After completing cancer treatment, many survivors face ongoing physical, mental, and lifestyle challenges. To address these issues, institutions like the Sylvester Comprehensive Cancer Center at UHealth – University of Miami Health System are implementing survivorship care plans to support patients after their initial treatment.
“A survivorship care plan is a living document, and it changes,” said Adrienne Vazquez Guerra, M.S.N., APRN, at Sylvester Comprehensive Cancer Center. “It’s a personalized document which summarizes a survivor’s medical history, treatment they received, side effects that they may be experiencing or at risk of and the different providers and their responsibilities for care. We see survivors at least yearly to check in on how they’re doing and if they need further support. If so, we make those updates and redistribute the plan.”
These individualized plans provide a summary of treatment as well as recommendations for follow-up care. The recommendations can include screening tests, blood work, monitoring for recurrence or new cancers, guidance on lifestyle modifications, and attention to emotional health and financial concerns. Survivorship care plans also consider late- and long-term effects of cancer therapy.
“We can support a cancer survivor as early as the end of their first line of treatment, and throughout the continuum of their journey,” Guerra said.
Institutions following National Comprehensive Cancer Network (NCCN) guidelines are required to offer such plans. At Sylvester Comprehensive Cancer Center, survivors have access to specialized wellness clinics and supportive services tailored to their needs.
“At Sylvester, we have a lot of experts within our walls,” Guerra said. “But if a survivor receives primary care outside our walls, we can also route their care recommendations to their chosen provider.”
The purpose of these plans is to coordinate care among multiple healthcare providers. This ensures that when survivors report symptoms—such as fatigue or nerve damage—or face other challenges like financial strain from medication costs, referrals can be made efficiently for additional services or support.
“We didn’t do our job if we cured your cancer but are then not helping to manage the long-term side effects,” Guerra said. “We have to make sure we, as providers, are all on the same page so that nothing slips through the cracks.”
Recent research shows that survivorship is becoming more common in the United States. A study published in July 2024 in the Journal of the National Cancer Institute found that nearly 18.1 million people were living as cancer survivors in January 2022—almost four times more than in 1975.
As this population grows, experts say survivorship care plans will play an increasingly important role in maintaining quality of life for those who have completed cancer treatment.
“Let’s say you saw a nutritionist when you were diagnosed with cancer a year ago,” Guerra said. “Your needs at that time were to maintain a healthy body weight because you were going to have chemotherapy. And now, two years later, you’re on hormone therapy, and it’s causing you to experience fatigue, and you’re not exercising as much. This is a perfect example of when it’s time to revisit the nutritionist. Many times I’ll refer patients back as needs change. It’s not just one and done; it’s a continuum of care.”
Guerra emphasized that open communication between survivors and healthcare teams is essential for effective post-treatment management: Survivors should advocate for themselves by voicing concerns or changing needs during follow-up visits.
For more information about Sylvester’s survivorship program or its approach to survivorship care planning visit Sylvester.org/survivorship.
