"Survivorship Care Plan: What It Is, Who Writes It"
A survivorship care plan is a written document with two halves: a summary of the cancer treatment a person received, and a plan for the follow-up care that comes after active treatment ends. The treatment summary records the diagnosis, the therapies delivered, and the clinicians who delivered them. The follow-up plan records what happens next, including who is responsible for ongoing monitoring, what late and long-term effects the care team wants watched for, and how to reach the treating institution. The document is produced by the treating cancer program, usually by an oncologist, advanced practice provider, or nurse, and is intended to be shared with both the patient and the primary care clinician who will carry much of the follow-up.
This article describes what the document is and how cancer programs produce it. It is not clinical guidance, and it does not describe what any individual's follow-up should look like. Those questions belong to the treating oncology team.
Where the Concept Came From
The survivorship care plan as a named artifact traces to the 2005 Institute of Medicine and National Research Council report From Cancer Patient to Cancer Survivor: Lost in Transition. That report described the period after active treatment as a poorly defined handoff, in which patients moved out of oncology follow-up without a clear record of what had been done to them and without a clear owner for what came next. Its central operational recommendation was that every patient completing primary cancer treatment should receive a written summary of that treatment together with a follow-up care plan.
The Institute of Medicine has since been reorganized into the National Academy of Medicine, but the report's framing stuck. The two-part structure it proposed, a treatment summary joined to a forward-looking care plan, is still the structure that accreditation standards, template publishers, and electronic health record vendors build to. Later work by the National Cancer Institute's Office of Cancer Survivorship and by professional societies expanded on the content, but did not change the basic shape.
What a Survivorship Care Plan Typically Contains
Content varies by cancer program and by template, but published templates converge on a similar set of fields. The table below describes the categories most templates include. It describes document structure only and is not a checklist for any individual's care.
| Section | Typical contents |
|---|---|
| Diagnosis | Cancer type, site, stage or extent of disease at diagnosis, and relevant pathology or biomarker findings |
| Treatment summary | Surgery, radiation, systemic therapy, and other treatments received, with agents, sites, and start and end dates |
| Treating clinicians | Names, roles, and contact information for the oncologists, surgeons, and other clinicians involved |
| Follow-up plan | The schedule and type of ongoing monitoring the care team has planned, and which clinician owns each element |
| Possible late and long-term effects | Effects associated with the treatments the person received, described so that both patient and primary care clinician know what to raise |
| Health maintenance and support | General wellness guidance, supportive care referrals, and psychosocial or financial support resources |
| Contacts and next steps | Who to call with questions, and how to re-enter the cancer program if something changes |
The distinguishing feature of the document is that it is portable. A discharge note lives in one health system's record. A survivorship care plan is meant to be handed to the patient and to any clinician who later needs the treatment history, including a primary care physician in a different system years later.
Who Produces the Plan
The plan is produced by the cancer program that delivered treatment. In practice, the work is distributed. The treatment summary is largely a data assembly task, drawn from the oncology record, and is often prepared by a nurse, nurse practitioner, physician assistant, or a dedicated survivorship coordinator. The follow-up portion requires clinical judgment and is authored or reviewed by the treating oncologist or an advanced practice provider on the team.
Delivery is usually anchored to a specific encounter. Many programs run a survivorship visit at the end of active treatment, at which the document is reviewed with the patient rather than simply mailed. Programs with a navigation function frequently attach the plan to that workflow, since navigators already hold the handoff. For a broader description of that role, see what patient navigation is and who performs it.
The ASCO Templates
The American Society of Clinical Oncology publishes survivorship care plan templates that many programs adopt directly or adapt. ASCO's current template pairs a treatment summary with a survivorship care plan in a single downloadable form, distributed through the ASCO Survivorship Compendium and free to adopt or adapt without seeking permission. They are widely used because they give a program a defensible, externally authored structure rather than a locally invented form, and because electronic health record vendors have built survivorship modules that map to similar fields.
ASCO is not the only publisher. Other professional and nonprofit organizations distribute templates, and many large cancer centers maintain their own. What matters operationally is less which template a program picks than whether the fields can be populated from the record without hours of manual chart abstraction, which is the single most common reason plans do not get produced.
How Commission on Cancer Standards Have Changed
The Commission on Cancer, a program of the American College of Surgeons, accredits cancer programs in the United States, and its standards are the main external reason most programs formalized survivorship work at all. The history matters, because a lot of writing on this topic is out of date.
Under the earlier generation of Commission on Cancer standards, accredited programs were required to deliver a survivorship care plan document to eligible patients who completed treatment, and compliance was measured largely by whether documents were produced and delivered. That document-delivery framing proved difficult in practice. Assembling a complete treatment summary was labor intensive, the required volume was high, and the evidence that handing over a document by itself changed outcomes was contested.
The Commission on Cancer's current standards, published as Optimal Resources for Cancer Care, replaced the document-delivery requirement with a survivorship program requirement under Standard 4.8, Survivorship Program. Accredited programs are now expected to establish a survivorship program with defined leadership and a designated team, to identify and offer a defined set of survivorship services, and to document that work annually, rather than to produce a set number of individual plan documents. Survivorship care plans remain a normal part of what such programs deliver, but they are one component of a program rather than the accreditation metric itself.
Programs should confirm current requirements against the standards document in force for their accreditation cycle, since the Commission on Cancer updates and clarifies standards over time.
Why Plans Are Hard to Produce at Scale
Three problems recur across cancer programs, and they are operational rather than clinical.
- Data assembly. Treatment histories are spread across surgical notes, infusion records, radiation oncology systems, and outside records. Auto-populating a treatment summary is only as good as the structured data underneath it.
- Ownership. The follow-up plan requires a clinician's signature and time, and that time competes with active treatment volume.
- Handoff. A plan that reaches the patient but never reaches the primary care clinician solves half the problem the original report identified.
The last problem is largely a communication problem. Programs that do this well have a defined path for getting the document into the patient's hands, confirming they received it, and routing a copy to the clinician who will own follow-up. Text and portal messaging are commonly used to confirm receipt and to prompt scheduling of the survivorship visit itself, which is a scheduling and outreach workflow rather than a clinical one. For more on how cancer programs structure that outreach, see our overview of oncology patient communication.
Frequently Asked Questions
What is a survivorship care plan?
It is a written document with two parts: a summary of the cancer treatment a person received, and a plan for follow-up care after active treatment ends. It is produced by the treating cancer program and is meant to be shared with the patient and with the clinicians who will handle ongoing care, including primary care.
Who writes a survivorship care plan?
The treating cancer program writes it. The treatment summary is often assembled by a nurse, advanced practice provider, or survivorship coordinator from the oncology record, while the follow-up portion is authored or reviewed by the treating oncologist or an advanced practice provider. Navigation staff frequently coordinate delivery.
Is a survivorship care plan required by the Commission on Cancer?
Not as a standalone document requirement. Earlier Commission on Cancer standards required delivery of survivorship care plan documents to eligible patients. The current standards in Optimal Resources for Cancer Care instead require accredited programs, under Standard 4.8, to establish a survivorship program with defined leadership and a defined slate of services offered across the year. Care plans remain common practice within those programs.
What is the difference between a treatment summary and a survivorship care plan?
The treatment summary is the backward-looking half: diagnosis, therapies received, dates, and treating clinicians. The survivorship care plan is the complete document, combining that summary with the forward-looking follow-up plan. In casual use the full document is often called a survivorship care plan, with the summary understood as a section inside it.
Where did survivorship care plans come from?
The concept was formalized in the 2005 Institute of Medicine and National Research Council report From Cancer Patient to Cancer Survivor: Lost in Transition, which recommended that every patient finishing primary cancer treatment receive a written treatment summary and follow-up care plan. Accreditation standards and professional society templates followed from that recommendation.
Are there free survivorship care plan templates?
Yes. The American Society of Clinical Oncology publishes survivorship care plan templates, including general and disease-specific versions, and other professional and nonprofit organizations distribute templates as well. Many electronic health record systems also include survivorship modules built to a similar field structure.
Does a survivorship care plan tell me what tests I need?
The follow-up section records what the treating care team has planned for that individual, which is a clinical decision made by that team. This article does not provide surveillance schedules or medical guidance. Questions about your own follow-up should go to your oncology team or primary care clinician.
Who should receive a copy of the plan?
At minimum the patient and the clinician who will own ongoing follow-up, which is often a primary care physician outside the cancer program. The portability of the document is the point: it exists so a treatment history travels with the person rather than staying inside one health system's record.
Getting the plan into the right hands
Producing the document is only half the job. Cancer programs still have to reach the patient, confirm the survivorship visit is scheduled, and route a copy to the follow-up clinician. FRANSiS supports that outreach with two-way texting and an AI Powered Helper that drafts replies for your staff to review and send, with HIPAA compliance supported and a signed BAA included. See FRANSiS for healthcare or contact us to talk through your survivorship workflow.
