Cancer Survivorship Nursing CE Course

e at diagnosis, stage of disease, performance status, comorbid conditions, and access to evidence-based treatment all contribute to outcomes. Insurance status, financial resources, and access to quality cancer care all further impact a patient’s survival and quality of life. Additionally, beliefs and preferences of patients, families, and providers often shape treatment decisions and influence the care trajectory. Despite national improvements in cancer outcomes, disparities persist, particularly among medically underserved populations. Individuals from minority or low-income communities are more likely to experience delayed diagnoses and suboptimal treatment, resulting in poorer outcomes. These disparities underscore the necessity for equitable access to high-quality, coordinated survivorship care that addresses the comprehensive spectrum of needs—clinical, psychosocial, and practical—for every individual affected by cancer (OCS, 2024; Wagle et al., 2025).

 

Evolution of Survivorship Care

The concept of cancer survivorship dates to the mid-1980s, when Dr. Fitzhugh Mullan published a landmark article titled “Seasons of Survival” in the New England Journal of Medicine. In this work, Dr. Mullan introduced a novel framework for understanding the three phases of cancer survivorship: the acute phase (covering diagnosis and active treatment), the extended phase (encompassing the posttreatment transition), and the permanent phase (focused on longer-term recovery or remission). His model laid the groundwork for a more structured understanding of survivorship (Mullan, 1985). In 1986, Dr. Mullan helped found the NCCS, which remains the longest-standing survivor-led cancer advocacy organization in the United States. The organization aimed to move away from framing individuals as “cancer victims” and instead champion them as “cancer survivors,” to reflect strength, resilience, and ongoing life beyond diagnosis. Dr. Mullan’s work has been widely utilized and expanded in recent decades. The NCCS continues to influence national policy and advocates for comprehensive survivorship care (NCCS, n.d.-b).

The momentum generated by Dr. Mullan’s work catalyzed broader national attention. In 2006, the Institute of Medicine (IOM) and National Research Council released a pivotal report titled “From Cancer Patient to Cancer Survivor: Lost in Transition.” The report highlighted significant gaps in posttreatment care and emphasized the importance of providing all cancer survivors with individualized care plans. These care plans were envisioned to guide patients through the transition from oncology-led care to shared management with primary care providers (IOM, 2006).

As survivorship gained recognition as a distinct phase of care, accreditation bodies began to formalize its importance. Cancer survivorship is now recognized as a critical component of quality cancer care by all major national cancer accreditation bodies in the United States. The Commission on Cancer (CoC), under the American College of Surgeons (ACOS), was one of the first accrediting bodies to incorporate survivorship into its standards formally. In 2012, the CoC began requiring accredited cancer programs to provide survivorship care plans (SCPs) to eligible patients, with implementation benchmarks rising to 75% by 2018; however, the operational burden of implementation led to the eventual removal of the SCP mandate. While no current numerical requirement exists for SCP delivery, survivorship remains a core focus. Programs must integrate SCPs as part of a fully developed survivorship program, with delivery encouraged but left to the institution’s discretion (ACOS, 2024).

Similarly, the National Accreditation Program for Breast Centers (NAPBC)—also part of the ACOS—requires breast programs to include survivorship as part of their accreditation, ensuring that breast cancer patients are offered comprehensive posttreatment education and resources, such as long-term follow-up care plans, psychosocial support, and health promotion strategies. This requirement reflects the reality that many breast cancer patients live for decades after diagnosis, often with ongoing physical or emotional needs (ACOS, 2025). While the NCI does not accredit programs in the traditional sense, it designates Comprehensive Cancer Centers based on excellence in research, clinical care, and community outreach. Survivorship care is a priority within these institutions, with many leading NCI-designated centers establishing formal survivorship clinics, conducting research on survivorship, and serving as models for integrated care nationwide (OCS, 2023).

Core Components of Cancer Survivorship

Survivorship encompasses several focal areas, including cancer recurrence, new cancer diagnosis, and secondary malignancies. Care consists of managing the long-term and late effects of treatment, quality of life, and economic issues associated with cancer care. It also includes the emotional and psychological consequences of a cancer diagnosis, its treatment, and the completion of treatment. Health promotion, cancer screening, prevention, early detection of new cancers, and the impact of other chronic and comorbid conditions are also essential aspects (refer to Table 1; ACS, 2024a; American Society of Clinical Oncology [ASCO], n.d.; Wagle et al., 2025).

Table 1

The Core Components of Survivorship Care

 

 (ACS, 2024a; ACOS, n.d., 2024)

Survivorship Care Plans

SCPs are comprehensive, personalized documents provided to patients upon the completion of cancer treatment. They’re designed to serve as a road map for ongoing care, improve communication and coordination across healthcare providers, and empower survivors with knowledge about their treatment history and future health needs. SCPs are a cornerstone of survivorship care and have been shown to positively impact patient outcomes, provider communication, and care continuity. SCP templates generally include four key sections that address both medical and supportive care needs (refer to Table 2; ACS, 2024a; Centers for Disease Control and Prevention [CDC], 2024; NCCS, n.d.-a; NCI, n.d.).

Table 2

Four Sections of SCPs

 

Treatment Summary	This section includes essential details, such as the cancer diagnosis (type, stage, and pertinent pathological features, including biomarkers and genetic mutations), treatments received (surgery, chemotherapy, and radiation), and the dates of treatment completion. It provides context for long-term surveillance and informs future clinical decisions.
Follow-Up Plan	Survivors receive a tailored follow-up care schedule, including physical examinations, laboratory testing, and diagnostic imaging to monitor for recurrence or late effects. This section helps ensure timely detection and intervention should complications or second cancers arise.
Health Promotion and Risk Reduction	SCPs provide practical recommendations to minimize the risk of recurrence and promote overall well-being. Common strategies include tobacco cessation, regular physical activity, healthy diet, weight management, and routine cancer screening for other malignancies.
Care Coordination	SCPs outline the roles and responsibilities of the care team, including oncologists, PCPs, surgeons, and other specialists, ensuring smooth communication and reducing duplication of services. Clear delineation of responsibilities supports patient trust and helps avoid gaps in care.

(ACS, 2024a; CDC, 2024; NCCS, n.d.-a; NCI, n.d.).

While SCPs are typically delivered at the conclusion of treatment, effective survivorship planning should begin early and evolve with the patient’s care journey. By integrating SCPs into electronic health records and aligning them with patient preferences, oncology teams can streamline survivorship planning into routine workflows. SCPs have been likened to hospital discharge plans, but they are broader in scope, addressing not just immediate posttreatment care but also long-term issues (ACS, 2024a; CDC, 2024; NCCS, n.d.-a). Recent studies underscore the value of SCPs in enhancing survivor outcomes. A 2021 study published in the Journal of Oncology Navigation & Survivorship reported that SCP delivery was associated with reduced psychological distress and improved self-efficacy among high-risk cancer survivors (Kelleher et al., 2021). A 2024 review also found that SCPs enhanced coordination of care and health literacy, particularly among underserved and rural populations (Tarver et al., 2024).

Models of Survivorship Care

Survivorship care models have diversified to meet the varied and evolving needs of people recovering from cancer. Returning to life after cancer is rarely a return to the prediagnosis norm; survivors frequently describe establishing a “new normal.” This transition can be prolonged and emotionally complex. When survivors’ unaddressed needs go unresolved, outcomes can worsen, including decreased quality of life, increased symptom burden, and higher rates of anxiety or depression. Models of survivorship care outline the structure and delivery of services, including the roles of providers and the stages of care they lead. No single model fits all. Oftentimes, models of cancer survivorship differ significantly based on the resources, staffing, and financial capabilities of the cancer institute. While some organizations can provide fully staffed cancer survivorship programs, others utilize the combined efforts of oncologists and advanced practice providers, along with assistance from oncology nurses or oncology nurse navigators, to facilitate the composition and delivery of SCPs. The key models are described in Table 3 (Chan et al., 2023; OCS, n.d.-a).

Table 3

Key Models of Survivorship Care

 

Oncology-Led	Oncology specialists’ direct survivorship care in the oncology-led model. While this ensures expertise, it may overburden specialists and limit accessibility.
Primary Care-Led	This model is coordinated by the patient’s PCP, leveraging the PCP’s oversight of ongoing health needs, and facilitates holistic management.
Shared Care	Shared care is a collaborative approach where oncology teams and PCPs comanage survivors. This model supports enhanced communication and coordination, aligning with the recommendations of multiple professional groups.
Multidisciplinary Clinics	Some organizations offer specialized clinics where multiple providers (e.g., medical, nursing, rehabilitation, psychosocial) deliver integrated care in one setting.
Nurse-Led	Specialized oncology nurses may take the lead in providing survivorship care across settings, coordinating assessments, and referrals.

(Chan et al., 2023; OCS, n.d.-a)

 

Quality of Life Domains

                Research identifies four key domains of quality of life for cancer survivors: physical, psychological, social, and spiritual. Each domain represents vital areas to monitor and support throughout the survivorship journey (ACS, 2024b; Voskanyan et al., 2024).

Physical

An estimated 25% of cancer survivors report a decreased quality of life due to the physical effects of cancer (ACS, 2022). The physical domain addresses the body’s health and functioning, which can be significantly affected by cancer and its treatment. Common concerns include pain, fatigue, and sleep disturbances, which are highly prevalent among survivors and often persist long after treatment ends. Survivors may also experience long-term treatment effects, such as chronic cardiac, pulmonary, neurological, endocrine, or skin issues, requiring ongoing monitoring and intervention. Bone loss is a common consequence of chemotherapy, steroid medications, hormonal therapy, or radiation therapy. Survivors should be educated on strategies to reduce their risk of bone loss, such as avoiding smoking, engaging in weight-bearing exercises, and consuming foods rich in calcium and vitamin D. Disruptions in intimacy or fertility are common and can significantly impact quality of life but are often overlooked. “Chemo brain” is another commonly reported phenomenon among survivors—a term used to describe a decline in memory, attention, or processing speed. Adequate rehabilitation, symptom management, and routine follow-up are crucial for comprehensively addressing these physical challenges (ACS, 2024b; NCI, 2025b).

Psychological

Emotional well-being is intricately tied to survivorship and includes anxiety, depression, and fear of cancer recurrence. An estimated 10% of cancer survivors report a decreased quality of life due to the emotional impact of their cancer or its treatment (ACS, 2022). A recent review confirmed that coping strategies, depression, and anxiety are among the most influential psychological factors affecting quality of life in survivors (Marzorati et al., 2025). Empowering survivors to engage actively in posttreatment care can help strengthen their sense of control and psychological resistance. Ultimately, psychological support, including counseling, support groups, and training in coping skills, is essential in addressing these needs (Voskanyan et al., 2024).

Social

              The social domain encompasses personal relationships, social roles, and livelihood. Research demonstrates that strong relationship support improves patient outcomes, while social withdrawal can exacerbate distress and symptoms. Survivors often face employment loss or disruptions, which contribute to economic strain and issues related to unaffordable health care costs and loss of insurance coverage. Cancer impacts family dynamics and body image. It can alter family roles and relationships and affect a person’s self-image and social confidence. For example, cancer treatments can lead to noticeable physical changes, such as surgical scars, ostomies, or the use of prosthetic devices. These alterations may affect how individuals perceive their bodies, and some may experience concerns about being judged or rejected by others due to their appearance. Targeted interventions—such as financial counseling, job support services, and family-inclusive care—are vital to alleviating these social burdens (ACS, 2023, 2024b; Chen et al., 2023; NCI, 2025a).

Spiritual

                The spiritual domain includes hope, purpose, meaning, and existential well-being. Survivors with higher resilience tend to have stronger spiritual well-being and receive more social support, which, in turn, enhances their quality of life. A study involving 286 adults with advanced cancer, conducted by Chen and colleagues (2023), identified spirituality as a more influential mediator than social support, indicating its potential as a key focus for survivorship interventions. Survivors who report deeper spiritual connections often demonstrate better coping and emotional adaptation. Furthermore, engagement with religious or spiritual practices can enhance resilience and psychological well-being. Supporting survivors in exploring meaning through pastoral care, life-review therapies, or meaning-centered activities is increasingly recognized as a core component of holistic survivorship (Firkins et al., 2025).

 

Comorbid Conditions in Cancer Survivors

Following cancer treatment, many survivors continue to experience—or develop—additional chronic health conditions that significantly affect their well-being. Beyond tobacco use, physical inactivity, poor nutrition, and obesity are the most critical risk factors for cancer recurrence, morbidity, and premature death. Studies consistently show that these factors raise the risk of cancer recurrence and progression, while also undermining overall health outcomes among those treated with curative intent. Among cancer survivors, the following chronic conditions are especially frequent (ACS, 2022; Ahmad et al., 2024):

• type 2 diabetes and glucose intolerance
• cardiovascular disease, such as coronary artery disease (CAD), hypertension, and hyperlipidemia
• obesity
• hypothyroidism
• depression and cognitive changes
• osteoarthritis
• osteoporosis

Long-term and Late Effects of Cancer and Cancer Treatment

Long-term effects of cancer and cancer treatment refer to the side effects or complications that linger after treatment ends, involve all body systems, and affect all health aspects. Long-term effects generally begin during treatment and continue beyond treatment completion. Late (latent) effects are unrecognized complications or side effects that are absent or subclinical at the end of treatment and can occur months to years after treatment has ended (ASCO, n.d.). Long-term and latent effects largely depend on the type of cancer, treatment received, preexisting conditions, underlying health problems, and any treatment-related complications. Effects can be related to chemotherapy, surgery, radiation, hormonal therapy, or a combination of any of these; alternatively, effects may be entirely nonspecific. Some of the most frequently reported long-term and latent effects associated with treatment modality are summarized in what follows (ACS, 2024b; NCI, 2025b):

• Surgical effects are generally site-specific and may include body image concerns (body dysmorphia), lymphedema, scarring, urinary or fecal incontinence, erectile dysfunction, and chronic pain.
• Radiation therapy effects are site-specific and can include lymphedema, hypothyroidism, skin discoloration, pulmonary toxicity, atherosclerosis, risk for skin cancer at irradiated sites, pericardial disease, and pain. Patients who received cervical or prostate radiation may experience ongoing urinary complications or sexual dysfunction. Radiation to the bowel for gastrointestinal (GI) malignancies can cause radiation proctitis, which is inflammation and damage to the lower parts of the colon. Radiation proctitis can cause chronic GI symptoms that can mimic irritable bowel syndrome, such as persistent abdominal pain, chronic diarrhea, and bloody stools. Patients may also experience loss of anal sphincter tone leading to chronic fecal incontinence. These patients are also at increased risk for developing an anal or a rectovaginal fistula (i.e., an abnormal connection between hollow spaces).
• The effects of chemotherapy are usually drug- and dose-specific. They commonly include sexual dysfunction, such as decreased libido, infertility, and dyspareunia (difficult or painful sexual intercourse). The heart may become damaged from cardiotoxic chemotherapy agents, leading to cardiomyopathy or heart failure. The lungs can become damaged from certain pulmonary toxic agents, leading to pulmonary fibrosis, lung scarring, decreased lung capacity, and chronic respiratory symptoms. Many patients experience long-term neurological deficits, including cognitive dysfunction, peripheral neuropathy, and neuromuscular impairments (loss of deep tendon reflexes). Some chemotherapy agents may increase a patient’s risk of developing secondary malignancies several years later, such as leukemia.
• Hormonal therapy is commonly administered over extended periods and often contributes to several ongoing and lasting side effects. For many estrogen-receptor–positive breast cancers, hormonal treatment may continue for 5 to 10 years. These effects can include premature menopause and accompanying vasomotor symptoms such as hot flashes and night sweats. Other effects include arthralgia (joint pain), vaginal atrophy leading to vaginal dryness and dyspareunia (painful intercourse), mood changes, weight gain, bone density loss (osteopenia or osteoporosis), and hyperlipidemia. In males, hormonal treatment can induce hot flashes and sexual dysfunction, including erectile dysfunction and loss of libido.
• Non–treatment-specific long-term and late effects can include chronic fatigue or psychosocial and emotional alterations, such as depression and anxiety.

 

American Cancer Society Survivorship Guidelines

The ACS (2022) survivorship guidelines were constructed to assist PCPs with the clinical care and management of survivors. The ACS currently offers four tumor-specific guidelines (breast, prostate, colorectal, and head and neck). The guidelines focus primarily on promoting healthy lifestyles, making behavioral changes, engaging in physical activity, and achieving weight loss among survivors. While the link between obesity and cancer is well established, survivorship studies demonstrate that cancer survivors engage in low physical activity levels and rarely adopt lifestyle modifications. Nearly two-thirds of patients gain weight during or after treatment. In response, the ACS has put forth weight management and healthy lifestyle guidelines tailored to the survivorship population. These guidelines address obesity in the context of a cancer diagnosis; inform patients and HCPs about the link between obesity and cancer; and focus on prevention, exercise, nutrition, and weight management. They highlight diet and physical activity recommendations during the continuum of cancer care but concentrate primarily on the needs of the survivorship population after treatment ends. Table 4 summarizes the main principles of the ACS guidelines (ACS, 2022).

Table 4

 

ACS Nutrition and Physical Activity Guidelines for Cancer Survivors

 

• Achieve and Maintain a Healthy Weight	Physical Activity	Nutrition
  behavioral strategies a one-on-one counseling session with a clinician structured weight-loss programs support groups health tracking using online tools or smartphone applications	engaging in regular physical activity avoiding inactivity returning to normal daily activities as soon as possible moderate vs. vigorous activity cardiovascular exercise at least 150 minutes per week, with strength training at least two days per week	limiting consumption of high-calorie foods and beverages food portion control a diet high in vegetables, fruits, and whole grains referral to a registered dietitian smoking cessation limit or avoid alcohol

(ACS, 2022)

Barriers to Survivorship Care

Multiple barriers limit access to effective survivorship services, including sociodemographic disparities, fragmented care models, and systemic challenges within the health care delivery system. One major obstacle is the lack of adequate insurance coverage and reimbursement mechanisms for survivorship services. Survivors who are uninsured or underinsured often struggle to access the necessary medical, psychosocial, and rehabilitative support following active treatment. Even when survivors are insured, many of the services central to survivorship care—such as care planning, counseling, and chronic symptom management—are not reimbursed at sustainable levels. This financial gap discourages healthcare providers from dedicating time and resources to comprehensive survivorship programming (NCCS, n.d.-a; Wagle et al., 2025).

Additionally, provider-level barriers have a significant impact on care delivery. PCPs may feel unprepared to manage cancer-specific complications, while oncologists cannot often follow survivors long-term. Without clear role delineation, survivors can fall through the cracks, especially when transitioning out of oncology care. Inadequate training for both oncology specialists and PCPs in survivorship practices, including late effects, surveillance, and psychosocial health, exacerbates this issue. As a result, providers may miss opportunities to address chronic fatigue, cognitive changes, sexual dysfunction, or emotional distress (Santos-Teles et al., 2024; Wagle et al., 2025).

Health system fragmentation further undermines survivorship care. Many health care organizations utilize electronic health record systems that lack interoperability, which prevents seamless communication between oncology and primary care teams, making it difficult to track treatment histories, follow-up schedules, or address active health issues. Limited data sharing contributes to duplication of services, missed screenings, and suboptimal care coordination. Additionally, social determinants of health play a significant role in limiting access to health care. Survivors facing language barriers, low health literacy, unemployment, or transportation challenges may struggle to understand and engage in their care. These nonclinical obstacles are especially common among historically underserved populations and must be addressed through culturally responsive, community-based approaches (Wagle et al., 2025).

 Despite their documented benefits, the implementation of SCPs remains inconsistent across health care settings. While SCPs are designed to bridge the gap between oncology and primary care, they are not yet routinely integrated into practice. Common reasons include time constraints, lack of reimbursement, unclear ownership between oncology and PCPs, and variability in documentation standards. Moreover, many providers remain uncertain about when and how to deliver SCPs or how to tailor them to meet patients’ needs. A 2022 mixed-methods study identified time constraints, lack of reimbursement (especially for non–healthcare provider–led services), and confusion about provider responsibility as major impediments to consistent SCP use (Santos-Teles et al., 2024).  Too often, SCPs are treated as one-time documents rather than dynamic tools that evolve with the survivor’s health status. Without strong institutional support or care coordination infrastructure, SCPs risk becoming underutilized and ineffective (NCCS, n.d.-a).

The Critical Role of Nurses in Cancer Survivorship

As patients move from active cancer treatment into long-term survivorship, the involvement of a knowledgeable healthcare provider is crucial to ensure continuity of care. Nurses are indispensable in delivering high-quality survivorship care. They bring a unique combination of clinical expertise, communication skills, and patient-centered advocacy that makes them especially well suited to guiding survivors through the posttreatment phase. Their training enables them to identify and manage long-term and late effects of cancer therapies that may persist or appear months or years after treatment ends. In many cases, survivors are unaware that such symptoms are related to their prior cancer care, and nurses play a key role in validating these experiences and initiating appropriate interventions or referrals. Nurses serve as educators and coaches, helping survivors understand the components of their SCP and promoting behaviors that support recovery and long-term wellness. Since health promotion is a core aspect of survivorship, nurses are well positioned to counsel patients on essential lifestyle modifications to maintain their health and ensure compliance with cancer screenings. These conversations are often more effective when delivered by nurses, who typically have more frequent contact with patients and can build trusted relationships that support behavioral change (Bae & Kim, 2024; Phothikul & Seven, 2023).

In addition to patient-facing responsibilities, nurses are the cornerstone of care coordination. One of the most challenging aspects of survivorship care is ensuring clear, timely communication between oncology specialists, PCPs, and other members of the care team. Survivors transition from intensive, oncology-led care to more decentralized follow-up with PCPs or multiple specialists. Nurses help prevent survivors from becoming “lost to follow-up.” By maintaining consistent contact, scheduling follow-ups, and reinforcing care plans, nurses provide a reliable touchpoint that supports engagement and adherence to long-term care recommendations. Nurses help bridge care gaps by ensuring SCPs are shared with relevant providers, facilitating referrals, and acting as a liaison between disciplines. Their involvement improves not only clinical outcomes but also survivor satisfaction and confidence in the care process. They are trained to assess the psychosocial dimensions of survivorship care and connect patients with counseling, peer support programs, or other mental health resources as needed. By addressing both clinical and emotional needs, they contribute to a more holistic model of care. As survivorship care models evolve, the central role of nurses in facilitating a safe, informed, and connected posttreatment experience must be recognized and integrated into all levels of survivorship planning (Bae & Kim, 2024; Phothikul & Seven, 2023).

 

Cancer Survivorship Resources

• American Cancer Society: http://cancer.org
• American Society of Clinical Oncology: http://www.asco.org
• LIVESTRONG (Lance Armstrong Foundation): www.livestrong.org
• National Comprehensive Cancer Network: www.nccn.org
• National Coalition for Cancer Survivorship: www.canceradvocacy.org
• National Cancer Institute, Office of Cancer Survivorship: https://cancercontrol.cancer.gov/ocs

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