Barriers and Facilitators to Implementing Cancer Survivorship Care Plans

Dorothy Dulko

Claire M. Pace

Kim L. Dittus

Brian L. Sprague

Lori A. Pollack

Nikki A. Hawkins

Berta M. Geller

survivor care plans, survivorship care plan, survivorship care plans
ONF 2013, 40(6), 575-580. DOI: 10.1188/13.ONF.575-580

Purpose/Objectives: To evaluate the process of survivorship care plan (SCP) completion and to survey oncology staff and primary care physicians (PCPs) regarding challenges of implementing SCPs.

Design: Descriptive pilot study.

Setting: Two facilities in Vermont, an urban academic medical center and a rural community academic cancer center.

Sample: 17 oncology clinical staff created SCPs, 39 PCPs completed surveys, and 58 patients (breast or colorectal cancer) participated in a telephone survey.

Methods: Using Journey Forward tools, SCPs were created and presented to patients. PCPs received the SCP with a survey assessing its usefulness and barriers to delivery. Oncology staff were interviewed to assess perceived challenges and benefits of SCPs. Qualitative and quantitative data were used to identify challenges to the development and implementation process as well as patient perceptions of the SCP visit.

Main Research Variables: SCP, healthcare provider perception of barriers to completion and implementation, and patient perception of SCP visit.

Findings: Oncology staff cited the time required to obtain information for SCPs as a challenge. Completing SCPs 3-6 months after treatment ended was optimal. All participants felt advanced practice professionals should complete and review SCPs with patients. The most common challenge for PCPs to implement SCP recommendations was insufficient knowledge of cancer survivor issues. Most patients found the care plan visit very useful, particularly within six months of diagnosis.

Conclusions: Creation time may be a barrier to widespread SCP implementation. Cancer survivors find SCPs useful, but PCPs feel insufficient knowledge of cancer survivor issues is a barrier to providing best follow-up care. Incorporating SCPs in electronic medical records may facilitate patient identification, appropriate staff scheduling, and timely SCP creation.

Implications for Nursing: Oncology nurse practitioners are well positioned to create and deliver SCPs, transitioning patients from oncology care to a PCP in a shared-care model of optimal wellness. Institution support for the time needed for SCP creation and review is imperative for sustaining this initiative.

Knowledge Translation: Accessing complete medical records is an obstacle for completing SCPs. A 3-6 month window to develop and deliver SCPs may be ideal. PCPs perceive insufficient knowledge of cancer survivor issues as a barrier to providing appropriate follow-up care.

Jump to a section


    Earle, C.C. (2006). Failing to plan is planning to fail: Improving the quality of care with survivorship care plans. Journal of Clinical Oncology, 24, 5112-5116. doi:10.1200/JCO.2006.06.5284
    Erikson, C., Salsberg, E., Forte, G., Bruinooge, S., & Goldstein, M. (2007). Future supply and demand for oncologists: Challenges to assuring access to oncology services. Journal of Oncology Practice, 3(2), 79-86.
    Gilbert, S.M., Miller, D.C., Hollenbeck, B.K., Montie, J.E., Wei, J.T. (2008). Cancer survivorship: Challenges and changing paradigms. Journal of Urology, 179, 431-438. doi:10.1016/j.juro.2007.09.029
    Harrington, C.B, Hansen, J.A., Moskowitz, M., Todd, B.L., & Feuerstein, M. (2010). It's not over when it's over: Long-term symptoms in cancer survivors—A systematic review. International Journal of Psychiatry in Medicine, 40, 163-181. doi:10.2190/PM.40.2.c
    Hausman, J., Ganz, P.A., Sellers, T.P., & Rosenquist, J. (2011). Journey forward: The new face of cancer survivorship care. American Journal of Managed Care, 17(5, Suppl.), e187-e193.
    Hewitt, M., Greenfield, S., & Stovall, E. (2005). From cancer patient to cancer survivor: Lost in transition. Washington, DC: National Academies Press.
    Howlader, N., Noone, A.M., Krapcho, M., Neyman, N., Aminou, R., Waldron, W., … Cronin, K.A. (Eds.). (2011). SEER Cancer Statistics Review, 1975-2009 (Vintage 2009 Populations). Retrieved from
    National Research Council. (2007). Implementing cancer survivorship care planning. Washington, DC: National Academies Press.
    Potosky, A.L., Han, P.K., Rowland, J., Klabunde, C.N., Smith, T., Aziz, N., … Stefanek, M. (2011). Differences between primary care physicians' and oncologists' knowledge, attitudes and practices regarding the care of cancer survivors. Journal of General Internal Medicine, 26, 1403-1410.
    Salz, T., Oeffinger, K.C., McCabe, M.S., Layne, T.M., & Bach, P.B. (2012). Survivorship care plans in research and practice. CA: A Cancer Journal for Clinicians, 62, 101-117. doi:10.3322/caac.20142
    Siegel, R., DeSantis, C., Virgo, K., Stein, K., Mariotto, A., Smith, T., … Ward, E. (2012). Cancer treatment and survivorship statistics, 2012. CA: A Cancer Journal for Clinicians, 62, 220-241.