{"entity":{"id":"survivorship-care-plan","kind":"technology","name":"Survivorship care and late-effects surveillance","aka":[],"tldr":"Organised follow-up for the 18 million US and 50+ million global cancer survivors: watching for recurrence and second cancers, managing long-term side effects such as heart damage, infertility, neuropathy and fatigue, and helping people return to work and life.","summary":"The IOM report 'From Cancer Patient to Cancer Survivor: Lost in Transition' (2006) launched survivorship as a phase of care and recommended a written survivorship care plan (SCP). Trials of SCPs alone showed little benefit (Grunfeld 2011), and the ACoS dropped the SCP mandate in 2020 in favour of comprehensive survivorship programmes. Core content: risk-based surveillance (COG Long-Term Follow-Up Guidelines for childhood cancer survivors, who have >95% cumulative chronic-condition incidence by age 50, St Jude Lifetime Cohort), cardio-oncology, endocrine and fertility issues, second primary cancers, neurocognitive effects, fatigue, sexual health, psychosocial and employment support, and health promotion. Delivery models: oncologist-led, nurse-led, shared care with primary care, and risk-stratified pathways (NHS personalised stratified follow-up). Adolescent and young adult survivors and rural/minority survivors have the largest gaps.","status":"established","asOf":"2026-09-08","wikipedia":"https://en.wikipedia.org/wiki/Cancer_survivor","links":[{"label":"COG Long-Term Follow-Up Guidelines","url":"http://www.survivorshipguidelines.org/"},{"label":"NCCN Survivorship guideline","url":"https://www.nccn.org/guidelines/guidelines-detail?category=3&id=1466"},{"label":"St Jude Lifetime Cohort","url":"https://sjlife.stjude.org/"},{"label":"NICE NG151: colorectal cancer, recommendations","url":"https://www.nice.org.uk/guidance/ng151/chapter/Recommendations"},{"label":"Bowel Cancer UK: long term and late side effects","url":"https://www.bowelcanceruk.org.uk/about-bowel-cancer/living-with-and-beyond-bowel-cancer/long-term-and-late-side-effects/"},{"label":"Macmillan: bowel changes after cancer treatment","url":"https://www.macmillan.org.uk/cancer-information-and-support/bowel-cancer/managing-bowel-changes-after-treatment"},{"label":"NICE NG122: lung cancer, follow-up and patient perspectives","url":"https://www.nice.org.uk/guidance/ng122/chapter/Follow-up-and-patient-perspectives"},{"label":"NICE NG122: lung cancer, support from clinical nurse specialists","url":"https://www.nice.org.uk/guidance/ng122/chapter/Support-from-clinical-nurse-specialists"},{"label":"Cancer Research UK: living with lung cancer","url":"https://www.cancerresearchuk.org/about-cancer/lung-cancer/living-with"},{"label":"Lymphoma Action: follow-up after lymphoma treatment","url":"https://lymphoma-action.org.uk/information-and-support/living-and-beyond-lymphoma/follow-after-lymphoma-treatment"},{"label":"Lymphoma Action: recovery after lymphoma treatment","url":"https://lymphoma-action.org.uk/information-and-support/living-and-beyond-lymphoma/recovery-after-lymphoma-treatment"},{"label":"Thompson et al., utility of routine post-therapy surveillance imaging in diffuse large B-cell lymphoma, Journal of Clinical Oncology 2014","url":"https://doi.org/10.1200/JCO.2014.55.7561"}],"tags":["gap-fill","supportive"],"related":[],"cancers":["hodgkin-lymphoma","testicular","breast-hr-positive","all-leukemia","wilms-tumor","medulloblastoma","colorectal","lung-cancer","nsclc","sclc","non-hodgkin-lymphoma","dlbcl","follicular-lymphoma","mantle-cell-lymphoma","marginal-zone-lymphoma","malt-lymphoma","splenic-marginal-zone-lymphoma","nodal-marginal-zone-lymphoma","waldenstrom","primary-mediastinal-b-cell-lymphoma","burkitt-lymphoma","early-stage-classical-hodgkin-lymphoma","advanced-stage-classical-hodgkin-lymphoma","relapsed-refractory-hodgkin-lymphoma","nodular-lymphocyte-predominant-hodgkin-lymphoma","peripheral-t-cell-lymphoma","angioimmunoblastic-t-cell-lymphoma","cutaneous-t-cell-lymphoma","sezary-syndrome","primary-cns-lymphoma"],"sections":["supportive-care","rejuvenation"],"technologies":["cardio-oncology","fertility-preservation","exercise-oncology","psycho-oncology","financial-navigation","geriatric-assessment","hearing-after-platinum-chemotherapy","dry-mouth-teeth-after-head-neck-radiotherapy","bowel-after-pelvic-radiotherapy","radiation-skin-recovery","lymphoedema-surgery-and-early-detection","cardiotoxicity-surveillance-recovery","rejuv-rehab-cancer-rehabilitation","rejuv-rehab-prospective-surveillance","rejuv-rehab-provision-gap"],"targets":[],"drugs":[],"companies":["childrens-oncology-group"],"institutions":[],"pathways":[],"terms":[],"trials":["ccss"],"people":[],"bottlenecks":[],"keyPapers":[],"journals":["journal-of-cancer-survivorship"],"dependsOn":[],"notes":["Bowel cancer: NICE NG151 says that for people who have had potentially curative surgical treatment for non-metastatic colorectal cancer, teams should offer follow-up for detection of local recurrence and distant metastases for the first 3 years, including serum carcinoembryonic antigen and CT of the chest, abdomen and pelvis. It also asks teams to help people prepare for discharge with advice on adapting physical activity, on diet including foods that contribute to diarrhoea, flatulence, incontinence and difficulty emptying the bowels, on stopping smoking, on how long recovery might take and on how, when and where to seek help if side effects become problematic.","Lung cancer: NICE NG122 (1.19.1) says to offer everyone with lung cancer an initial follow-up appointment with a specialist within 6 weeks of completing treatment to discuss ongoing care, and regular appointments after this rather than relying on the person requesting appointments when they have symptoms; (1.19.2) to offer protocol-driven follow-up led by a lung cancer clinical nurse specialist as an option for people with a life expectancy of more than 3 months; and (1.19.3) to ensure people know how to contact that nurse between scheduled hospital visits.","Lymphoma: Lymphoma Action says the team should give the person and their general practitioner a written treatment summary listing the treatment given, its possible side effects including long-term ones, the late effects to expect, the symptoms that could mean the lymphoma has returned with who to contact at any hour, and any lifestyle recommendations. It also says scans are not routinely used in ongoing follow-up because they are unlikely to identify lymphoma and there is no evidence that they change treatment or outcomes, which matches the finding that surveillance imaging detected relapse before symptoms in 9 of 552 people in remission from diffuse large B-cell lymphoma."],"principle":"Risk-stratified, guideline-based lifelong surveillance and management of late effects, with explicit transfer of information and responsibility between oncology and primary care, and attention to the whole person (work, finances, relationships).","strengths":["Evidence-based screening prevents or detects late effects (e.g. breast MRI after chest radiation)","Nurse-led and primary-care models are as safe as specialist follow-up for low-risk survivors","Childhood survivor guidelines are mature and international (IGHG)"],"limitations":["Care plans alone do not change outcomes","Fragmentation between oncology and primary care","Adult late-effects guidelines less developed than paediatric"],"since":2006},"route":"/technologies/survivorship-care-plan/","neighbours":{"cancer":[{"id":"all-leukemia","kind":"cancer","name":"Acute lymphoblastic leukaemia","route":"/cancers/all-leukemia/"},{"id":"aya-cancers","kind":"cancer","name":"Adolescent and young adult cancers (ages 15 to 39)","route":"/cancers/aya-cancers/"},{"id":"advanced-stage-classical-hodgkin-lymphoma","kind":"cancer","name":"Advanced-stage classical Hodgkin lymphoma (stage III to IV)","route":"/cancers/advanced-stage-classical-hodgkin-lymphoma/"},{"id":"basal-cell-carcinoma","kind":"cancer","name":"Basal cell carcinoma","route":"/cancers/basal-cell-carcinoma/"},{"id":"breast-cancer","kind":"cancer","name":"Breast cancer (all types)","route":"/cancers/breast-cancer/"},{"id":"burkitt-lymphoma","kind":"cancer","name":"Burkitt lymphoma","route":"/cancers/burkitt-lymphoma/"},{"id":"childhood-cancers","kind":"cancer","name":"Childhood cancers (all types)","route":"/cancers/childhood-cancers/"},{"id":"colorectal","kind":"cancer","name":"Colorectal cancer","route":"/cancers/colorectal/"},{"id":"craniopharyngioma","kind":"cancer","name":"Craniopharyngioma","route":"/cancers/craniopharyngioma/"},{"id":"cutaneous-scc","kind":"cancer","name":"Cutaneous squamous cell carcinoma","route":"/cancers/cutaneous-scc/"},{"id":"cutaneous-t-cell-lymphoma","kind":"cancer","name":"Cutaneous T-cell lymphoma (mycosis fungoides and Sezary syndrome)","route":"/cancers/cutaneous-t-cell-lymphoma/"},{"id":"dlbcl","kind":"cancer","name":"Diffuse large B-cell lymphoma","route":"/cancers/dlbcl/"},{"id":"early-stage-classical-hodgkin-lymphoma","kind":"cancer","name":"Early-stage classical Hodgkin lymphoma (stage I to II)","route":"/cancers/early-stage-classical-hodgkin-lymphoma/"},{"id":"ependymoma","kind":"cancer","name":"Ependymoma","route":"/cancers/ependymoma/"},{"id":"malt-lymphoma","kind":"cancer","name":"Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)","route":"/cancers/malt-lymphoma/"},{"id":"follicular-lymphoma","kind":"cancer","name":"Follicular lymphoma","route":"/cancers/follicular-lymphoma/"},{"id":"paediatric-germ-cell-tumours","kind":"cancer","name":"Germ cell tumours of childhood and adolescence (extracranial and CNS)","route":"/cancers/paediatric-germ-cell-tumours/"},{"id":"medulloblastoma-group-3-4","kind":"cancer","name":"Group 3 and group 4 medulloblastoma (non-WNT/non-SHH)","route":"/cancers/medulloblastoma-group-3-4/"},{"id":"hepatoblastoma","kind":"cancer","name":"Hepatoblastoma","route":"/cancers/hepatoblastoma/"},{"id":"hodgkin-lymphoma","kind":"cancer","name":"Hodgkin lymphoma","route":"/cancers/hodgkin-lymphoma/"},{"id":"breast-hr-positive","kind":"cancer","name":"HR-positive / HER2-negative breast cancer","route":"/cancers/breast-hr-positive/"},{"id":"langerhans-cell-histiocytosis","kind":"cancer","name":"Langerhans cell histiocytosis (LCH)","route":"/cancers/langerhans-cell-histiocytosis/"},{"id":"lung-cancer","kind":"cancer","name":"Lung cancer (all types)","route":"/cancers/lung-cancer/"},{"id":"mantle-cell-lymphoma","kind":"cancer","name":"Mantle cell lymphoma","route":"/cancers/mantle-cell-lymphoma/"},{"id":"marginal-zone-lymphoma","kind":"cancer","name":"Marginal zone lymphoma","route":"/cancers/marginal-zone-lymphoma/"},{"id":"medulloblastoma","kind":"cancer","name":"Medulloblastoma","route":"/cancers/medulloblastoma/"},{"id":"lch-multisystem","kind":"cancer","name":"Multisystem Langerhans cell histiocytosis (with or without risk-organ involvement)","route":"/cancers/lch-multisystem/"},{"id":"nodal-marginal-zone-lymphoma","kind":"cancer","name":"Nodal marginal zone lymphoma","route":"/cancers/nodal-marginal-zone-lymphoma/"},{"id":"angioimmunoblastic-t-cell-lymphoma","kind":"cancer","name":"Nodal T-follicular helper cell lymphoma, angioimmunoblastic type (angioimmunoblastic T-cell lymphoma)","route":"/cancers/angioimmunoblastic-t-cell-lymphoma/"},{"id":"nodular-lymphocyte-predominant-hodgkin-lymphoma","kind":"cancer","name":"Nodular lymphocyte-predominant Hodgkin lymphoma (nodular lymphocyte-predominant B-cell lymphoma)","route":"/cancers/nodular-lymphocyte-predominant-hodgkin-lymphoma/"},{"id":"non-hodgkin-lymphoma","kind":"cancer","name":"Non-Hodgkin lymphoma (all types)","route":"/cancers/non-hodgkin-lymphoma/"},{"id":"nsclc","kind":"cancer","name":"Non-small-cell lung cancer","route":"/cancers/nsclc/"},{"id":"paediatric-low-grade-glioma","kind":"cancer","name":"Paediatric low-grade glioma","route":"/cancers/paediatric-low-grade-glioma/"},{"id":"peripheral-t-cell-lymphoma","kind":"cancer","name":"Peripheral T-cell lymphomas (including cutaneous T-cell lymphoma)","route":"/cancers/peripheral-t-cell-lymphoma/"},{"id":"primary-cns-lymphoma","kind":"cancer","name":"Primary CNS lymphoma","route":"/cancers/primary-cns-lymphoma/"},{"id":"primary-mediastinal-b-cell-lymphoma","kind":"cancer","name":"Primary mediastinal (thymic) large B-cell lymphoma","route":"/cancers/primary-mediastinal-b-cell-lymphoma/"},{"id":"prostate","kind":"cancer","name":"Prostate cancer","route":"/cancers/prostate/"},{"id":"relapsed-refractory-hodgkin-lymphoma","kind":"cancer","name":"Relapsed and refractory classical Hodgkin lymphoma","route":"/cancers/relapsed-refractory-hodgkin-lymphoma/"},{"id":"sezary-syndrome","kind":"cancer","name":"Sezary syndrome","route":"/cancers/sezary-syndrome/"},{"id":"skin-cancer","kind":"cancer","name":"Skin cancer (all types)","route":"/cancers/skin-cancer/"},{"id":"sclc","kind":"cancer","name":"Small-cell lung cancer","route":"/cancers/sclc/"},{"id":"splenic-marginal-zone-lymphoma","kind":"cancer","name":"Splenic marginal zone lymphoma","route":"/cancers/splenic-marginal-zone-lymphoma/"},{"id":"testicular","kind":"cancer","name":"Testicular germ cell 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