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Survivorship care plan

SURVIVORSHIP CARE PLAN
Prescription for LIFE
Significant Past Medical History

Cancer Diagnosis
Dx #1:
Date of Diagnosis:
Initial Stage:
Pathology Details: Dx #2: Date of Diagnosis: Initial Stage: Pathology Details:

Cancer Treatment
Surgery
Surgeon:
Chemotherapy, Biotherapy, Targeted TherapyMedical Oncologist: Note cumulative dose of adriamycin if received Most Recent Disease Evaluation DATE EXAM Major Toxicities, Events During Treatment (note whether resolved) 1. 2. Persistent Effects Following Completion of Treatment
Other Needs Identified at End of Treatment
1.
2.

Post Cancer Treatment Care

Follow-Up Schedule with Oncologist
Tests / Evaluations with each F/U visit:
Late Effects to Monitor in Patients Receiving (Most late effects are quite rare, occurring many months to years following treatment. Early recognition and treatment can help ensure the best possible outcome) Cardiomyopathy, Heart Failure, Dysrhythmias (Adriamycin, Other anthracyclines, Taxanes, High dose Carotid Artery Stenosis (Neck XRT) Cataracts (5-FU, Busulfan, Long-term steroids, Tamoxifen, Anastrozole, Cranial XRT) Cognitive Impairment (Methotrexate, Velcade, Multiagent chemotherapy, Immunotherapy, Hormone Coronary Artery Disease (Cisplatin, Other platinums, Chest XRT) Dental Caries, Xerostomia (Head & Neck XRT) Difficulty healing from trauma or surgery in the irradiated field Early Menopause (Taxanes, High dose cyclophosphamide, Alkylating agents, Anti-estrogen therapies, Electrolyte Disturbance [low magnesium, low potassium] (Platinums, Ifosfamide, Taxanes) Esophagitis, Stricture, Difficulty Swallowing, Reflux, Motility Disorders (Chest XRT, Mantle XRT) Fatigue (Most chemotherapy agents) Fibrosis of Skin, Sub-q & Deeper Tissues (XRT) Gastric Ulcers, Indigestion, Gastritis, Perforation (Abdominal XRT) GI Bleeding, Diarrhea, Pain, Tenesmus, Obstruction, Fistula (Abdominal XRT, Pelvic XRT) Hearing Loss (Cisplatin, Carboplatin, Head & Neck XRT) Prescription for LIFE, Pearlman Survivorship Care Plan. Adapted from: Haylock, P.J., Mitchell, S.A., Cox, T., Temple, S.V., Curtiss, C.P. (2007). The cancer survivor's prescription for living. AJN, 107(4), 58-70. Hemorrhagic Cystitis, Reduced Bladder Capacity, Nephritis (Cyclophosphamide, Ifosfamide, Low-Dose Methotrexate, Abdominal XRT, Pelvic XRT) Hyperglycemia (Long-term steroids) Hypothyroidism (Neck XRT, Mantle XRT, Brain XRT) Impaired Immune Function (Methotrexate, Rituxan, Campath, Fludara, Long-term steroids, High dose Infertility (Alkylating agents, Ara-C, Velcade, Vincas, Testicular, Pelvic XRT, Abdominal XRT) Kidney Impairment (Ifosfamide, Cisplatin, Methotrexate, BCNU, 5-FU, Melphalan, Mitomycin-C, Liver Dysfunction, Cirrhosis (Methotrexate, BCNU, L-asparaginase, Chlorambucil, High dose busulfan, High dose cyclophosphamide, Mithramycin, Tamoxifen) Lymphedema, Pain, Erythema (Breast XRT) MDS, Leukemia (Cyclophosphamide, Ifosfamide, Other alkylating agents, Anthracyclines, Platinums, Taxanes, Fludara, High dose therapy, Stem cell transplant, XRT) Myelopathies (Spinal Cord XRT) Osteonecrosis Femoral Head, Other Large Joints (Long-term steroids, Breast cancer pts receiving CMF; Testicular cancer pts receiving cisplatin, bleomycin, etoposide, vinblastine) Osteonecrosis of the Jaw (IV bisphosphonates, Head & Neck XRT) Osteoporosis (Cyclophosphamide, Methotrexate, Ifosfamide, Doxorubicin, Long-term steroids, Androgen deprivation in prostate pts, Aromatase inhibitors) Osteoradionecrosis (Head & Neck XRT, XRT to any field containing significant bony tissue) Pericarditis, Pericardial Effusion, Pleural Effusion, Pneumothorax, Ischemic Heart Disease, Valvular Peripheral Neuropathy (Cisplatin, Taxanes, Oxaliplatin, Vincas) Proctitis (Pelvic XRT) Pulmonary Fibrosis, Pneumonitis (Bleomycin, BCNU, CCNU, Chlorambucil, Melphalan, Busulfan, Cyclophosphamide, Methotrexate, Oxaliplatin, Chest XRT, Mantle XRT) Retinal Damage, Glaucoma (Cranial XRT) Second Cancer in Irradiated Field Second Cancers, such as Bladder Cancer, Leukemia, Lymphoma (Cyclophosphamide, Other alkylating agents, BCNU, Anthracyclines, Topotecan, Irinotecan, Multiple other chemotherapy agents, Long-term steroids) Septic Arthritis (XRT involving hip, shoulder, other joints) Sexual Dysfunction (Pelvic XRT) Visual Disturbance (Cisplatin, Tamoxifen) Weight Gain (Long term steroids, Multiagent chemo for ALL, Hormonal therapies) Screening ExamsMammogram DATE RESULTS Repeat yearly. Colonoscopy DATE MD RESULTS Repeat every 5 years. Pap Smear DATE MD RESULTS Repeat yearly. PSA / Rectal DATE MD RESULTS Repeat _______________ Wellness (check all that apply) Nutrition and healthy weight management: Prescription for LIFE, Pearlman Survivorship Care Plan. Adapted from: Haylock, P.J., Mitchell, S.A., Cox, T., Temple, S.V., Curtiss, C.P. (2007). The cancer survivor's prescription for living. AJN, 107(4), 58-70. Problems Noted in Follow-Up with Oncologist (include any instructions or treatment given for problem) 1. 2. 3. Contacts at Pearlman Cancer Center for Post-Treatment Issues Social Worker: 229.259.4638 Triage Nurse: 229.259.4600, select option to speak with the nurse Prescription for LIFE, Pearlman Survivorship Care Plan. Adapted from: Haylock, P.J., Mitchell, S.A., Cox, T., Temple, S.V., Curtiss, C.P. (2007). The cancer survivor's prescription for living. AJN, 107(4), 58-70.

Source: http://www.sgmc.org/sites/www/Uploads/files/Services/Pearlman%20Survivorship%20Care%20Plan.pdf

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