Survivorship and Coordination of Care: Care Plans, Late Effects, and Transitions
Survivorship care
Every patient completing curative-intent treatment needs a survivorship care plan: treatment summary, surveillance schedule, late-effect risks, health-promotion advice, and explicit designation of who is responsible for each follow-up element. Shared care with primary care works only when responsibilities are documented.
Late and long-term effects
Screen for organ toxicity (anthracycline or trastuzumab cardiomyopathy requiring periodic echocardiography; cisplatin nephrotoxicity and ototoxicity; bleomycin pulmonary toxicity), peripheral neuropathy, lymphedema, premature ovarian insufficiency and infertility, sexual dysfunction, osteoporosis, hypothyroidism after neck radiation, and secondary malignancies (therapy-related AML/MDS, radiation-associated solid tumors). Distress, depression, anxiety, fear of recurrence, cognitive complaints, and financial toxicity are common and should be screened with a validated tool at intervals.
Health promotion and coordination
Counsel on physical activity, weight management, tobacco cessation, alcohol limits, sun protection, immunizations, and bone health. Fertility preservation must be discussed before gonadotoxic therapy. Coordinate transfers of care, reconcile oral anticancer medications for adherence and drug interactions, and ensure risk-appropriate screening (for example, earlier breast MRI for BRCA carriers) continues.
Worked example
A 45-year-old woman treated with doxorubicin and chest-wall radiation reports fatigue and palpitations 3 years later. Her survivorship plan calls for periodic echocardiography and cardiovascular risk-factor management; new cardiac symptoms warrant prompt evaluation rather than being attributed automatically to "cancer fatigue."
Traps: dismissing new symptoms as expected late effects without evaluation, omitting secondary-cancer surveillance, and neglecting fertility and sexual health discussions.