Improving Survivorship Care Through Enhanced Communication and Coordination

Almost 14 million people have received a cancer diagnosis, and that number is expected to grow to 18 million by 2022 (deMoor, et al, 2012).  To serve this critical population, the American College of Surgeons has adopted a position statement that survivorship care plans (SCP), which are tools to help provide information about the person's cancer, treatment, and follow-up plans, should be standard care by 2015. This has the potential to help the person and their doctors talk about and coordinate the plans for care. Different examples have been developed but it is not clear what patients and providers would actually prefer regarding the format, timing, and delivery of the SCP and how it might be used. 

The Health-e-NC grant is funding 2 linked projects as part of this overall study. The first focuses on the development and evaluation of paired sets of personalized survivorship care plans - one version for the patient, the other for the health care provider; paired sets are developed and tested for breast, colon, prostate, and lung cancer survivors who have completed cancer treatment. The second linked project focuses on enhancing coordinated care between oncology and primary care providers using the SCP and other identified communication strategies.

Focus groups are conducted for each sub-project and include cancer survivors, primary care providers, and oncologists regarding communication and coordination of care.  Focus group participants provide feedback on current versions of SCPs developed for patients and primary care providers, as well as on additional ways to improve communication and coordination of care during and after cancer treatment. Findings from the focus groups will guide a future survivorship care intervention that may influence care for cancer survivors across North Carolina and the country. 

Findings: In one arm of the study, the team conducted two focus groups of survivors with advanced or metastatic cancer where participants reviewed a sample JourneyForward? SCP modified for advanced cancer. Evaluation of transcripts and field notes revealed that A Cancer Care Plan developed by the oncologist, similar to a SCP but more focused on current management, may be more useful for survivors with advanced cancer. Exploring this topic in larger groups of more diverse survivors with advanced cancer will help to elucidate the details a written plan of care should contain, and how to promote effective coordination between oncology and primary care providers.

Geographic areas: Orange, Durham, Wake, and Buncombe

Research Team: Deboarh Mayer, PhD, RN, associate professor of nursing (principal investigator), Donald Rosenstein, MD, professor of psychiatry and Director of the UNC Comprehensive Cancer Support Program, Gary Asher, MD, MPH, assistant professor of family medicine, Ronald Chen, MD, MPH, assistant professor of radiation oncology, Laura Hanson, MD, MPH, professor of geriatric medicine and adjunct associate professor of epidemiology, Stephanie Wheeler, PhD, assistant professor of health policy and management; research staff include Devon Check, Adrian Gerstel, and Melissa Green, project manager.

For more information about this research study, contact Melissa Green, project manager, at