated an increase in the delivery of SCPs from zero to 57, and a practice
change adherence (SCP delivery) of 84 percent from August 2017 to January 2018. Survivors
and providers verbalize value in SCPs. Twenty-two breast cancer survivors completed a pre CSI
questionnaire and 20 of those completed a post CSI questionnaire. No statistical significance was
found in the comparison of SCPs effect on survivors’ confidence in cancer self-care knowledge
and care satisfaction to that of standard follow-up care; however, when comparing the pre and
post questionnaire averages an improvement was noted across the board. Survivors’ confidence

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in their knowledge of: preventing and treating long-term physical effects, community resources
available to them, family cancer risk, family risk information, and overall care satisfaction were
the areas of most clinical significant improvement post survivorship visit and SCP delivery. For
graphical representation of CSI questionnaire statistical and average findings reference appendix
G and H.
Discussion
Throughout this project a team-based approach was utilized. The organization’s
colorectal practice implemented SCPs through a workflow that was slightly different from
breast’s. This team-based approach was shown useful through CSI questionnaire findings. An
overall improvement in breast and colorectal cancer survivors' confidence in cancer self-care
knowledge and care satisfaction was demonstrated, which is consistent with current literature
and supports the continuation of SCP delivery. The colorectal practice identified significance in
results unlike the breast practice. This was most likely due to their provider workflow
consistency. Unfortunately provider inconsistency occurred in the breast practice due to an
unexpected absence. This resulted in acquiring other providers who did not receive as extensive
of education on SCP workflow and delivery as the original provider. This contributed to missed
survivorship consults and delivery inconsistency due to a variation in eligible survivor
identification. Organization compliance requires continued improvement to reach future SCP
delivery recommendations; however, this project enhances current research findings in the fact
that SCP effect is increased through consistency in provider education and the use of a focused
survivorship visit. Project limitations included a small sample size and a six-month observation
time. Another six months would have not only added to the sample size, but also allowed for the
evaluation of SCP delivery effect on patient outcomes such as: National Comprehensive Cancer

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Network follow-guideline adherence and health promotion behaviors (vaccine adherence and
smoking cessation). The cost of the vended SCP product may be viewed as a burden by some,
however, the reduction in cost of care through improvements in survivors’ self-efficacy and
disease prevention and health promotion practices may decrease the use of unnecessary
healthcare resources. With this outcome vended SCP products may be viewed as a cost saving.
Future research should include larger sample sizes and further investigation to identify the best
SCP tool and delivery process.
Conclusion
SCP delivery through a strategically designed survivorship visit shows to be an
operational framework that improves the transition from cancer patient to survivor. This project
aids as a guide for organization SCP implementation and CoC standard 3.3 requirement
compliance. The implementation of SCPs at a survivorship visit not only serves as a device to
instill greater confidence in survivors’ cancer self-care knowledge, but also improves survivors’
overall care satisfaction. In the end, effectively empowering cancer survivors in their
survivorship transition has the potential to improve their chances for long-term survival and
optimize their quality of life.

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Centers for Disease Control and Prevention. (2016). Cancer survivorship: Basic information for
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(2014). Associations among survivorship care plans, experiences of survivorship care,
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Survivorship, 8, 627-637. http://dx.doi.org/10.1007/s11764-014-0371-5
Forsythe, L. P., Parry, C., Alfano, C. M., Kent, E. E., Leach, C. R., Haggstrom, D. A., ...
Rowland, J. H. (2013). Use of survivorship care plans in the United States: Associations
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Haq, R., Heus, L., Baker, N. A., Dastur, D., Leung, F., Leung, E., ... Parsons, J. A. (2013).
Designing a multifaceted survivorship care plan to meet the information and
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Hebdon, M., Abrahamson, K., McComb, S., & Sands, L. (2014). Transitioning patients to
survivorship care: a systematic review . Oncology Nursing Forum, 6, 615-625.
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Hewitt, M., Greenfield, S., & Stovall, E. (2006). From cancer patient to cancer survivor: lost in
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Kinnane, N., Lai-Kwon, J., Gates, P., Shilkin, P., & Jefford, M. (2016). The impact of
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B. E., ... & Pisu, M. (2016). Treatment summaries and follow-up care instructions for
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Oncologist, 21(7), 817-824. http://dx.doi.org/10.1634/theoncologist.2015-0517
Klemanski, D. L., Browning, K. K., & Kue, J. (2016). Survivorship care plan preferences of
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Kvale, E. A., Huang, C. S., Meneses, K. M., Demark-Wahnefried, W., Bae, S., Azuero, C. B., ...
Ritchie, C. S. (2016). Patient-centered support in the survivorship care transition:
Outcomes from the patient-owned survivorship care plan intervention. Cancer, 32323242. http://dx.doi.org/10.1002/cncr.30136
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evidenced based practice model. (Unpublished data). Phoenix, AZ: Mayo Clinic
Mayer, D. K., Birken, S. A., Check, D. K., & Chen, R. C. (2015). Summing it up: An integrative
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http://dx.doi.org/10.1002/cncr.28884
MeInyk, B.M., Fineout-Overholt, E. (2015). Evidence-based practice in nursing & healthcare: a
guide to best practice. 3rd ed. Philadelphia, PA: Wolters Kluwer Health

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Miller, R. (2008). Implementing a survivorship care plan for patients with breast cancer. Clinical
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Oancea, S. C., & Cheruvu, V. K. (2016). Psychological distress among adult cancer survivors:
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http://dx.doi.org/10.1007/s00520-016-3291-2
Palmer, S. C., Jacobs, L. A., Mao, J. J., & Stricker, C. T. (2012). Are cancer survivors confident
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f?src=TAPResource
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A. (2015). Outcomes and satisfaction after delivery of a breast cancer survivorship care
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Petiprin, A. (2016) Health promotion model. Retrieved from http://www.nursingtheory.org/theories-and-models/pender-health-promotion-model.php
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https://lib.asu.edu
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Wagner, E.H. (1998). Chronic disease management: what will it take to improve care for chronic
illness? Effective Clinical Practice, 12(1), 2-4. http://ecp.acponline.org/pastiss.htm

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Appendix A
Search Strategy: CINHAL

25

SURVIVORSHIP CARE PLANNING
Appendix B
Search Strategy: PubMed

26

SURVIVORSHIP CARE PLANNING
Appendix C
Search Strategy: PsychINFO

27

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28

Appendix D
Evaluation Table
Citation

Boekhout, A. H.
(2015). A
survivorship care
plan for breast
cancer survivors:
Extended results of
a randomized
clinical trial
Country: Canada
Disclosure/Conflict
of Interest: None to
disclose
Funding: Canadian
Breast Cancer
Research Alliance

Conceptual
Framework
Inferred:
Change theory

Design/Method

Design:
Randomized
Control Trial

Pender’s HPM
Conducts the
progress of
health
promotion
interventions.

Purpose:
Determine
whether SCP
utilization in BC
patients
improved
patient-reported
outcomes/health
care utilization
when
transitioning
care to PCP.

Sample/Setting

N= 408
N I=164
N C=173
MA intervention: 61.9
(SD: 10.2)
MA control:
61 (SD: 10.2)
TOT, I: TM: 47, BCS:
117. R:133, CT: 68,
HT: 113
TOT C: TM: 42,
BCS:131, R: 143, CT:
71, HT: 130
MFD, I: <24 mo.:70
>/=24mo: 94
MFD, C: <24mo: 69
>/=24mo: 104
Inclusion Criteria: early
stage breast CA, no
recurrence or
secondary cancer.
Completed primary
>/=3 months to

Major Variables &
Definitions

Measurement

Data
Analysis

Findings

IV1: SCP receipt
IV2: No SCP receipt

Questionnaires
at baseline, 3,
6, 18, and 34
months.
Telephone
interviews at 9,
15, and 21
months.

All analyses
were
performed
with SAS
version 9.1 or
R version
2.7.1

DV1-5 No
difference between
control/intervention
group.

DV1: CSD,
DV2: HRQL
DV3: PS
DV4: CCC
DV5: GA

Impact of
Event Scale
(IES), Profile
of Mood States
questionnaire
(POMS),
Physical and
Mental
Component
SP-36
summary
scales (PSC,
MSC), the
Medical
Outcomes
Study-Patient
Satisfaction
Questionnaire
(MOS-PSQ),
and the CCCQ

Decision for Use in
Practice/Application to
Practice
LOE: II
Strengths: generalizable
to practice settings;
sample size; looked at
short-term and long-term
benefit/sustainability of
SCPs
Limitations: adherence
score based upon patient
self-report; misclassified
tests as routine when
they are diagnostic; IES
sensitivity
Applicability/Feasibility:
Further research must be
conducted in
determining the essential
elements of SCPs that
provide benefit for
survivors prior to a
widespread
implementation.

AR: attrition rate, BC: breast cancer, BCS: breast conserving surgery, BRFSS: behavioral risk factor surveillance system, C: Control, CaSUN: cancer survivors’
unmet needs measure, CC: colon cancer, CCC: continuity and coordination of care, CCCQ: coordination of care questionnaire, CDa: complete data CHC:
childhood cancer, CS: cancer survivors, CSD: cancer specific distress, CT: chemo therapy, DS: disease stage, DV: dependent variable, EOL: end of life, EORT:
European organization for research and treatment, ES: entire sample, F: female, FCI: follow-up care intervention, FU: follow-up, G: group, GA: guideline
adherence, GC: gynecological cancer, GSI: global severity index, HC: health care, HPM: health promotion model, HRQL: health related quality of life, HT:
hormone therapy, I: intervention, IOM: institute of medicine, IV: independent variable, N/n: number, M: male, MA: mean age, MFD: months from diagnosis,
MS: marital status, PC: palliative care, PCP: primary provider, POSTCARE: patient-owned survivorship transition care for activated, empowered survivors, PR:
peer reviewed, PRO: patient reported outcomes, PS: patient satisfaction, QLS: qualitative study, QTS: quantitative study, RCT: randomized control trial RT:
radiation therapy, SCP: survivorship care plan, TM: total mastectomy, TOC: type of cancer, TOT: type of treatment U: unknown, y/o: years-old

SURVIVORSHIP CARE PLANNING

29

enrollment, Established
PCP for FU care
Exclusion Criteria:
persistent
complications of
primary treatment,
previously enrollment
in continuous oncology
FU, primary cancer
other BC, shared PCP
with another study
participant
AR:71
Brennan, M.E.
(2014).
Survivorship care
plans in cancer: a
systematic review
of care plan
outcomes
Country: Australia
Disclosures/Conflict
of Interest: unstated
Funding: The
Friends of The
Mater Foundation

Inferred:
Henderson
Need Theory
Qualify of life
theory- based
from Maslow’s
theory of needs.

Design:
Systematic
Review
Purpose:
Review
evidence of SCP
implementation
in practice.

N= 2,286 participants.
Articles n=10
n=5 RCT’s
n=5 non RCTs
TOC:
BC, CC, GC, CHC
Mean age range:
37-62
Inclusion criteria:
original studies
evaluating written care
plans for CS, and
reporting HRQL, and
SOC
Exclusion criteria:
articles evaluating SCP
in metastatic disease,
and studies that
evaluated a single

IV1: paper
based/online SCP
IV2:
oncologist/nurse/PCP
delivered SCPs
IV3: Other SCP
templates

Cancer
Survivor
Unmet Needs
Scale

DV1: Survivor
distress
DV2: CCC
DV3: oncological
outcomes
DV4: ability to
identify FU provider
DV5: change in
unmeet needs

EORT quality
of life
questionnaire

Multiple likert
scales

Brief symptom
inventory 18

“QualSyst”
tool for SR
Descriptive
statistics,
multivariate
regression, ttest

No significant
findings related to
distress, care
coordination,
satisfaction, or
cancer outcomes.

LOE: I

SCPs improved
survivor follow-up
clinician
identification
(p=0.005).

Limitation: small
amount of
heterogeneous literature;
few RCTs.

Higher Satisfaction
with SCPs,
understanding of
SCP, and CCC (did
not meet statistical
significance)

Strengths: heterogeneity
in SCP content.
Represent data from
2,288 cancer survivors.

Lack of homogeneity
between cancer type/
stage of disease.
Inconsistency in
evaluation tools.
Ceiling effect in SCP
satisfaction.
Applicability: evidence
supports increased
patient satisfaction and

AR: attrition rate, BC: breast cancer, BCS: breast conserving surgery, BRFSS: behavioral risk factor surveillance system, C: Control, CaSUN: cancer survivors’
unmet needs measure, CC: colon cancer, CCC: continuity and coordination of care, CCCQ: coordination of care questionnaire, CDa: complete data CHC:
childhood cancer, CS: cancer survivors, CSD: cancer specific distress, CT: chemo therapy, DS: disease stage, DV: dependent variable, EOL: end of life, EORT:
European organization for research and treatment, ES: entire sample, F: female, FCI: follow-up care intervention, FU: follow-up, G: group, GA: guideline
adherence, GC: gynecological cancer, GSI: global severity index, HC: health care, HPM: health promotion model, HRQL: health related quality of life, HT:
hormone therapy, I: intervention, IOM: institute of medicine, IV: independent variable, N/n: number, M: male, MA: mean age, MFD: months from diagnosis,
MS: marital status, PC: palliative care, PCP: primary provider, POSTCARE: patient-owned survivorship transition care for activated, empowered survivors, PR:
peer reviewed, PRO: patient reported outcomes, PS: patient satisfaction, QLS: qualitative study, QTS: quantitative study, RCT: randomized control trial RT:
radiation therapy, SCP: survivorship care plan, TM: total mastectomy, TOC: type of cancer, TOT: type of treatment U: unknown, y/o: years-old

SURVIVORSHIP CARE PLANNING

30

variable of care

self-reported
understanding of
survivorship care.

AR: N/A

Feasibility: SCPs took 14 hours to develop.
Bulloch, K. J.
(2015). Systematic
approach to
providing breast
cancer survivors
with survivorship
care plans: a
feasibility study
Country: USA
Disclosure/Conflict
of Interest: Several
authors provide
disclosures

Funding: American
Society Grant

Inferred:
Explanatory
Theory
Pender’s HPM

Design:
Pre/post
feasibility study
Purpose:
1. Assess
feasibility of
SCPs.
2. Determine if
knowledge of
diagnosis,
treatment, and
risk of long term
adverse event
improved post
receipt of SCP.

N= 67 total sample
CDa: n=51
MA;, ES 55.9
MA, CDa: 56.8
DS, ES:
Stage 1: n=32
Stage 2: n=25
Stage 3: n=11
DS, CDa:
Stage 1: n=24
Stage 2: n-19
Stage 3: n=8
TOT, ES:
RT: n=43
C: n=36
HT: n=52
TOT, CD:
RT: n=36
CT: n=29
HT: n=39

IV1: care prior to
SCP
IV2: care post SCP
DV1: feasibility
DV2: diagnosis
knowledge
DV3: treatment
knowledge
DV4: Knowledge of
risk for long-term
adverse effects.

Three selfadministered
surveys at
baseline visit
and two
surveys at F/U
visit.
Impact of
events scale,
profile of
mood states
questionnaire,
physical and
mental
component SF36

Multivariable
logistic
regression
analysis

DV2: improved
understanding of
cancer stage at F/U
visit post SCP
receipt (not
significant)
DV4: improved
understanding of
risk of leukemia at
F/U visit post SCP
receipt (p=0.0348)
84% patient
satisfaction with
SCP

LOE: IV
Strengths: First study of
its kind
Limitations: Small
sample size; information
was collected from
single health care system
(not a generalized
population); adverse
events were not
personalized to
treatment
Applicability/feasibility:
With the improvement
in patient survivorship
knowledge it is feasible
to deliver SCPs to breast
cancer survivors at their
post-op visit.

AR:16
Setting:
Smilow Cancer
Hospital Breast Center
at Yale –New Haven,

AR: attrition rate, BC: breast cancer, BCS: breast conserving surgery, BRFSS: behavioral risk factor surveillance system, C: Control, CaSUN: cancer survivors’
unmet needs measure, CC: colon cancer, CCC: continuity and coordination of care, CCCQ: coordination of care questionnaire, CDa: complete data CHC:
childhood cancer, CS: cancer survivors, CSD: cancer specific distress, CT: chemo therapy, DS: disease stage, DV: dependent variable, EOL: end of life, EORT:
European organization for research and treatment, ES: entire sample, F: female, FCI: follow-up care intervention, FU: follow-up, G: group, GA: guideline
adherence, GC: gynecological cancer, GSI: global severity index, HC: health care, HPM: health promotion model, HRQL: health related quality of life, HT:
hormone therapy, I: intervention, IOM: institute of medicine, IV: independent variable, N/n: number, M: male, MA: mean age, MFD: months from diagnosis,
MS: marital status, PC: palliative care, PCP: primary provider, POSTCARE: patient-owned survivorship transition care for activated, empowered survivors, PR:
peer reviewed, PRO: patient reported outcomes, PS: patient satisfaction, QLS: qualitative study, QTS: quantitative study, RCT: randomized control trial RT:
radiation therapy, SCP: survivorship care plan, TM: total mastectomy, TOC: type of cancer, TOT: type of treatment U: unknown, y/o: years-old

SURVIVORSHIP CARE PLANNING

31

Inclusion criteria:
confirmed diagnosis
BC staged 1-3. BC
surgery at stated
setting, >18 y/o,
English literacy
Exclusion criteria:
stage 0 or metastatic
disease.
Jefford, M. (2016).
A randomized
controlled trial of a
nurse led supportive
care package
(SurvivorCare) for
survivors of
colorectal cancer
Country: Australia
Disclosures/Conflict
of Interest/Funding:
Denied financial
relationships

Inferred:
Social
Cognitive
Theory
Pender’s HPM

Design:
Randomized
Control Trial
Purpose:
Evaluate
effectiveness of
SCP/care
package on
psychological
distress, HRQL,
unmet info.
needs, and
psychosocial
outcomes in CR
CS.

N= 217
N I= 106
N C= 110
Median age: 64
(M: 52% F:48%)
TOC: CC(56%), RC
(35%), OLS (10%)
SOD: S1 (7%) , S2
(22%), S3 (71%)
AR: 1
Inclusion criteria:
confirm diagnosis of
CC or CR, stage I-III
disease, rx w/ curative
intent. >18 y/o,
English speaking
Exclusion criteria:
cognitive/psychological
impairment,
determined too unwell
to participate, hx of
other malignancy with
exception of non-

IV1: SurvivorCare
IV2: Usual Care

BSI-18 and
GSI

DV1: Psychological
distress
DV2: HRQL
DV3: Change in
Unmet needs.

European
organization
for research
and treatment
(EORTC QLQ
C-30)
Ideals of
Survivorship
care survey
(self
developed)
CaSUN

SPSS
statistics.
Descriptive
statistics
T test (Mannwhitney U)
and Chisquare tests as
appropriate.
Hochberg’s
modify
Bonferroni
test for
primary
outcome
analysis.

No difference in
Distress and HQOL
between IV1 and
IV2
IV1 more satisfied
with multiple
aspects of post
treatment care
(p=<0.05 on 10 of
15 questions about
perception of care)

LOE: II
Strengths: validation of
strong sensitivity and
appropriateness of
assessment tools.
N>100, Diagnosis
homogeneity.
Limitations:
Heterogeneity of
baseline cancer
distress/time since
diagnosis.
Applicability:
Demonstration of
intervention usefulness
in elements of
survivorship care.
Highest usefulness in
patients with higher
CaSUN scores.
Feasibility: Research
needs to carefully
identify study endpoints.

AR: attrition rate, BC: breast cancer, BCS: breast conserving surgery, BRFSS: behavioral risk factor surveillance system, C: Control, CaSUN: cancer survivors’
unmet needs measure, CC: colon cancer, CCC: continuity and coordination of care, CCCQ: coordination of care questionnaire, CDa: complete data CHC:
childhood cancer, CS: cancer survivors, CSD: cancer specific distress, CT: chemo therapy, DS: disease stage, DV: dependent variable, EOL: end of life, EORT:
European organization for research and treatment, ES: entire sample, F: female, FCI: follow-up care intervention, FU: follow-up, G: group, GA: guideline
adherence, GC: gynecological cancer, GSI: global severity index, HC: health care, HPM: health promotion model, HRQL: health related quality of life, HT:
hormone therapy, I: intervention, IOM: institute of medicine, IV: independent variable, N/n: number, M: male, MA: mean age, MFD: months from diagnosis,
MS: marital status, PC: palliative care, PCP: primary provider, POSTCARE: patient-owned survivorship transition care for activated, empowered survivors, PR:
peer reviewed, PRO: patient reported outcomes, PS: patient satisfaction, QLS: qualitative study, QTS: quantitative study, RCT: randomized control trial RT:
radiation therapy, SCP: survivorship care plan, TM: total mastectomy, TOC: type of cancer, TOT: type of treatment U: unknown, y/o: years-old

SURVIVORSHIP CARE PLANNING

32

melantanomous skin
cancer, and enrollment
in a conflicting
supportive care trial
Keesing, S. (2015).
Cancer survivors’
experiences of using
survivorship care
plans: a systematic
review of
qualitative studies
Country: USA
Disclosure/Conflict
of Interest/Funding:
None

Inferred:
Self-care theory
1. Addresses
knowledge and
experience
2. Influences
cancer patients’
self- reliance
and
responsibility
for care.
Pender’s HPM

Design:
Systematic
Review
Purpose:
Review and
document
current
qualitative
literature that
examines CS’s
experience
using SCPs.

N= 11 qualitative
studies.
Interview: n= 4,
Focused groups: n= 6
Action research: n= 1
Range of number of
participants: 7-40.
TOC:
BC: n= 7,
CC: n= 2
other: n= 3
Inclusion criteria:
>/= 18 y/o, publication
2000-2014, published
in English
Exclusion criteria:
Abstract only, studies
that examined
palliative phase of
disease, or experience
of cancer treatment.

IV: Use of SCP
DV : CS perspective
on SCPs and
experiences of SCP
use in care.

KMET (close
method 14
item)

Critical
appraisal:
Standard
quality
assessment
criteria for
evaluating
primary
research
papers from a
variety of
fields by
Kamet, lee
and cook.

SCP: Significant
reduction of
duplicate materials,
improved CCC, and
increased
communication
between survivor
and health care
provider.

LOE: I
Strengths: first published
qualitative SR. 11
databases included.
Utilized validated
methods/tools for
conducting SR.
Limitations: Difference
in amount of qualitative
data.
Applicability/Feasibility:
SCPs found to be
practical tool in
survivorship care. Future
research to examine
practical issues related
to delivery across a
variety of care contexts.

AR: N/A

AR: attrition rate, BC: breast cancer, BCS: breast conserving surgery, BRFSS: behavioral risk factor surveillance system, C: Control, CaSUN: cancer survivors’
unmet needs measure, CC: colon cancer, CCC: continuity and coordination of care, CCCQ: coordination of care questionnaire, CDa: complete data CHC:
childhood cancer, CS: cancer survivors, CSD: cancer specific distress, CT: chemo therapy, DS: disease stage, DV: dependent variable, EOL: end of life, EORT:
European organization for research and treatment, ES: entire sample, F: female, FCI: follow-up care intervention, FU: follow-up, G: group, GA: guideline
adherence, GC: gynecological cancer, GSI: global severity index, HC: health care, HPM: health promotion model, HRQL: health related quality of life, HT:
hormone therapy, I: intervention, IOM: institute of medicine, IV: independent variable, N/n: number, M: male, MA: mean age, MFD: months from diagnosis,
MS: marital status, PC: palliative care, PCP: primary provider, POSTCARE: patient-owned survivorship transition care for activated, empowered survivors, PR:
peer reviewed, PRO: patient reported outcomes, PS: patient satisfaction, QLS: qualitative study, QTS: quantitative study, RCT: randomized control trial RT:
radiation therapy, SCP: survivorship care plan, TM: total mastectomy, TOC: type of cancer, TOT: type of treatment U: unknown, y/o: years-old

SURVIVORSHIP CARE PLANNING
Kenzik, K. M.
(2016). Treatment
summaries and
follow-up care
instructions for
cancer survivors:
Improving survivor
self-efficacy, and
healthcare
utilization

Inferred:
Social
Cognitive
Theory

Country: USA
Disclosure/Conflict
of Interest: None
stated

Design:
Cross-Sectional
Purpose:
Examine how
treatment
summaries
(SCP) both
written and
verbal are
associated with
self-efficacy and
healthcare
utilization.

33

N= 441
MA: 74.7
F(60%) M (40%)
Education:
LSE: 49%
TOC:
prostate and breast
cancer
Mean time from
diagnosis: 4.6 years

IV1: Delivery of
written summary of
cancer treatment w/
SCP by health
professional
IV2: written
summary of SCP w/o
explanation.
IV3: verbal delivery
of FU care plan w/o
written summary.
DV 1: ER visits
DV 2:
hospitalizations

Stanford
chronic illness
self-efficacy
scale
Study pertinent
developed
questions:
SCP type/
delivery.
ER visits/
hospitalization
in last year,

Setting:
hospital based; 12
different sites across
Alabama, Georgia,
Mississippi, Florida,
Tennessee

Funding:
Department of
Health and Human
Services

Primary
analysis: 3
multiple
linear
regression
models
Exploratory
analysis:
Mediation
analysis to
estimate
association
between
variables
Post Hoc
analysis

IV1: increased selfefficacy scores
(B=0.72, SD=0.27,
p=0.009) and
decreased
emergency room
visits/hospitalization
DV1-DV2
decreased
significantly with
IV1

Inclusion Criteria: CS
who had completed
treatment, follow
completion of initial
survey and were >/= 2
years

Design:
Systematic
Review
Purpose:
Describe and

N= 29 total
Quantitative= 19
RCT= 3
Pre/post test= 1
Survey with descriptive

Limitations: reliance on
patient self-report of
SCP type/delivery.
Patient-provider
relationship/recollection
of information=
influence of self-efficacy
scores. Lack of insight
to content or
standardization of SCPs.

Future research:
Examine how SCPs help
survivors, identify how
to effectively implement
verbal SCP explanation

Exclusion criteria:
incomplete survey, < 2
years post treatment
Inferred:
Explanatory
Theory

Strengths: large sample
size, evaluation of
several HC sites.
Evaluation of older
cancer survivors.
Use of validated
measurement tool.

Applicability/feasibility:
Suggestion: SCPs
influence survivor’s
behavior/health
outcome.

AR = 0

Klemanski, D. L.
(2016).
Survivorship care
plan preferences of
cancer survivors
and health care

LOE: IV

IV: SCP use
IV2: usual care
Patient variables:
DV 1: Survivorship
experiences

Focus groups,
individual
interviews
Mixed
methods

Critical
appraisal:
Quality
assessment
tool for QTS
Joanna Briggs

SCP: Improved
CCC between PCP
and oncologist.
Improved survivor
understanding of

LOE: I
Strengths: large amount
of heterogeneous data
Limitations: mostly

AR: attrition rate, BC: breast cancer, BCS: breast conserving surgery, BRFSS: behavioral risk factor surveillance system, C: Control, CaSUN: cancer survivors’
unmet needs measure, CC: colon cancer, CCC: continuity and coordination of care, CCCQ: coordination of care questionnaire, CDa: complete data CHC:
childhood cancer, CS: cancer survivors, CSD: cancer specific distress, CT: chemo therapy, DS: disease stage, DV: dependent variable, EOL: end of life, EORT:
European organization for research and treatment, ES: entire sample, F: female, FCI: follow-up care intervention, FU: follow-up, G: group, GA: guideline
adherence, GC: gynecological cancer, GSI: global severity index, HC: health care, HPM: health promotion model, HRQL: health related quality of life, HT:
hormone therapy, I: intervention, IOM: institute of medicine, IV: independent variable, N/n: number, M: male, MA: mean age, MFD: months from diagnosis,
MS: marital status, PC: palliative care, PCP: primary provider, POSTCARE: patient-owned survivorship transition care for activated, empowered survivors, PR:
peer reviewed, PRO: patient reported outcomes, PS: patient satisfaction, QLS: qualitative study, QTS: quantitative study, RCT: randomized control trial RT:
radiation therapy, SCP: survivorship care plan, TM: total mastectomy, TOC: type of cancer, TOT: type of treatment U: unknown, y/o: years-old

SURVIVORSHIP CARE PLANNING
providers: a
systematic review
and quality
appraisal of the
evidence.
Country:
US Publication
(included reviews
published in Canada
and Australia)
Disclosure/Conflict
of Interest/Funding:
None

examine the use
of treatment
summaries and
SCP in current
practice, as well
as critically
appraise
relevant
literature
regarding
preferences and
usefulness of
SCP in practice.

34

analysis= 15
Qualitative= 10
Study characteristics:
Survivor perspectives
(N=20)
Cancer survivor
perspective only
(N=14)
Survivor and provider
perspective (N=6)
TOC: BC (n=10) CC
(n=3) GC (n=1), other
malignancies (n=6)

Settings:
cancer centers,
oncology clinics,
tertiary care centers,
community cancer
centers

DV 2: Quality of
care
DV 3: Satisfaction
(with collaborative
communication
between care
providers)
DV4: Perceived gaps
in CS care
DV 5: Delivery of
SCP
Provider variables:
DV 1 : Perceived
barriers to SCP
implementation
DV 2: Role
clarification in SCP
DV 3: Confidence in
management of CS
care.

appraisal tool
Transparent
reporting of
evaluation with
nonrandomized
design

Institute’s
qualitative
assessment
and review
instrument.

survivorship care.

exploratory studies.
Narrow gender/TOC
focus. Heterogeneity in
SCPs format/HC
settings.
Applicability/feasibility:
Improved follow-up care
(provider/patient
perspective).
Future research:
identify/prioritize patient
preferences in
survivorship care, and
SCP delivery across
settings

Inclusion:
QLS or QTS related to
preference of items to
be incorporated in
SCPs, reported by CS,
care givers, or health
care providers, Studies
published Jan 2005Dec 2013, Original
work/ PRJ, English,
Exclusion:
study addressed
PC/hospice/EOL care,
pertained survival and

AR: attrition rate, BC: breast cancer, BCS: breast conserving surgery, BRFSS: behavioral risk factor surveillance system, C: Control, CaSUN: cancer survivors’
unmet needs measure, CC: colon cancer, CCC: continuity and coordination of care, CCCQ: coordination of care questionnaire, CDa: complete data CHC:
childhood cancer, CS: cancer survivors, CSD: cancer specific distress, CT: chemo therapy, DS: disease stage, DV: dependent variable, EOL: end of life, EORT:
European organization for research and treatment, ES: entire sample, F: female, FCI: follow-up care intervention, FU: follow-up, G: group, GA: guideline
adherence, GC: gynecological cancer, GSI: global severity index, HC: health care, HPM: health promotion model, HRQL: health related quality of life, HT:
hormone therapy, I: intervention, IOM: institute of medicine, IV: independent variable, N/n: number, M: male, MA: mean age, MFD: months from diagnosis,
MS: marital status, PC: palliative care, PCP: primary provider, POSTCARE: patient-owned survivorship transition care for activated, empowered survivors, PR:
peer reviewed, PRO: patient reported outcomes, PS: patient satisfaction, QLS: qualitative study, QTS: quantitative study, RCT: randomized control trial RT:
radiation therapy, SCP: survivorship care plan, TM: total mastectomy, TOC: type of cancer, TOT: type of treatment U: unknown, y/o: years-old

SURVIVORSHIP CARE PLANNING

35

mortality statistics,
targeted sample was
pediatric or adolescent
oncology, secondary
works.
AR: N/A
Kvale, E. A. (2016).
Patient-centered
support in the
survivorship care
transition:
Outcomes from the
patient-owned
survivorship care
plan intervention

Explicitly
states:
POSTCARE
conceptual
model; derived
from chronic
care model/IOM
survivorship
policies

Country: USA

Pender’s HPM

Disclosure/Conflict
of Interest: Three
authors received
support from
National Institute
of Health
Funding: Grant
support from
American Cancer
Society

Design:
Randomized
Control Trial

N= 79
I: n-40
C: n=39

IV 1: POSTCARE
intervention
IV 2: usual care

Purpose:
Determine the
impact that the
POSTCARE
intervention had
on patient
outcomes/care
coordination.

MA, I: 57.23
MA, C: 59.51
TOC: breast
TOT, I:
LNB: n=32
LND: n=17
CT: n=23
RT: n=27
S: n=40
TOT C;
LNB: n=30
LND: n=9
CT: n=18
RT: n=26
S: n=39
Inclusion criteria: >/=
19 y/o, non-metastatic
disease, completion of
treatment within one
year
Exclusion criteria:
outside of one year of
active treatment

DV1: HRQL
DV2: Depression
DV3: Self efficacy
and self-management

Health literacy:
Rapid estimate
of adult
literacy in
medicine-short
form.
Comorbidity:
Charleston
comorbidity
index
HQOL: 36item shortform health
survey
Depression:
PHQ-9
Limitations,
social
role/activities:
4-item
social/role
activities
limitation.
Selfmanagement:
13-item patient
activation

SPSS:
Version 22
and SAS
version 9.4.
Descriptive
analysis:
demographics
and treatment
characteristic.

IV 1: lower social
role limitations
(p=0.014), and
higher self efficacy
(0.07) .

Chi-square
test for
comparison
between
groups
regarding
frequency.

IV 1: Three HQOL
domains had
meaningful
improvement at 3
mo. FU: physical
role (p=0.009),
bodily pain
(p=0.03), emotional
role (p=0.04).

Student t test
for within
group
comparison.
Generalized
linear model
used to
examine
effect of
intervention
coordination
and patient
reported

IV 1: higher self
reported health
(p=0.017).

LOE: II
Strengths: examines
several variables, use of
valid measurements
tools.
Limitations: population
(breast patients only);
not generalizable. Small
sample size. Limited
power. Long-term effect
not captured.
Applicability: Support
and emphasis of data
about importance of
providing a SCP and
health care providers
role in discussing
content.
Feasibility: Future
research to identify how
HC provider can deliver
SCP (effectively,
sensible, and with
impact)

AR: attrition rate, BC: breast cancer, BCS: breast conserving surgery, BRFSS: behavioral risk factor surveillance system, C: Control, CaSUN: cancer survivors’
unmet needs measure, CC: colon cancer, CCC: continuity and coordination of care, CCCQ: coordination of care questionnaire, CDa: complete data CHC:
childhood cancer, CS: cancer survivors, CSD: cancer specific distress, CT: chemo therapy, DS: disease stage, DV: dependent variable, EOL: end of life, EORT:
European organization for research and treatment, ES: entire sample, F: female, FCI: follow-up care intervention, FU: follow-up, G: group, GA: guideline
adherence, GC: gynecological cancer, GSI: global severity index, HC: health care, HPM: health promotion model, HRQL: health related quality of life, HT:
hormone therapy, I: intervention, IOM: institute of medicine, IV: independent variable, N/n: number, M: male, MA: mean age, MFD: months from diagnosis,
MS: marital status, PC: palliative care, PCP: primary provider, POSTCARE: patient-owned survivorship transition care for activated, empowered survivors, PR:
peer reviewed, PRO: patient reported outcomes, PS: patient satisfaction, QLS: qualitative study, QTS: quantitative study, RCT: randomized control trial RT:
radiation therapy, SCP: survivorship care plan, TM: total mastectomy, TOC: type of cancer, TOT: type of treatment U: unknown, y/o: years-old

SURVIVORSHIP CARE PLANNING

36

measure-short
form.

outcomes.

Self efficacy:
Self efficacy
for managing
chronic disease
6-item scale

Mayer, D. K.
(2015). Summing it
up: an integrative
review of studies of
cancer survivor care
plans
Country: USA
Disclosure/Conflict
of Interest: None
Funding: The
University of North
Carolina

Mentioned:
Dobediam
Model

Design:
Integrative
Review
Purpose:
Summarize
current
scientific
knowledge, and
empirical data
regarding SCP
in adult CS, and
identification of
knowledge gaps
in survivorship
care

N= 42 studies

IV: SCP

Populations:
CS
HCP

DV 1: SCP content
DV 2: SCP
dissemination and
implementation
DV3: survivor and
provider outcomes

Categories of Focus:
1.Content of SCP
2.Dissemination/
Implementation
3.Survivor/provider
outcomes
AR: 0
Inclusion Criteria:
results of empirical
study, CS diagnosed at
>/= 18 y/o, relate to
cancer and report
findings that associated
with SCPs
Exclusion Criteria:

Interviews,
focus groups,
and multiple
unspecified
survey tools

PRISMA

Discrepancy
between HC
providers/survivors
in desired SCP
content
Improved PCPreported
CCC/confidence in
survivorship
knowledge (p<0.05)
Lack of info. on
delivery preference
Few studies found
patients preferred
delivery right before
or directly after
treatment.
Only 12.5% of
patients received
SCP (10 cancer

LOE: I
Strength: evaluation of a
vast amount of evidence.
Both provider and
survivor perspectives
evaluated.
Limitations: 4 high level
studies availability.
Limited generalizability
(lack of diversity).
Weak testing of data
measurement tools
Applicability: Low SCP
receptivity/
implementation
Feasibility: Future
research to address SCP
methodology, content ,
and outcomes.

AR: attrition rate, BC: breast cancer, BCS: breast conserving surgery, BRFSS: behavioral risk factor surveillance system, C: Control, CaSUN: cancer survivors’
unmet needs measure, CC: colon cancer, CCC: continuity and coordination of care, CCCQ: coordination of care questionnaire, CDa: complete data CHC:
childhood cancer, CS: cancer survivors, CSD: cancer specific distress, CT: chemo therapy, DS: disease stage, DV: dependent variable, EOL: end of life, EORT:
European organization for research and treatment, ES: entire sample, F: female, FCI: follow-up care intervention, FU: follow-up, G: group, GA: guideline
adherence, GC: gynecological cancer, GSI: global severity index, HC: health care, HPM: health promotion model, HRQL: health related quality of life, HT:
hormone therapy, I: intervention, IOM: institute of medicine, IV: independent variable, N/n: number, M: male, MA: mean age, MFD: months from diagnosis,
MS: marital status, PC: palliative care, PCP: primary provider, POSTCARE: patient-owned survivorship transition care for activated, empowered survivors, PR:
peer reviewed, PRO: patient reported outcomes, PS: patient satisfaction, QLS: qualitative study, QTS: quantitative study, RCT: randomized control trial RT:
radiation therapy, SCP: survivorship care plan, TM: total mastectomy, TOC: type of cancer, TOT: type of treatment U: unknown, y/o: years-old

SURVIVORSHIP CARE PLANNING

37

abstracts or
presentations, adult
survivors of childhood
cancer, and nonempirical data

Oancea, S. C.
(2016).
Psychological
distress among adult
cancer survivors:
Importance of
survivorship care
plan.
Country: USA
Disclosure/Conflict
of Interest/Funding:
None

Inferred:
Health Belief
Model
Pender’s HPM

Design:
Cross-sectional
Purpose:
To examine
association
between
recipient of SCP
and
psychological
distress in adult
cancer survivors
post treatment.

N= 3,191
G1: CS 1-5 y from
diagnosis
N:1046
Median age: 58.85
F (n=610)
M (n=436)
Received FCI: n:789
Received TS: n:366
G2: CS >5 y from
diagnosis
N:2145
Median age: 64.52
F (n=1463)
M (n=682)
EL:
LTS: N=173
S: n=709
SC: n=573
CD or more: n=690
Received SCI: n=1424

programs)

IV 1: TS only
IV: FCI only
IV: TS + FCI
IV 4: non TS or FCI
DV 1: Psychological
distress

Behavioral risk
factor
surveillance
system
questionnaire.
Cancer
survivorship
and anxiety
and depression
modules

Descriptive
statistics.
Critical
analysis: SAS
b 9.4, using
survey
procedures.
Multivariable
weighted
logistic
regression
(investigate
association
between
variables)

Short-term cancer
survivors: Distress
3x higher if only
FCI receipt, as
compared to FCI +
TS (AOR= 3.14,
95% CI [1.297.65]).
Long-term cancer
survivors: distress
was 2x higher only
FCI receipt (AOR=
2.18, 95% CI [1.144.19]).

LOE: IV
Strengths: sample size,
first study to look at
long-term distress.
Limitations:
underrepresentation of
TS, but no FCI group.
Pain severity/comorbid
conditions not controlled
or assessed. Questions
subject to recall;
potential bias
Applicability: SCPs has
potential to enhance
short/long-term
psychological wellbeing.

AR: attrition rate, BC: breast cancer, BCS: breast conserving surgery, BRFSS: behavioral risk factor surveillance system, C: Control, CaSUN: cancer survivors’
unmet needs measure, CC: colon cancer, CCC: continuity and coordination of care, CCCQ: coordination of care questionnaire, CDa: complete data CHC:
childhood cancer, CS: cancer survivors, CSD: cancer specific distress, CT: chemo therapy, DS: disease stage, DV: dependent variable, EOL: end of life, EORT:
European organization for research and treatment, ES: entire sample, F: female, FCI: follow-up care intervention, FU: follow-up, G: group, GA: guideline
adherence, GC: gynecological cancer, GSI: global severity index, HC: health care, HPM: health promotion model, HRQL: health related quality of life, HT:
hormone therapy, I: intervention, IOM: institute of medicine, IV: independent variable, N/n: number, M: male, MA: mean age, MFD: months from diagnosis,
MS: marital status, PC: palliative care, PCP: primary provider, POSTCARE: patient-owned survivorship transition care for activated, empowered survivors, PR:
peer reviewed, PRO: patient reported outcomes, PS: patient satisfaction, QLS: qualitative study, QTS: quantitative study, RCT: randomized control trial RT:
radiation therapy, SCP: survivorship care plan, TM: total mastectomy, TOC: type of cancer, TOT: type of treatment U: unknown, y/o: years-old

SURVIVORSHIP CARE PLANNING

38

Received TS; n=611

Feasibility: Future
research to investigation
SCP implementation
barriers.

Setting: Telephone
survey based from
BRFSS registry
Inclusion criteria:
Cancer diagnosis at
>/=18 y/o, not pregnant
at time of study, >1
year post diagnosis.
Exclusion: incomplete
survey completion

Palmer, S. C.
(2015). Outcomes
and satisfaction
after delivery of a
breast cancer
survivorship care
plan: Results of a
multi-center trial
Country: USA
Disclosure/Conflict
of Interest: Authors
provided disclosure,
but no conflict of
interest
Funding: Livestrong
Foundation

Inferred:
Theory
Reasoned
Action.
Pender’s HPM

Design:
Perspective
Cohort
Purpose:
Explore the
outcomes
associated with
delivery of
comprehensive
SCP to BC
survivors.

N= 139
MA: 53.93
Mean MFD: 3.43
Stage at diagnosis:
Stage 0: n=10
Stage 1: n=52
Stage 2 n=51
Stage 3 n=21
TOT:
CT; 93
HT: 96
Mean SF-12 mental
health score: 54.38
(sd:11.19)
Mean SF-12 physical
health score: 47.97
(sd:8.85)
Setting:
Seven NCI designated
comprehensive cancer

IV1: Care prior to
SCP
IV2: SCP delivery
DV1: SCP utilization
DV2: satisfaction
DV3: knowledge
DV4: CCC

Quality of
Life: Medical
study short
form (SF)- 12
SCP materials:
16-item
investigatory
developed
survey see
table 2.
Satisfaction:
global
satisfaction on
5-likert scale.
Perceived
coordination,
knowledge,
behavior was
assessed
(measurement
tool not stated)

Weak
description of
statistical
methods:
software
Descriptive
statistics:
Cronchbach’s
alpha, and ttest

SCP utilization:
IV2: SCP use: 64%
for decision to
exercise, 62% for
dietary changes, and
62% for directing
FU care.
SCP satisfactions:
90% satisfied
Knowledge:
IV2 improved
perceived
survivorship
knowledge/ CCC
(p=<0.001)

LOE: II
Strengths: sample
characteristics, cancer
settings. Pre and post
assessment, high
retention, Standardized
visits/materials
Limitations: Quasiexperimental design,
narrow demographic
population, tools (self
made). Self-report vs.
chart abstraction
Applicability: suggests
SCPs/delivery
standardization across an
array of settings. Useful
in new BC survivors.
Feasibility:
Success at all sites

AR: attrition rate, BC: breast cancer, BCS: breast conserving surgery, BRFSS: behavioral risk factor surveillance system, C: Control, CaSUN: cancer survivors’
unmet needs measure, CC: colon cancer, CCC: continuity and coordination of care, CCCQ: coordination of care questionnaire, CDa: complete data CHC:
childhood cancer, CS: cancer survivors, CSD: cancer specific distress, CT: chemo therapy, DS: disease stage, DV: dependent variable, EOL: end of life, EORT:
European organization for research and treatment, ES: entire sample, F: female, FCI: follow-up care intervention, FU: follow-up, G: group, GA: guideline
adherence, GC: gynecological cancer, GSI: global severity index, HC: health care, HPM: health promotion model, HRQL: health related quality of life, HT:
hormone therapy, I: intervention, IOM: institute of medicine, IV: independent variable, N/n: number, M: male, MA: mean age, MFD: months from diagnosis,
MS: marital status, PC: palliative care, PCP: primary provider, POSTCARE: patient-owned survivorship transition care for activated, empowered survivors, PR:
peer reviewed, PRO: patient reported outcomes, PS: patient satisfaction, QLS: qualitative study, QTS: quantitative study, RCT: randomized control trial RT:
radiation therapy, SCP: survivorship care plan, TM: total mastectomy, TOC: type of cancer, TOT: type of treatment U: unknown, y/o: years-old

SURVIVORSHIP CARE PLANNING

39

centers and their
community practices.
Inclusion criteria: >/=
18 y/o, diagnosis and
treatment of primary
BC or DCI, completion
of cancer therapy, and
scheduled survivorship
visit at SCOEN

suggests with
institutional
commitment, financial,
and logistical support
SCPs can be effectively
delivered

Exclusion criteria:
unable to complete
inform consent d/t
barriers, and previous
recipients of SCPs

AR: attrition rate, BC: breast cancer, BCS: breast conserving surgery, BRFSS: behavioral risk factor surveillance system, C: Control, CaSUN: cancer survivors’
unmet needs measure, CC: colon cancer, CCC: continuity and coordination of care, CCCQ: coordination of care questionnaire, CDa: complete data CHC:
childhood cancer, CS: cancer survivors, CSD: cancer specific distress, CT: chemo therapy, DS: disease stage, DV: dependent variable, EOL: end of life, EORT:
European organization for research and treatment, ES: entire sample, F: female, FCI: follow-up care intervention, FU: follow-up, G: group, GA: guideline
adherence, GC: gynecological cancer, GSI: global severity index, HC: health care, HPM: health promotion model, HRQL: health related quality of life, HT:
hormone therapy, I: intervention, IOM: institute of medicine, IV: independent variable, N/n: number, M: male, MA: mean age, MFD: months from diagnosis,
MS: marital status, PC: palliative care, PCP: primary provider, POSTCARE: patient-owned survivorship transition care for activated, empowered survivors, PR:
peer reviewed, PRO: patient reported outcomes, PS: patient satisfaction, QLS: qualitative study, QTS: quantitative study, RCT: randomized control trial RT:
radiation therapy, SCP: survivorship care plan, TM: total mastectomy, TOC: type of cancer, TOT: type of treatment U: unknown, y/o: years-old

SURVIVORSHIP CARE PLANNING

40

Appendix E
Synthesis Table

NS
NS
NS
NS
NS




NS

X

X
NS






NS

NS



Palmer

2016
I
SR
N/A
X

Oancea

2016
VI
CS
1d
X

Mayer

2016 2015
II
I
RCT SR
6m N/A
X
X

Kvale

2015
VI
FS
2m
X

Klemanski

Jefford

2014
I
SR
N/A
X

Kenzik

Bulloch

2015
II
RCT
24m
X

Keesing

Brennan

Year
LOE
Design
Length
SCP
SCPSV
TS
QOL
S
SCK
COC
FUGRA
SD
HPB
SE

Boekhout

Studies

2016
II
RCT
3m

2015
I
SR
N/A
X

2016
VI
CS
1d
X

2015
II
PCS
3m
X

X

NS


X



NS













CS: cross-sectional study, COC: coordination of care, FS: feasibility study, FUGRA: follow-up
guideline recommendation adherence, HPB: health promotion behaviors, LOE: level of evidence, NS:
not significant, PC: perspective cohort study, QOL: quality of life, RCT: randomized control trial, S:
satisfaction, SCK: survivorship care knowledge, SCP: survivorship care plan, SCPSV: survivorship
care plan survivorship visit, SD: survivor distress, SE: self-efficacy, SR: systematic review, TS:
treatment summary

SURVIVORSHIP CARE PLANNING
Appendix F
Evidence-Based Practice Model
© 2017 Mayo Foundation for Medical Education and Research.

41

SURVIVORSHIP CARE PLANNING

42

Appendix G
CSI Questionnaire Analysis
Paired Samples Test
Paired Differences
95% Confidence
Interval of the
Difference
Upper

t

df

Sig. (2-tailed)

Pair 1

Type - Type2

.333

.370

19

.716

Pair 2

Stage - Stage2

.215

.000

19

1.000

Pair 4

Prevent - Prevent2

.159

-.809

19

.428

Pair 5

Physical Effects - Physical

.263

.000

19

1.000

.007

-2.042

19

.055

.088

-1.453

19

.163

.215

.000

19

1.000

.189

-.438

19

.666

.200

-.438

18

.667

.260

-.767

19

.453

.133

-1.287

18

.215

.202

-1.073

18

.297

.379

-.644

17

.528

.349

-1.031

17

.317

.121

-1.699

17

.108

Effects2
Pair 6

Prevent Physical Effects Prevent Physical Effects2

Pair 7

Treat Physical Effects - Treat
Physical Effects2

Pair 8

Emotional Effects - Emotional
Effects2

Pair 9

Prevent Emotional Effects Prevent Emotional Effects2

Pair 10

Treat Emotional Effects - Treat
Emotional Effects2

Pair 11

Community Resources Community Resources2

Pair 12

Family Risk - Family Risk2

Pair 13

Family information - Family
information2

Pair 14

Survivorship care - Survivorship
care2

Pair 15

Wellness - Wellness2

Pair 16

Health Promotion - Health
Promotion2

SURVIVORSHIP CARE PLANNING

43

Appendix H
Pre/Post CSI Questionnaire Averages

Confidence in Diagnosis,
Treatment, and Prevention
Series1
2.8

2.8

2.8

2.9

Series2
2.9

3.0
2.4

2.3

Type

Stage

Treatments

Prevent

Confidence in Long-term Effects
Series1
2.4 2.4

Physical
Effects

2.5
2.1

Prevent
Physical
Effects

2.3

2.6

Treat
Physical
Effects

Series2
2.5 2.6

2.5 2.6

2.5 2.6

Treat
Emotional Prevent
Effects
Emotional Emotional
Effects
Effects

SURVIVORSHIP CARE PLANNING

44

Confidence in Resources and Risk
Series1

Series2
2.6

2.6

2.6

2.4

2.3

Community Resources

2.3

Family Risk

Family information

Satisfaction
Series1

Series2

4.9
4.7

4.3

Survivorship care

4.7

4.6

Wellness

4.2

Health Promotion