Table 3.
Scorecard - Survivorship Care Plan Items
| Information Domain | Item | Descriptor |
|---|---|---|
| Potential Toxicities and Late Effects | 1 | Are any treatment toxicities (Note: actual or possible) identified? |
| 2 | Is the expected course (Note: critical component = time) of recovery from toxicities identified? | |
| 3 | What possible long-term and late effects could result from treatments received? | |
| 4 | What are symptoms from these possible long-term and late effects of treatment? | |
| Breast Cancer Surveillance | 5 | What breast cancer-specific surveillance testing is recommended? |
| 6 | How frequently should recommended breast cancer-specific surveillance testing be performed? (Note: 1 point maximum given for any test recommended) | |
| 7 | What provider is responsible for ordering/providing BC-specific surveillance testing? | |
| Non-breast Cancer Surveillance | 8 | What non-BC cancer surveillance testing (e.g., colonoscopy, PAP) is recommended? (Note: 1 point maximum given for any test recommended) |
| 9 | How frequently should recommended non-BC cancer surveillance testing be performed? | |
| 10 | What provider is responsible for ordering/providing non-BC cancer surveillance testing? | |
| Non-Cancer Surveillance | 11 | What non-cancer surveillance testing (e.g., lipid profiles) is recommended? (Note: 1 point maximum given for any test recommended) |
| 12 | How frequently should recommended non-CA surveillance testing be performed? | |
| 13 | What provider is responsible for ordering/providing non-CA surveillance testing? | |
| Signs & Symptoms of Cancer | 14 | What are possible signs of breast cancer recurrence? |
| 15 | What are possible signs of second cancers? (Note: 1 point maximum given for any sign/second cancer noted) | |
| Potential Psychosocial Effects | 16 | What are the possible effects of BC on the marital/partner relationship (not incl. sexual functioning)? |
| 17 | What are the possible effects of BC on sexual functioning? | |
| 18 | What are the possible effects of BC on work/employment? | |
| 19 | What are the possible effects of BC on parenting? | |
| 20 | What are the possible effects of BC on insurance? | |
| 21 | What are the possible effects of BC on finances? | |
| 22 | What is the potential future need for psychosocial support? | |
| Referral Information | 23 | What are potential referral sources for counseling? |
| 24 | What are potential referral sources for legal aid? | |
| 25 | What are potential referral sources for financial assistance? | |
| 26 | Are referrals to specific follow-up care providers given? (e.g., PCP, rehabilitation, fertility, support groups) (Note: point awarded only for referrals to specific providers or services) | |
| 27 | Is a list of cancer-related resources and information (e.g., Internet-based, major cancer support organizations) provided? | |
| Prevention/Health Promotion | 28 | What are specific recommendations for healthy behaviors (e.g., physical activity, diet, weight, immunizations, etc.) |
| 29 | Is information on known effective chemoprevention strategies for secondary cancer prevention discussed? (i.e., tamoxifen in women post ipsilateral mastectomy; aspirin for colorectal cancer prevention) | |
| Genetic Testing Recommendations | 30 | Is information provided on who should consider genetic counseling and testing? |
| Familial Cancer Risk | 31 | Are recommendations provided on what information first degree relatives should be given about their cancer risk? |
| 32 | Are recommendations provided regarding what specific cancer screening tests first degree relatives should undergo? |
Scoring: Each item is worth 1 point, maximum. Items can receive a point in two ways: a) Score 1 point for each item if present and detailed in the SCP or accompanying materials. b) Score 1 point if SCP or accompanying materials provide a space for information regardless of completeness of document provided to patient. Please note additional scoring instructions for items 1, 2, 6, 8, 11, 15, 26. Total possible = 32 points.