Transitioning Patients to Survivorship Care: A Systematic Review

Megan Hebdon

Kathy Abrahamson

Sara McComb

Laura Sands

healthcare delivery, survivorship, healthcare providers, review, Institute of Medicine, nurse-led intervention
ONF 2014, 41(6), 615-625. DOI: 10.1188/14.ONF.615-625

Problem Identification: In 2005, the Institute of Medicine (IOM) released a seminal report on cancer survivorship that discussed the goals and structure of cancer survivorship care with the recommendation to use a survivorship care plan (SCP). However, the manner in which these recommendations are operationalized and their relationship to patient outcomes are unknown.

Literature Search: A systematic literature search was conducted using PubMed, CINAHL®, and the Cochrane Database. Articles were selected if they included a provider-mediated intervention and were published after 2005, for a total of nine articles.

Data Evaluation: The studies were evaluated according to the purposes of survivorship care, the use of an SCP, and models of care recommended by the IOM.

Conclusions: The outcomes of the studies were not conclusive in supporting a specific model of survivorship care or the use of a SCP. Two of the nine studies adhered to the IOM goals of survivorship care and SCP recommendations in their interventions.

Implications for Practice: The design and testing of nurse-led survivorship programs is imperative, as nurses may be effective in ensuring consistent, patient-centered education for cancer survivors.

Jump to a section


    American Cancer Society. (2013). Survivorship care plans. Retrieved from
    American College of Surgeons. (2012). Cancer program standards 2012: Ensuring patient-centered care. Retrieved from
    Aziz, N. M., Oeffinger, K. C., Brooks, S., & Turoff, A. J. (2006). Comprehensive long-term follow-up programs for pediatric cancer survivors. Cancer, 107, 841-848. doi:10.1002/cncr.22096
    Beaver, K., Campbell, M., Willamson, S., Procter, D., Sheridan, J., Heath, J., & Susnerwala, S. (2012). An exploratory randomized controlled trial comparing telephone and hospital follow-up after treatment for colorectal cancer. Colorectal Disease, 14, 1201-1209. doi:10.1111/j.1463-1318.2012.02936.x
    Blaauwbroek, R., Barf, H. A., Groenier, K. H., Kremer, L. C., van der Meer, K., Tissing, W. J. E., & Postma, A. (2012). Family doctor-driven follow-up for adult childhood cancer survivors supported by a web-based survivor care plan. Journal of Cancer Survivorship, 6, 163-171. doi:10.1007/s11764-011-0207-5
    Blaauwbroek, R., Tuinier, W., Meyboom-de Jong, B., Kamps, W. A., & Postma, A. (2008). Shared care by paediatric oncologists and family doctors for long-term follow-up of adult childhood cancer survivors: A pilot study. Lancet Oncology, 9, 232-238.
    Brothers, B. M., Easley, A., Salani, R., & Andersen, B. L. (2013). Do survivorship care plans impact patients' evaluations of care? A randomized evaluation with gynecologic oncology patients. Gynecologic Oncology, 129, 554-558. doi.10.1016/j.ygyno.2013.02.037
    Casillas, J., Syrjala, K. L., Ganz, P. A., Hammond, E., Marcus, A. C., Moss, K. M., … Friedman, D. L. (2011). How confident are young adult cancer survivors in managing their survivorship care? A report from the Livestrong survivorship center of excellence network. Journal of Cancer Survivorship, 5, 371-381. doi:10.1007/s11764-011-0199-1
    Centers for Disease Control and Prevention. (2004). A national action plan for cancer survivorship: Advancing public health strategies. Retrieved from
    Cheung, W. Y., Neville, B. A., Cameron, D. B., Cook, E. F., & Earle, C. C. (2009). Comparisons of patient and physician expectations for cancer survivorship care. Journal of Clinical Oncology, 27, 2489-2495. doi:10.12O0/JCO.2008.20.3232
    Curcio, K. R., Lambe, C., Schneider, S., & Khan, K. (2012). Evaluation of a cancer survivorship protocol: Transitioning patients to survivors. Clinical Journal of Oncology Nursing, 16, 400-406. doi.10.1188/12.CJON.400-406
    de Moor, J. S., Mariotto, A. B., Parry, C., Alfano, C. M., Padgett, L., Kent, E. E., … Rowland, J. H. (2013). Cancer survivors in the United States: Prevalence across the survivorship trajectory and implications for care. Cancer Epidemiology, Biomarkers, and Prevention, 22, 561-567.
    DiCicco-Bloom, B., & Cunningham, R. S. (2013). The experience of information sharing among primary care clinicians with cancer survivors and their oncologists. Journal of Cancer Survivorship, 7, 124-130. doi:10.1007/s11764-012-0253-7
    Faul, L. A., Rivers, B., Shibata, D., Townsend, I., Cabrera, P., Quinn, G. P., & Jacobsen, P. B. (2012). Survivorship care planning in colorectal cancer: Feedback from survivors and providers. Journal of Psychosocial Oncology, 30, 198-216. doi:10.1080/07347332.2011.651260
    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 with survivorship care. Journal of the National Cancer Institute, 16, 1579-1587. doi:10.1093/jnci/djt258
    Grunfeld, E., Julian, J. A., Pond, G., Maunsell, E., Coyle, D., Folkes, A., … Levine, M. N. (2011). Evaluation survivorship care plans: Results of a randomized, clinical trial of patients with breast cancer. Journal of Clinical Oncology, 29, 4755-4762. doi:10.1200/JCO.2011.36.8373
    Grunfeld, E., Levine, M. N., Julian, J. A., Coyle, D., Szechtman, B., Mirsky, D., … Whelan, T. (2006). Randomized trial of long-term follow-up for early-stage breast cancer: A comparison of family physician versus specialist care. Journal of Clinical Oncology, 24, 848-855.
    Hahn, E. E., Ganz, P. A., Melisko, M. E., Pierce, J. P., von-Friederichs-Fitzwater, M., Lane, K. T., & Hiatt, R. A. (2013). Provider perceptions and expectations of breast cancer posttreatment care: A University of California Athena Breast Health Network project. Journal of Cancer Survivorship, 7, 323-330. doi:10.1007/s11764-013-1269-7
    Hewitt, M., Greenfield, S., & Stovall, E. (2005). From cancer patient to cancer survivor: Lost in transition. Washington, DC: National Academies Press.
    Hewitt, M. E., Bamundo, A., Day, R., & Harvey, C. (2007). Perspectives on post-treatment cancer care: Qualitative research with survivors, nurses, and physicians. Journal of Clinical Oncology, 25, 2270-2273. doi:10.12O0/JCO.2006.10.0626
    Hill-Kayser, C. E., Vachari, C., Hampshire, M. K., Jacobs, L. A., & Metz, J. M. (2009). An internet tool for creation of cancer survivorship care plans for survivors and health care providers: Design, implementation, use and user satisfaction. Journal of Medical Internet Research, 11(3), e39. doi:10.2196/jmir.1223
    Howell, D., Hack, T. F., Oliver, T. K., Chulak, T., Mayo, S., Aubin, M., … Sinclair, S. (2012). Models of care for post-treatment follow-up of adult cancer survivors: A systematic review and quality appraisal of the evidence. Journal of Cancer Survivorship, 6, 359-371.
    H. R. 3590-111th Congress: Patient Protection and Affordable Care Act. (2009). Retrieved from
    Hudson, S. V., Miller, S. M., Hemler, J., Ferrante, J. M., Lyle, J., Oeffinger, K. C., & DiPaola, R. S. (2012). Adult cancer survivors discuss follow-up in primary care: ‘Not what I want, but maybe what I need’. Annals of Family Medicine, 10, 418-427.
    Institute of Medicine. (2010). Making a difference. Retrieved from
    Jack, B. W., Chetty, V. K. Anthony, D., Greenwald, J. L., Sanchez, G. M., Johnson, A. E., … Culpepper, L. (2009). A reengineered hospital discharge program to decrease hospitalization. Annals of Internal Medicine, 150, 178-187. doi:10.7326/0003-4819-150-3-200902030-00007
    Jefford, M., Lotfi-Jam, K., Baravelli, C., Grogan, S., Rogers, M., Krishnasamy, M., … Schofield, P. (2011). Development and pilot testing of a nurse-led posttreatment support package for bowel cancer survivors. Cancer Nursing, 34, E1-E10.
    Kantsiper, M., McDonald, E. L., Geller, G., Shockney, L., Snyder, C., & Wolff, A. C. (2009). Transitioning to breast cancer survivorship: Perspectives of patients, cancer specialists, and primary care providers. Journal of General Internal Medicine, 24, 459-466.
    Landier, W. (2009). Survivorship care: Essential components and models of delivery. Oncology, 23(4), 46-53.
    Livestrong. (2010). Defining survivorship care: Lessons learned from the Livestrong Survivorship Center of Excellence Network. Retrieved from
    Mayer, E. L., Gropper, A. B., Neville, B. A., Partridge, A. H., Cameron, D. B., Winer, E. P., & Earle, C. C. (2012). Breast cancer survivors' perceptions of survivorship care options. Journal of Clinical Oncology, 30, 158-163. doi:10.12O0/JCO.2011.36.9264
    McCabe, M. S., Bhatia, S., Oeffinger, K. C., Reaman, G. H., Tyne, C., Wollins, D. S., & Hudson, M. M. (2013). American Society of Clinical Oncology statement: Achieve high-quality cancer survivorship care. Journal of Clinical Oncology, 31, 631-640. doi:10.1200/JCO.2012.46.6854
    McFarlane, K., Dixon, L., Wakeman, C. J., Robertson, G. M., Eglington, T. W., & Frizelle, F. A. (2011). The process and outcomes of a nurse-led colorectal cancer follow-up clinic. Colorectal Disease, 14, e245-e249. doi:10.1111/j.1463-1318.2011.02923.x
    National Cancer Institute. (2010). SEER stat fact sheets: All sites. Retrieved from
    National Comprehensive Cancer Network. (2013). NCCN guidelines: Survivorship. Retrieved from
    Palmer, S. C., Jacobs, L. A., DeMichele, A., Risendal, B., Jones, A. F., & Tompkins Stricker, C. (2013). Metrics to evaluate treatment summaries and survivorship care plans: A scorecard. Supportive Care in Cancer, 22, 1475-1483. doi:10.1007/s00520-013-2107-x
    Parry, C., Morningstar, E., Kendall, J., & Coleman, E. A. (2011). Working without a net: Leukemia and lymphoma survivors' perspectives on care delivery at end-of-treatment and beyond. Journal of Psychosocial Oncology, 29, 175-198. doi:10.1080/07347332.2010.548444.
    Siegel, R., Naishadham, D., & Jemal, A. (2012). Cancer statistics, 2012. CA: A Cancer Journal for Clinicians, 62, 10-29. doi:10.3322/caac.20138
    Tompkins Stricker, C., Jacobs, L. A., Risendal, B., Jones, A., Panzer, S., Ganz, P. A., … Palmer, S. C. (2011). Survivorship care planning after the Institute of Medicine recommendations: How are we faring? Journal of Cancer Survivorship, 5, 358-370. doi:10.1007/s11764-011-0196-4
    Wattchow, D. A., Weller, D. P., Esterman, A., Pilotto, L. S., McGorm, K., Hammett, Z., … Silagy, C. (2006). General practice vs surgical-based follow-up for patients with colon cancer: Randomised controlled trial. British Journal of Cancer, 94, 1116-1121. doi.10.1038/sj.bjc.6603052
    Wheelock, A., Mihalis, E., Hamolsky, D., Ernest, M. L., Lopez, N. S., Hwang, J., & Melisko, M. (2013). Survivorship clinic group education sessions: Adoption, acceptance, and attendance. Journal of Cancer Education, 28, 79-83. doi:10.1007/s13187-013-0452-6