When survivors eventually become adults, they can no longer be followed at the Children’s Hospital.  Transition of care to an adult program is difficult.  Care given through a co-ordinated multidisciplinary team at the same hospital, which is available to youths, no longer exists for adult survivors.  Adult services are fragmented and physicians who care for adults may not understand the different late effects.

To facilitate transition of care, survivorship care plans are currently given to patients who leave the BC children’s hospital.  Because each cancer survivor had a different type of cancer, at a different age, in a different part of their body with different therapies, every individual has different long term health risks.  An individualized survivorship care plan can be built outlining what those particular risks are and how that individual should best be followed.

The following examples are from the “Journey Forward” website:

Journey Forward

Survivorship Care Planning

A Survivorship Care Plan is a coordinated post-treatment plan built by the survivor’s oncology team, a primary care physician and other health care professionals. The oncologist creates a summary of the survivor’s treatment and includes direction for future care.

A typical Survivorship Care Plan includes:

  1. Patient diagnosis and treatment summary
  2. Best schedule for follow-up tests
  3. Information on late and long-term effects of cancer treatment
  4. List of symptoms to look for
  5. List of support resources

This comprehensive medical summary, given to the survivor and their primary care physician, helps support better survivorship care. The plan includes important information for monitoring possible secondary cancers and any late or long-term effects of the survivor’s cancer treatment. A Survivorship Care Plan also relieves a survivor of having to recall all the details of their treatment and ensures all future health care providers are working as a team for the survivor’s care.

Here is an excellent lecture about transition of care and the associated challenges:

Models for Transition of Care for Childhood Cancer Survivors