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When main treatment ends, you should get a written summary of the treatment you had, side effects to look out for, signs the cancer might be back, who to contact, and the follow-up planned. In England it goes to you and your GP. Trials found the written plan alone did not make people feel better; it works best with a real conversation about who looks after you next.
The Institute of Medicine's 2006 report recommended that every survivor receive a survivorship care plan: a treatment summary and a follow-up care plan, to improve communication with the patient and between the oncology team and primary care (as summarised in ASCO's 2014 statement, which also revised the template because plans were rarely completed). The NCI tells patients they should receive one when treatment ends. In England the same handover is part of personalised care and support planning: a holistic needs assessment and a personalised care and support plan; an end of treatment summary written by the hospital clinician and shared with the patient and GP, containing the treatment given, possible side effects, the signs and symptoms of recurrence and contact details; and a cancer care review in primary care, which the Quality and Outcomes Framework requires within 12 months of the end of acute treatment. ESMO's 2022 consensus names five components of survivorship care (physical effects, psychological effects, social, work and financial effects, surveillance for recurrence and second cancers, and prevention and health promotion) and leaves the care model to local circumstances.
The evidence on the written plan is consistently negative for patient-reported outcomes. In a randomised trial of 408 women after early breast cancer, a care plan reviewed with a nurse made no difference to distress or any patient-reported secondary outcome; its one gain was that more patients knew their GP was now responsible. A cluster randomised trial of automatically generated plans in endometrial cancer found more information received but no gain in satisfaction, and more symptoms and concern reported. A 2018 systematic review (13 randomised studies) and a 2020 meta-analysis (eight trials, 1,286 survivors) found no improvement in patient-reported outcomes, with more positive signals for information received and for care delivery when the plan comes with counselling. The defensible protocol is therefore the handover itself (the summary, the named responsible clinician, the needs assessment and the follow-up schedule) rather than the document as an end in itself.
Why: Your GP and other doctors need to know what treatment you had, sometimes years later, and you need a copy too.
“A Treatment Summary is a document produced by the hospital clinician at the end of initial treatment for cancer. It's designed to be shared with the patient and their GP.”
Why: These are what you and your GP need in order to notice problems early and know where to turn.
“The End of Treatment Summary usually contains: an overview of any treatment the patient has received details of any potential side effects of treatment the signs and symptoms of cancer recurrence contact details to address any concerns.”
Why: Knowing which tests and appointments to expect, and what help exists, makes the move out of active treatment less uncertain.
“A follow-up care plan is a summary of your treatment, along with recommendations for your cancer care after treatment ends. Your plan may also include suggestions to help meet other needs, such as emotional, social, or financial issues.”
Why: Tests and decisions can fall between clinics; a named person and shared notes prevent that.
“Ask each doctor you see to share notes with your other doctors.”
Why: Physical, practical, emotional and social problems after treatment are common and are easier to deal with when they are found early.
“A Personalised Care and Support Plan ensures people’s physical, practical, emotional and social needs are identified and addressed at the earliest opportunity.”
Why: A conversation with the GP or practice nurse brings the cancer experience into everyday care and points to local support.
“The Quality and Outcomes Framework (QOF) requires primary care professionals to carry out a CCR at the time of a patient's diagnosis (within 3 months) and after a patient has received acute treatment (within 12 months).”
Why: Life after cancer treatment involves much more than checking for recurrence.
“We identified five main components of survivorship care: (i) physical effects of cancer and chronic medical conditions; (ii) psychological effects of cancer; (iii) social, work and financial effects of cancer; (iv) surveillance for recurrences and second cancers; and (v) cancer prevention and overall health and well-being promotion.”
Why: In trials, handing over a document did not on its own make people feel better or less worried.
“Findings are limited but more positive for proximal outcomes (eg, information received) and for care delivery, particularly when SCPs are accompanied by counseling to prepare survivors for future clinical encounters.”
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
Every major body read still recommends a written handover at the end of treatment: a treatment summary and follow-up plan shared with the patient and primary care (NCI, ASCO 2014, the English personalised care model), within survivorship care that covers the five ESMO components. The trials disagree with the expectation behind it: randomised trials and two systematic reviews found that written plans do not improve distress, quality of life or satisfaction. The best-supported practice is to keep the summary for what it does do (move information and make responsibility clear) and put the effort into the needs assessment, the named responsible clinician and follow-through, not into the document. The full ESMO 2022 consensus and the full ASCO 2014 statement could not be read.
Macmillan Cancer Support 2026 · National Cancer Institute 2026 · ASCO, Journal of Oncology Practice 2014 · ESMO, Annals of Oncology 2022 · Journal of Clinical Oncology 2011 · Journal of Clinical Oncology 2018 · The Oncologist 2020
Where it differs: A care plan reviewed in a 30-minute educational session with a nurse, and sent with a follow-up guideline to the GP, on top of a discharge visit.
Evidence: Randomised trial of 408 women after early breast cancer at nine centres: no difference in cancer-related distress at 12 months or in any patient-reported secondary outcome; more patients correctly named their GP as responsible for follow-up (98.7 against 89.1 per cent). Read as an abstract.
Where it differs: A patient-tailored plan generated by a button in the gynaecological oncology registration system, rather than written by hand.
Evidence: Cluster randomised trial in 12 Dutch hospitals with women newly diagnosed with endometrial cancer: more information received, no difference in satisfaction with information or care, and more symptoms, illness concern, emotional impact and GP contact reported in the care plan arm. Read as an abstract.
Where it differs: Builds the handover from four parts (needs assessment and care plan, end of treatment summary, cancer care review in primary care, and health and well-being information) and ties the GP review to a contractual timing.
Evidence: Described by Macmillan Cancer Support as the NHS personalised care model, built on the earlier Recovery Package; no randomised trial of the package as a whole was read.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Survivorship care plans do not improve patient-reported outcomes “SCPs appear feasible but do not improve survivors' patient-reported outcomes.” | meta-analysis of eight randomised trials (1,286 survivors) | The Oncologist 2020 |
| Randomised evidence on the effect of care plans on well-being is generally negative “Existing research provides little evidence that SCPs improve health outcomes and health care delivery.” | systematic review of 13 randomised and 11 non-randomised studies | Journal of Clinical Oncology 2018 |
| A care plan reviewed with a nurse did not reduce distress after breast cancer “There were no differences between groups on cancer-related distress or on any of the patient-reported secondary outcomes, and there were no differences when the two strata were analyzed separately.” | single randomised trial, 408 women | Journal of Clinical Oncology 2011 |
| ACS/ASCO breast survivorship recommendations mostly rest on consensus “Most of the evidence is not sufficient to warrant a strong evidence-based recommendation.” | expert consensus; most evidence not sufficient for a strong recommendation | ACS and ASCO, Journal of Clinical Oncology 2016 |
Shares European Society for Medical Oncology (ESMO), American Society of Clinical Oncology (ASCO), Quality of life, Late effects and survivorship toxicity and the tags protocol, survivorship.
Shares American Society of Clinical Oncology (ASCO) and the tags protocol, survivorship.
Shares American Society of Clinical Oncology (ASCO) and the tags protocol, survivorship.
Shares European Society for Medical Oncology (ESMO), American Society of Clinical Oncology (ASCO) and the tags protocol, survivorship.
Shares European Society for Medical Oncology (ESMO), American Society of Clinical Oncology (ASCO) and the tags protocol, survivorship.
Shares European Society for Medical Oncology (ESMO), American Society of Clinical Oncology (ASCO) and the tags protocol, survivorship.
Shares Follow-up after treatment for early breast cancer and the tags protocol, survivorship.
Shares Late effects and survivorship toxicity and the tags protocol, survivorship.