Three models of clinical care for adult cancer survivors are being tested by the Network (Shapiro et al. 2009), and the NP carries out key clinical care roles in each of them. In the first model, the “consult model”, the survivor is seen once by an NP or physician with survivorship expertize. The visit typically includes universal screening for psychosocial late effects, treatment-specific clinical assessments (medical and family history, review of systems, physical examination, clinical laboratory evaluation, imaging and other studies) with referrals and other follow-up as clinically indicated. Following the visit, a form of the individualized SCP and results of any assessments are sent to the patient, referring primary care provider, and oncology treatment team. The goal is to empower survivors with information about their cancer treatment, their future health risks, and what can be done to manage those risks including healthy behaviors and regular health care. Responsibility for the care of the survivor remains with the oncology treatment team and/or primary care provider, who through the consultation are also educated about the survivor’s treatment history and health risks and can apply the consultant’s recommendations about regular monitoring. In the second model, the “ongoing care model”, the oncology treatment team hands responsibility for the care of the survivor over to a survivorship nurse practitioner or physician, at an established point in time post-treatment completion. The patient is seen on a regular basis, usually annually, by the survivorship health professional for ongoing monitoring and education about survivorship issues. Communication is maintained between treatment teams and primary care providers. In the third model, the “integrated care model”, survivorship care is provided by the oncology treatment team. An SCP is prepared when the patient completes treatment, and then discussed with the patient at a subsequent “survivorship” visit and annually thereafter by a treatment team NP. Responsibility for the care of the survivor remains with the treatment team in the short term. Patients who are at low risk for late onset versus persistent treatment effects can be identified and eventually transitioned to primary care with recommendations for regular screenings and ongoing communication between providers (Shapiro et al. 2009).

Although yet to be systematically evaluated through research, the integrated model of care for adults with cancer may have disadvantages that resemble those previously observed, in the care of childhood cancer survivors. Some of disadvantages could be that: (a) the needs of patients in active treatment are prioritized over survivors’ typically non-urgent needs, and more so as the number of patients in active treatment continues to grow (Shulman 2009), (b) the main area of concern at treatment completion is disease recurrence and so when information about late effects is presented at the end of treatment survivorship visit, patients and family caregivers may not absorb it, (c) survivors can feel social pressure to express only gratitude for successful treatment completion, and therefore lack willingness to discuss negative aspects of their treatment with those who delivered it. Furthermore, as the literature expands, oncology nurses and other health professionals may find it challenging to keep up with innovations in treatments and growing knowledge about survivorship. The benefits of the integrated approach include increased opportunities for direct communication and collaboration among health professionals.

Nurse Practitioners who provide clinical care for survivors can examine the survivor’s treatment summary to determine his or her cancer-related health risks, and thus offer an approach to clinical care. Survivors who are at low risk for late effects might participate in annual postal assessments apropos to health-related quality of life and risk-based interim history. Postal assessments are reviewed by the nurse or NP who then initiates clinical evaluation for the patients reporting concerning signs and symptoms. At the other end of the risk spectrum, the NP may do ongoing symptom management and care coordination for survivors whose actual or potential late effects are numerous or complex, for example, survivors who have been treated with cranial or mantle radiation.

The role of the nurse to date has been fairly constant across COE clinical programs. Ideally, following the IOM recommendations (Institute of Medicine 2006), a treatment summary is completed and distributed to the patient at the completion of therapy. Therefore, a role for nursing in the clinical care of cancer survivors within the realm of medical record review and abstraction is to create a treatment summary. Network members have created institution-specific treatment summary templates that are intended to be completed by an oncology health professional such as a nurse, and if at all possible may become part of the survivor’s electronic medical record. Alternatively, “A Prescription for Living” (Haylock et al. 2007), is a generic template that any nurse or survivor can use to create an individualized treatment summary based on the official medical record or the survivor’s personal records. Along these same lines, the Network is collaborating with University of Pennsylvania’s OncoLink to expand its Web-based treatment summary and Survivorship Care Plan (SCP) (see Table 3), which is called OncoLife™ (Shapiro et al. 2009).

In creating the treatment summary, the nurse should address all of the essential elements including: the cancer diagnosis and date, treating oncologist(s), elements of the treatment regimen (type and date of any surgeries to control the cancer; chemotherapy agents, routes of administration, and total dose when indicated; radiation type, field, fractionation, and total dose; transplant type and date), major acute treatment effects including psychosocial difficulties, date of treatment completion, current health status including non-cancer related comorbid conditions, and persistent treatment effects and known late effects. Essential elements of the SCP include all of the components of the treatment summary plus recommendations about cancer and treatment-specific screenings, advice about lifestyle changes to optimize the survivor’s health, and information about the availability of psychosocial resources and referrals (Institute of Medicine 2007).

Unlike pediatrics, widely accepted exposure driven evidence-based or consensus-based guidelines are not yet available to guide creation of the SCP