Cancer Survivorship for Primary Care Annotated Bibliography

Abstract

Long-term cancer survivorship care is a relatively new and rapidly advancing field of research. Increasing cancer survivorship rates have created a huge population of long-term cancer survivors whose cancer-specific needs challenge healthcare infrastructure and highlight a significant deficit of knowledge and guidelines in transitional care from treatment to normalcy/prolonged survivorship. As the paradigm of cancer care has changed from a fixation on the curative to the maintenance on long-term overall quality of life, so to, has the delineation of responsibility between oncologists and primary care physicians (PCPs). As more patients enjoy long-term survival, PCPs play a more comprehensive role in cancer care following acute treatment. To this end, this annotated bibliography was written to provide PCPs and other readers with an up-to-date and robust base of knowledge on long-term cancer survivorship, including definitions and epidemiological information as well as specific considerations and recommendations on physical, psychosocial, sexual, and comorbidity needs of survivors. Additionally, significant information is included on survivorship care, specifically Survivorship Care Plans (SPCs) and their evolution, utilization by oncologists and PCPs, and current gaps, as well as an introduction to patient navigation programs. Given rapid advancements in cancer research, this bibliography is meant to serve as current baseline reference outlining the state of the science.

Background

Survival is the new normal in cancer care. There are nearly 15 million cancer survivors in the United States. Clinically, this new paradigm of cancer survivorship is still in its infancy. As described by several Institute of Medicine (IOM) reports, including “From Cancer Patient to Cancer Survivor: Lost in Transition,” there is a significant shortfall of knowledge, research, and attention to long-term cancer survivorship. Even in the past decade, attitudes have shifted from exclusive fixation on disease eradication to maintenance of long-term well-being, including a new emphasis on comprehensive primary care after acute treatment. Needless to say, research continues to progress swiftly and the latest developments often raise more questions than they answer. To that end, this bibliography serves two interconnected purposes; to give the reader a base of knowledge which will assist him or her in navigating the frontier of cancer survivorship clinical care, and to outline the numerous research directions underway.

Methods

The purpose of this annotated bibliography was to conduct a thorough review of the current cancer survivorship literature and condense it into a useful resource. We utilized multiple sources to identify the core articles for review. First, we conducted a literature review from the online database PubMed.gov, accessed through the Department of Family Medicine at the University of Colorado at Denver Anschutz Medical Campus. The initial search criteria “cancer survivorship” yielded over 300,000 individual publications. The search was narrowed to specific survivor needs using the term “patient needs”, in combination with terms like “psychosocial”, “physical”, and “sexual” following “cancer survivorship”. Each specific search yielded 50-300 articles, subsequently narrowed to “English language” in the final selection. Initial screening of articles was completed by the authors and only recent articles, general interest, and those representing national organizations (eg, IOM) were included in the final report.

Second, based on early findings of the emerging importance of survivorship care planning, a separate literature search was completed for “cancer survivorship care planning” yielding over 1000 articles. Narrowing the search term to “cancer survivorship care plans” yielded 298 articles.

Third, additional articles were identified through the references and endnotes of published manuscripts and reports, suggestions from colleagues and recommendations from collaborating cancer experts. Finally, these same search terms were crossed referenced for additional scholarly articles and gray literature in Google and Google Scholar.

The combined searches included over 250 articles on cancer survivorship. The authors reviewed these to identify the seminal papers, those essential to primary care providers, and articles of duplicate or similar topic. The final selection included in this annotated bibliography includes 31 articles that provide the reader with a broad understanding of the current state-of-the-science in cancer survivorship. The annotations include an analysis of the research, ideas, and recommendations to inform the reader about clinical care, research gaps, and best practices for survivorship care. By selecting and describing a collection of articles that includes some general and specific topics, this bibliography provides a guided tour through the topic. The annotations provide a core understanding of cancer survivorship and an accessible resource for learning more about cancer survivorship.

Results

Seven broad rubrics emerged from analysis related to various aspects of cancer survivorship.

1. General background on cancer survivorship

2. Epidemiology of cancer survivorship

3. Psychosocial considerations in cancer survivorship

4. Physical and medical considerations in cancer survivorship

5. Special populations in cancer survivorship

6. Survivorship Care Plans (SCPs)

7. Other issues in cancer survivorship

I. General background on cancer survivorship

This section introduces several seminal reports from the Institute of Medicine (IOM) which have been critical to our changing understanding and strategy for addressing cancer care and long-term survivorship. Given the length of these resources, adequate summary and analysis is outside the scope of this annotated bibliography. Nonetheless, they will be included and alluded to throughout because of their foundational influence. They provide a valuable baseline for understanding the field of cancer survivorship, the scope of cancer survivorship, and the numerous gaps in our knowledge and care for cancer survivors.

Hewitt, Maria, Susan L. Weiner, and Joseph V. Simone, eds. Childhood cancer survivorship: improving care and quality of life. National Academies Press, 2003.¹

This IOM report on childhood cancer survivorship played an important preliminary role in changing the conversation of cancer care from “curing” the initial disease to long-term quality of life care. Recognizing childhood cancer survivors are a unique population given the longstanding impacts cancer can have on their lives, the IOM called for increased post-treatment surveillance and interventions to address long-term complications. This report was an early turning point in the approach to cancer care, emphasizing the need for improved quality care for survivors past acute treatment and into the future.

Hewitt, Maria, Sheldon Greenfield, and Ellen Stovall, eds. From cancer patient to cancer survivor: lost in transition. National Academies Press, 2005.²

This hallmark report from the IOM has played an instrumental role in garnering attention and support for improving long-term cancer survivorship care. It is fundamental to the changing paradigm of cancer care from exclusively acute treatment and disease eradication to the maintenance of general well-being.

Levit, Laura, et al. “Delivering high-quality cancer care: charting a new course for a system in crisis.” Institute of Medicine. Washington, DC: Institute of Medicine (2013).³

This most recent IOM cancer care report outlines the systematic failures of cancer care and articulates the systematic changes necessary to avoid a crisis in clinical care for cancer survivors. Specifically, the committee proposed improved patient engagement and provider coordination, utilization of evidence-based care, increased emphasis on health care information technology, translation of evidence into clinical practice, and guaranteed accessibility and affordability.

II. Epidemiology

The following articles provide a helpful starting place for understanding the scope of cancer survivorship. Included are resources that articulate the definition of cancer survivorship and describe the demographics, the epidemiology, and the changing paradigm of long-term cancer survivorship.

Siegel, Rebecca, et al. “Cancer treatment and survivorship statistics, 2012.” CA: a cancer journal for clinicians 62.4 (2012): 220-241.⁴

This highly cited article by Siegel and colleagues offers a wide array of general background information and statistics on cancer and survivorship including prevalence, survival, and treatment statistics on selected cancers. This article contains a large amount of demographic information and statistics and is a highly useful starting point for cancer survivorship research.

Siegel et al. define cancer survivorship as, “any person who has been diagnosed with cancer, from the time of diagnosis through the balance of life. They further describe 3 distinct phases of survivorship: 1) the time from diagnosis to the end of initial treatment, 2) the transition from treatment to extended survival, and 3) long-term survival. In 2012, there were 13.7 million cancer survivors in the United States, estimated to grow to 18 million by 2022. Prostate cancer accounts for 43% of male survivors, while colorectal cancer accounts for 9% and skin cancer, 7%. Among women, breast cancer accounts for 41% of survivors, uterine and colon cancer account for 8% each. Thirty-five percent of survivors are more than 10 years from their initial diagnosis and treatment. While childhood cancers are rare, there are 60,000 adult survivors of childhood cancers in the U.S.

Aziz, Noreen M., and Julia H. Rowland. “Trends and advances in cancer survivorship research: challenge and opportunity.” Seminars in radiation oncology. Vol. 13. No. 3. WB Saunders, 2003.⁵

In this seminal article, Aziz and Rowland describe the rapidly changing paradigm of cancer survivorship in the 21^st century and areas of research critical to addressing a burgeoning population of cancer survivors. Whereas cancer was once effectively a death-sentence, advancements in treatment and acute care have necessitated increased focus on long-term survivorship and the management of post-treatment complications and comorbidities. Late and long-term effects, which were once non-issues due to low survivorship, are neither well understood nor researched; furthermore, many prevalent types of cancer (excluding breast cancer) are still understudied. Aziz and Rowland contend the majority of cancer survivorship knowledge focuses on the short period following diagnosis, and call for a shift towards long-term survivorship research.

Erikson, Clese, et al. “Future supply and demand for oncologists: challenges to assuring access to oncology services.” Journal of Oncology Practice 3.2 (2007): 79-86.⁶

This American Society of Clinical Oncology (ASCO) commissioned study analyzes the possibility of future oncology service shortages and provides general recommendations for addressing this significant shortfall. Projections suggest increasing cancer survivorship coupled with an aging population will increase demand for oncology services at a rate that will outstrip supply, resulting in a deficit of 9-15 million visits annually (∼2500-4000 oncologists) by 2020. Erikson and colleagues offer a number of potential strategies for addressing such a shortage, including increasing the role of primary care providers (PCPs), nurse practitioners (NPs), and physician assistants (PAs). This paper demonstrates the increasing strain an aging general population and growing cancer survivorship population will place on the American healthcare system. Furthermore, it substantiates claims that primary care providers will play a critical role in the future of long-term cancer survivorship care. Mariotto et al. provide projections of overall cancer costs that further exemplify the national impact of long-term cancer survivorship and significant implications for policy makers moving forward.⁷

III. Psychosocial considerations

The following references provide a basic understanding of the psychosocial, psychological, emotional, and sexual needs, met and unmet, of cancer survivors.

Beckjord, Ellen Burke, et al. “Health-related information needs in a large and diverse sample of adult cancer survivors: implications for cancer care.” Journal of Cancer Survivorship 2.3 (2008): 179-189.⁸

Beckjord and colleagues conducted a large-scale study to determine the informational needs of cancer survivors that are entering the “Lost in Transition” phase of care. Namely, the majority of research prior to this study was focused on the informational needs of survivors directly following diagnosis, with little research on informational needs of survivors transitioning to long-term survival care. There was significant information needs by 71% of participants on tests and treatments, 68% on health promotion, 63% on side effects and symptoms, 54% on interpersonal and emotional issues, 42% on insurance, and 31% on sexual function and fertility. Beckjord and colleagues concluded that the “Lost in Transition” report very accurately portrayed the state of long-term cancer survivorship care. Consistent with IOM recommendations, they contend cancer care must undergo a significant culture change to create an information and communication-based environment with patients who are highly active and engaged throughout the care process.

Stanton, Annette L. “Psychosocial concerns and interventions for cancer survivors.” Journal of Clinical Oncology 24.32 (2006): 5132-5137.⁹

Cancer survivors, especially in the periods closely following diagnosis, have higher rates of psychological and psychosocial issues such as depression and anxiety. Somewhat surprisingly, long-term disease-free survivors report quality of life consistent with non-cancer populations and many individuals derive positive meaning from cancer diagnoses. Nonetheless, a majority of patients report receiving inadequate information from health care providers and wish for additional attention on emotional and psychological health. With the growth of the Patient-Centered Medical Home, and integrated behavioral health in primary care, increasing knowledge of psychosocial health concerns will be critical to ongoing improvements in primary care based cancer survivorship.

Zeltzer, Lonnie K., et al. “Psychological status in childhood cancer survivors: a report from the Childhood Cancer Survivor Study.” Journal of Clinical Oncology 27.14 (2009): 2396-2404.¹⁰

In this report from Childhood Cancer Survivor Study (CCSS), Zeltzer and colleagues analyze the psychological health of childhood cancer survivors. As they describe in the introduction, studies and statistics on the psychological health of childhood survivors are very significant because treatment occurred during the formative years of development and survivors are generally expected to live for 60+ years following treatment. Generally speaking, childhood cancer survivors are fairly healthy. Nonetheless, comprehensive comparisons demonstrate issues with impaired physical health, poor psychological health, and low quality of life. Survivors are 80% more likely than siblings to report mental health impairments, five times more likely to report functional impairments, and twice as likely to report emotional distress. Up to 40% of survivors display one or more domains of dysfunction, including attention, memory, processing speed, and executive function among others. Not surprisingly, survivors in poor health were more likely to report psychological symptoms like depression or anxiety.

Hordern, Amanda, and Annette Street. “Issues of intimacy and sexuality in the face of cancer: the patient perspective.” Cancer nursing 30.6 (2007): E11-E18.¹¹

Increasingly, patients desire active participation in addressing sexual health concerns instead of the usual dismissal of sexual health concerns as unimportant in the fight against cancer. Suggestions of patients' increased desire for information and control in care decisions, especially regarding sexual health issues, is indicative of the evolving paradigm of cancer survivorship. Additional focus on psychosocial and sexual health concerns represents the transition towards survivorship care as a matter of broad general health. Additionally, Jacobs and Pucci describe sexual and psychosocial health concerns in greater depth within the context of fertility and parenthood.¹²

IV. Physical and medical considerations

The following resources are beneficial for an in-depth understanding of the physical and medical needs of cancer survivors as well as lifestyle interventions and co-morbidities.

Miller, Kenneth D., and Laura R. Triano. “Medical issues in cancer survivors—a review.” The Cancer Journal 14.6 (2008): 375-387.¹³

Miller and Triano present a comprehensive synthesis of literature on medical complications in cancer survivors following acute treatment. The article includes late and long-term health complications following chemotherapy, surgery, and radiation therapy with significant information for different types of cancer and specific drugs and treatments. Specifically, Miller and Triano review the cardiovascular, pulmonary, gastrointestinal, rheumatologic, endocrine, renal, and neurologic sequelae that may arise. Long-term effects of cancer therapy are medical problems that persist for months or years after treatment ends. Late effects are medical problems that do not develop or become apparent until years after treatment ends. Following detailed descriptions of physical health concerns of long-term cancer survivors, Miller and Triano point out the increasingly important role of primary care providers in surveillance and care of late and long-term effects. Brearley et al describe the most significant physical and practical problems for survivors and provide critical areas of research focus in a literature review commissioned by the National Cancer Survivorship Initiative (NCSI).¹⁴

Rock, Cheryl L., et al. “Nutrition and physical activity guidelines for cancer survivors.” CA: a Cancer Journal for Clinicians 62.4 (2012): 242-274.¹⁵

This American Cancer Society (ACS) report synthesizes the recommendations of nutrition and physical activity experts for the implementation of clinical best practices during cancer survivorship. The report is written comprehensively to assist health professionals in serving patients, but may be utilized by patients directly as indicated by simplified layman's recommendations throughout and a large frequently asked questions section at the end. Rock and colleagues' focus on dietary and physical activity recommendations post-acute treatment makes it rather influential given the changing trajectory of cancer survivorship. Pekmezi and Demark-Wahnefried present additional evidence in support of lifestyle interventions with an evaluation of various dietary, weight management, and physical activity guidelines from organizations like the American Cancer Society (ACS).¹⁶

Pryce, Joanna, Fehmidah Munir, and Cheryl Haslam. “Cancer survivorship and work: symptoms, supervisor response, co-worker disclosure and work adjustment.” Journal of occupational rehabilitation 17.1 (2007): 83-92.¹⁷

In this British study, Pryce and colleagues attempt to further understand the work experience of cancer survivors during and after treatment. Survey results suggest just 30% of survivors continued to work during treatment. Individuals who were able to work flexibly and disclose their cancer to colleagues were generally more likely to continue work during treatment. During-treatment work was associated with difficulties managing fatigue and the need for paid time off to attend medical appointments. Return to work following treatment was also correlated with difficulties managing fatigue, the stress of cancer, and physical changes. Pryce and colleagues maintain that survivors often have mismatched expectations with their actual ability to work. De Boer and colleagues give additional insight into the relationship between cancer survivorship and unemployment with their systematic literature review.¹⁸

Earle, Craig C., and Bridget A. Neville. “Under use of necessary care among cancer survivors.” Cancer 101.8 (2004): 1712-1719.¹⁹

Earle and Neville sought to analyze the quality of care cancer survivors receive for chronic comorbidities. Results show cancer survivors were consistently less likely to receive recommended non-cancer related care for chronic conditions such as diabetes and heart disease. According to Earle and Neville, cancer survivors often lose consistent contact and health-seeking behavior with primary care providers, putting pressure on oncologists to manage comorbidities. However, “patients who were followed only by oncologists received significantly worse preventive care compared with patients who also had a primary care physician.” Patnaik et al studied this phenomenon in older breast cancer patients and found cardiovascular disease and other comorbidities account for a greater percentage of mortality than the breast cancer itself, further suggesting significant deficits in comorbidity management for long-term survivors.²⁰

V. Special Populations

This section provides information and recommendations on special populations of cancer survivors.

Oeffinger, Kevin C., et al. “Chronic health conditions in adult survivors of childhood cancer.” New England Journal of Medicine 355.15 (2006): 1572-1582.²¹

Prior to this seminal article, a number of small studies including a report from the Institute of Medicine had concluded the health outcomes of adult survivors of childhood cancers warranted additional research and attention. Oeffinger and colleagues highlight the myriad and substantial health concerns of adult survivors of childhood cancers by comparing health outcomes of siblings with and without cancer. Compared to their siblings with no cancer history, survivors were 3.3 times more likely to have a chronic health condition. Survivors were 8.2 times more likely than siblings to have a severe or life-threatening condition. This study helps to articulate the degree to which long-term cancer survivors suffer from long-term and late effects, comorbidities, and high risk of secondary cancers. Oeffinger and colleagues' research ultimately helped underscore the need for additional surveillance interventions by health providers and spur further research into long-term childhood cancer survivorship. Soliman and Agresta conclude insufficient attention is given to adolescent and young adult cancer patient (15-29 yrs old), evidenced by a slower improvement in survival rates relative to pediatric cancer patients, and call for the creation of an adolescent and young adult specific survivorship discipline.²² Aizer et al conclude racial disparities in cancer mortality, especially for African Americans, have not decreased since 1988 and highlight a deficit of understanding of the biological and social differences of African Americans most likely resulting from underrepresentation in clinical trials.²³

VI. Survivorship Care Plans (SCPs)

This section provides a basic understanding of the benefits of SCPs and the growing literature on implementing SCPs in oncology and primary care practice.

Oeffinger, Kevin C., and Mary S. McCabe. “Models for delivering survivorship care.” Journal of Clinical Oncology 24.32 (2006): 5117-5124.²⁴

Oeffinger and McCabe describe the status quo of cancer survivorship care following acute treatment and present various models that could aid in providing improved long-term care. Gilbert and colleagues also allude to these models and echo many of the observations and recommendations of Oeffinger and McCabe. ²⁵ Previously, cancer survivorship care has been plagued by a lack of clear guidelines or communication between providers. This article is separated into two sections, one focusing on community based shared-care models and the other focusing on various survivorship programs within academic institutions. Oeffinger and McCabe's recommendations are a necessary inclusion in this bibliography because they encapsulate the atmosphere of shifting focus onto long-term survivorship and initiatives for the development of comprehensive survivor programs. Earle outlines the basic organization of SCPs and articulates the framework from which SCPs have grown in the past 10 years.²⁶

Blanch-Hartigan, Danielle, et al. “Provision and Discussion of Survivorship Care Plans Among Cancer Survivors: Results of a Nationally Representative Survey of Oncologists and Primary Care Physicians.” Journal of Clinical Oncology 32.15 (2014): 1578-1585.²⁷

In this nationally representative study, Blanch-Hartigan and colleagues surveyed over 1100 oncologists and 1000 primary care physicians regarding their approach to cancer survivorship. While almost two thirds of oncologists reported giving survivors long-term care recommendations, only one-half reported having discussions on the delineation of responsibility between PCPs and oncologists in the long-term and less than 10% reported providing survivors with a written SCP. Only one-third of PCPs reported consistently discussing the delineation of provider responsibility with survivors while only one in five PCPs reported consistently discussing long-term survivorship care recommendations. Nonetheless, training on survivorship and improved communication between PCPs and oncologists have been shown to improve attention to survivorship care. More specifically, oncologists who receive training on late and long-term effects are more likely to discuss provider responsibility with survivors. Additionally, PCPs who received any kind of treatment summary or follow-up documentation from a survivor's oncologist were more likely to discuss survivorship care. Blanch-Hartigan and colleagues present this study as a nationally comprehensive benchmark of physicians' survivorship care communication. Salz et all describe current shortfalls in creation and implementation of SCPs in an extensive review of studies on SCP efficacy.²⁸

VII. Other issues

This section provides several important papers on other issues in cancer survivorship

Kim, Youngmee, and Barbara A. Given. “Quality of life of family caregivers of cancer survivors.” Cancer 112.S11 (2008): 2556-2568.²⁹

Kim and Given present a very comprehensive review of literature published from 1996-2007 on quality of life (QOL) of caregivers of cancer survivors. Kim and Given explain the majority of research examining caregiver QOL is focused on the acute treatment phase closely following diagnosis. Research suggests there are a number of caregiver characteristics leading to increased stress, including being a woman, of younger age, or of lower socioeconomic status. Evidence further indicates almost all interventions were only successful at increasing caregiver knowledge rather than improving QOL. Kim and colleagues also assess psychosocial and quality of life needs of caregivers at different points along the continuum of survivorship.³⁰

Paskett, Electra D., J. Harrop, and Kristen J. Wells. “Patient navigation: an update on the state of the science.” CA: a cancer journal for clinicians 61.4 (2011): 237-249³¹

Paskett and colleagues present an updated systematic literature review that details current research on patient navigation in cancer care. Patient navigators are community members (nurses, community health workers, lay people, cancer survivors etc.) who work to decrease barriers to access along the entire cancer care continuum. Evidence suggests patient navigation programs effectively increase screening rates for breast, cervical, and colorectal cancer. In addition to efficacy studies, the review described the patient perspectives on the roles of patient navigators. Their duties are generally grouped into two types: instrumental interventions are those such as providing transportation that are logistical in nature whereas relationship interventions are meant to improve the relationship between the patient and the system of care. Given the rapid rise of patient navigation, such programs will likely play a critical role in the future of cancer survivorship.

Conclusion

Cancer care is undergoing dramatic transformation. Once just a matter of acute treatment and end-of-life care, long-term survivorship is now the norm. The changing trajectory in cancer outcomes demands equal changes in cancer policy. Clinical guidelines and recommendations must keep up with the rapid changes and be disseminated more widely to primary care providers as well as oncologists. Patients can be engaged partners in their long-term care. Research priorities must include study and evaluation of long-term survivorship patterns, needs, late and long-term effects, and ways to improve and maximize quality of life. Insurance rules and regulations will need to consider changes in coverage for long-term care needs, medications, and active surveillance that are unique to cancer survivors.

The clinical paradigm for cancer care requires a shift in how the American healthcare system views cancer. While patients hear the words “cancer free”, they know that there are healthcare issues they will forever deal with. There has been extensive research and training on the care of patients with chronic conditions, from diabetes and asthma to depression and obesity. Cancer survivorship may be the newest of the “chronic conditions.” It demands clinical care that understands the chronic nature of the condition and the long-term healthcare needs of the patients. Clinical policies, guidelines, recommendations should reflect the new long-term nature of cancer care.

A successful clinical policy will require adequate research to support the discovery, development, and dissemination of evidence-based guidelines and recommendations. Research institutions and funding agencies will need to align their funding policies with the needs of the population. The single-minded focus on cure has brought great success. That success demands new policies for research funding, training, subject recruitment, and program evaluation that considers the long-term needs of survivors. Without additional research on the health impacts of acute treatment, the chronic nature of cancer survivorship, and the social impact of cancer treatment, survivors will not have access to evidence-based clinical care. While there has been a recognition in the long-term nature of cancer care, federal funding agencies have not kept up with the rapidly expanding need to study cancer survivorship. This manuscript provides a starting point for considering funding opportunities that may impact millions of cancer survivors.

Health coverage policies also reflect the historically acute nature of cancer treatment. While the Affordable Care Act requires coverage for preventive care, the rules and regulations are based on the average risk population. There are few, if any, provisions for active surveillance in cancer survivors. Prevention and early detection are particularly important in cancer survivors, and coverage policies should reflect the unique needs of survivors.

Finally, perhaps the most important policy implications of the new long-term nature of cancer survivorship are the social and cultural ideas around cancer. At one time, cancer was considered a religious curse, an ailment brought on by an angry, but just, god. The advent of science-based medicine transformed this superstitious thinking into the idea of cancer as a battle to be fought. Win or lose, the focus of our cultural ideas was on the fight to beat this cancer. Now, more and more battles are won. But cancer survivorship is fraught with additional healthcare need, clinical surveillance and treatment, relational needs, medical, and political understanding. Cultural constructs and ideas about cancer survivorship demand attention in the clinic, the community, cancer funding agencies, board rooms, even the chambers of our elected officials.

Highlights.

1. Cancer treatment is moving from acute cure to long-term survival management.

2. Survivorship requires collaboration between patient, oncologist and primary care.

3. Survivorship Care Plans are essential tools for improving cancer survivorship.

4. This annotated review provides a core understanding of cancer survivorship.