Tricia Cox on 7/18/2012 at Oncology Center. Sarah Randolf. Female

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1 SAMPLE This Survivorship Care Plan will facilitate cancer care following active treatment. It may include important contact information, a treatment summary, recommendations for follow-up care testing, a directory of support services and resources, and other information. [1] Survivorship Care Plan for Lung Cancer Prepared by: Tricia Cox on 7/18/2012 at Oncology Center General Information Patient Name Sarah Randolf Medical record number Phone (home) Date of birth 9/12/1962 Age at diagnosis 50 Gender Female Support contact Howard Randolf, Care team Medical oncologist Dr. Jones, Primary care physician Dr. Smith, Nurse/nurse practitioner Tricia Cox, Mental health/social worker Sue Green, Coordination of care Surgeon Dr. White, Background Information Diagnosis Tobacco use-past Tobacco use current Other health concerns Location Relevant preoperative findings Definitive surgery Symptoms/signs Yes No COPD, Hypertension, hypercholesterolemia RUL (Right Upper Lobe) cardiac issues, On 6/14/2012 of squamous cell carcinoma via Wedge resection 2013 Journey Forward. All Rights Reserved. Journey Forward thanks Tricia Cox MS, ANP, AOCNP for her content contribution.

2 Completeness of resection TNM stage Pathologic stage Final pathologic details R1 (Microscopic residual tumor) T2 (Tumors greater than 3 cm but less than 7 cm), N1 (The tumor has spread to nearby nodes on the same side of the body), M0 (No distant metastasis) IIa (The tumor was 3 cm or less in size with spread to lymph nodes) Poorly differentiated Treatment Plan & Summary Patient's height 66 in Pre-Treatment Post-Treatment Patient's weight 165 lb 158 lb Patient's BSA 1.87 m² 1.83 m² Patient's BMI ECOG performance status 0 (Asymptomatic) 0 (Asymptomatic) Regimen Treatment on clinical trial Paclitaxel/Carboplatin followed by thoracic RT Paciltaxel 200 mg/m² every 3 weeks over 3 hours, 2 cycles Carboplatin AUC 6, 2 cycles followed by thoracic RT No Chemotherapy agents # cycles % dose reduction Paclitaxel 2 0 Carboplatain 2 0 Chemotherapy treatment period 8/6/2012-9/24/2012 Major side effects of treatment Reason for stopping treatment Treatment-related hospitalization Ongoing toxicities Hair loss, Nausea/vomiting, Neuropathy, Low blood count, Fatigue, Diarrhea Completed therapy No Yes: Peripheral neuropathy Radiation therapy 60Gy Administered 9/27/ /8/2012

3 Follow-Up Care UPON SCREENING, THE PATIENT HAS BEEN DETERMINED TO HAVE THE FOLLOWING ISSUE(S): Patients Please consult your health care provider for medical advice specific to you before using any medications, supplements, or other products, and before beginning any lifestyle program. Needs/Concerns Memory problems and/or confusion Wellness (e.g., diet, exercise, smoking cessation) Suggested intervention(s) Patients should know that 25% of cancer patients have cognitive dysfunction after treatment and it usually gets better over time Rule out depression, sleep disturbance Maintenance of body weight as weight gain is associated with recurrence Regular physical activity (e.g., walking 20 minutes daily) Avoidance of smoking/smoking cessation counseling, if appropriate Limitation of alcohol intake to less than 1 drink, 2-3x per week Surveillance When/How often Coordinating provider Medical oncology visits Every 6-12 months for 2 years Dr. Jones Imaging: Chest CT with contrast Every 6-12 months for 2 years Dr. Jones Colonoscopy Every 5 years Dr. Smith Mammogram Yearly Dr. Smith Pap smear Every 5 years Dr. Smith Referrals provided Psychologist Social worker Dr. Fin Susan Green

4 What Happens After Treatment For Non-Small Cell Lung Cancer? Completing treatment can be both stressful and exciting. You will be relieved to finish treatment, yet it is hard not to worry about cancer coming back. (When cancer returns, it is called recurrence.) This is a very common concern among those who have had cancer. It may take a while before your confidence in your own recovery begins to feel real and your fears are somewhat relieved. You can learn more about what to look for and how to learn to live with the possibility of cancer coming back in the document, Living With Uncertainty: The Fear of Cancer Recurrence (http://www.cancer.org/sslink/living-with-uncertainty-toc). Follow-up care After your treatment is over, it is very important to keep all follow-up appointments. During these visits, your doctors will ask about symptoms, do physical exams, and may order blood tests or imaging tests such as CT scans or x-rays. Most doctors recommend follow-up visits and CT scans every 4 to 6 months for the first 2 years after treatment, and yearly visits and CT scans after this. Follow-up is needed to check for cancer recurrence or spread, as well as possible side effects of certain treatments. This is the time for you to ask your health care team any questions you need answered and to discuss any concerns you might have. Almost any cancer treatment can have side effects. Some may last for a few weeks to several months, but others can be permanent. Don't hesitate to tell your cancer care team about any symptoms or side effects that bother you so they can help you manage them. If cancer does recur, treatment will depend on the location of the cancer and what treatments you've had before. It may be surgery, radiation therapy, chemotherapy, targeted therapy, or some combination of these. For more information on how recurrent cancer is treated, see the section "How is non-small cell lung cancer treated?" For more general information on dealing with a recurrence, you may also want to see the document, When Your Cancer Comes Back: Cancer Recurrence (http://www.cancer.org/sslink/when-your-cancer-comes-back-toc). Keep medical insurance and copies of your medical records At some point after your cancer diagnosis and treatment, you may find yourself in the office of a new doctor. Your original doctor may have moved or retired, or you may have moved or changed doctors for some reason. It is important that you be able to give your new doctor the exact details of your diagnosis and treatment. Make sure you have the following information handy: a copy of your pathology report(s) from any biopsy or surgery if you had surgery, a copy of your operative report(s) if you were hospitalized, a copy of the discharge summary that doctors must prepare when patients are sent home if you had radiation therapy, a summary of the type and dose of radiation and when and where it was given if you had chemotherapy or targeted therapies, a list of your drugs, drug doses, and when you took them It is also important to keep medical insurance. Even though no one wants to think of their cancer coming back, it is always a possibility. If it happens, the last thing you want is to have to worry about paying for treatment American Cancer Society. All Rights Reserved.

5 Life After Cancer Treatment: Managing Memory and Concentration Changes "Not being able to concentrate the way I used to has been the hardest for me. I'm hoping it doesn't affect my work." Josh Research shows that one in four people with cancer reports memory and attention problems after chemotherapy. This is sometimes called "chemobrain." Many survivors describe this as "brain fog," which can lead to problems paying attention, finding the right word, or remembering new things. These effects can begin soon after treatment ends, or they may not appear until much later. They don't always go away. If a person is older, it can be hard to tell whether these changes in memory and concentration are a result of treatment or of the aging process. Either way, some feel they just can't focus as they once did. Research is starting to explore why some people develop problems with memory and concentration while others don't. It seems that people who have had chemotherapy or have had radiation to the head area are at higher risk for these problems. People who had high doses of chemotherapy may have memory problems, but even those who had standard doses have reported memory changes. Getting Help Your doctor can help you with memory and concentration problems. Talk with him or her if: You are still having memory and thinking problems. You may want to ask about seeing a specialist (called a neuropsychologist) to help you with these problems. You think a medicine you are taking could be causing or adding to your problem. You think you suffer from depression or anxiety. These problems can affect attention, concentration, and memory. You are going through menopause. Some memory and concentration problems can be related to menopause. Improving Memory and Concentration Cancer survivors have found many ways to help improve their memory after cancer treatment. See if any of these ideas work for you: Jot it down. You can write down each task, how long it will take, and where you need to go in a notebook or pocket calendar. Plan your whole day. Keep it simple, and be realistic about how much you can do in a day. Set up reminders. Put small signs around the house to remind you of things to do, such as taking out the trash or locking the door. Group long numbers into chunks. For example, the phone number can be repeated as "eight-twelve, fifty-eight, forty-six." Talk yourself through tasks. When doing a task with a number of steps, such as cooking or working on a computer, whisper each step to yourself. Manage stress. Managing stress better may improve your memory and attention. And learning how to relax can help you remain calm even in stressful moments. Go over what you plan to say. Before you go to family events or work functions, go over names, dates, and key points you want to make. Repeat what you want to remember. Saying it a couple of times can help your mind hold on to the information. For more information about chemobrain, view the fact sheet Cognitive Problems After Chemotherapy online at

6 End Notes Note 1: Important caution. This is a summary document whose purpose is to review the highlights of the cancer chemotherapy treatment plan for this patient. This does not replace information available in the medical record, a complete medical history provided by the patient, examination and diagnostic information, or educational materials that describe strategies for coping with cancer and adjuvant chemotherapy in detail. Both medical science and an individual s health care needs change, and therefore this document is current only as of the date of preparation. This summary document does not prescribe or recommend any particular medical treatment or care for cancer or any other disease and does not substitute for the independent medical judgment of the treating professional.

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