A Survivorship Care Plan contains information about the survivor’s individual risks and care requirements, based on evidence-based recommendations, and can evolve over time with changing health and personal needs, as well as from new or updated guidelines. A personalised Survivorship Care Plan is an essential part of person-centred Survivorship Care, in particular to support self-management. Survivorship Care Plans delivered by a Survivorship Care clinic also increase general physicians’ knowledge of late effects and should contribute to earlier detection of health problems in primary care, thus resulting in both an increased well-being and a lower financial burden. 1

For the Care intervention, the healthcare professional (HCP) prepares a preliminary Survivorship Care Plan before the clinic visit based on the risk factors identified in the Treatment Summary and Survivor Questionnaire, by

First page of the Survivorship Care plan template

consulting the evidence- and consensus-based recommendations included in the intervention. At the clinic visit, the preliminary Survivorship Care Plan is discussed with the survivor and revised in a two-way sharing of information that is essential for the initiation of the survivor-HCP partnership. Then, the HCP executes the diagnostic tests as per the Survivorship Care Plan and schedules those that cannot be done during the visit. Diagnostic test results are discussed during a follow-up communication, during which the Survivorship Care Plan is finalised. The final Survivorship Care Plan includes the Treatment Summary and personalised recommendations for lifestyle and surveillance. The survivor and other relevant HCPs will receive the Survivorship Care Plan by post and/or e-mail. Using their personalised Survivorship Care Plan as a guide, survivors can then self-manage their own care, with the essential support of their HCPs.

During development of the Care intervention, a standardised format for the Survivorship Care Plan was agreed by first reviewing six care plan templates currently used in Survivorship Care (in Austria, Utrecht (the Netherlands), Lund (Sweden), Newcastle upon Tyne (United Kingdom) and Memphis (United States)), as well as the plan used in the Survivorship Passport (Italy). Following an extensive evaluation and consensus process that involved consultation with researchers, HCPs and survivor representatives, a final Survivorship Care Plan template was agreed in English and then translated to Dutch, Czech and Swedish. 2 Minor modifications to the SurPass (in Italian) were implemented to align with the final Survivorship Care Plan template.

The Survivorship Care Plan template in English as well as the Survivorship Care Plan User Manual in English is provided below. Translations of the Survivorship Care Plan template in Czech, Dutch and Swedish are available upon request through PanCare (

Delivering the Care Intervention via the Survivorship Passport (SurPass)

The digital Survivorship Passport (SurPass, is an innovative tool that was used to deliver the Care intervention in Italy, including the Treatment Summary and Survivorship Care Plan. In PanCareFollowUp, generation of the recommendations for discussion with the survivor at the clinic visit was automated, significantly reducing the time required to prepare the preliminary Survivorship Care Plan. Data for the Treatment Summary was entered manually from medical records, which was a time-consuming procedure, but semi-automation of data entry is being pursued to make this process quicker in a follow-on project, PanCareSurPass. PanCareSurPass is developing SurPass v2.0 with (semi-) automated data transfer using HL7 FHIR standards, and versions available in Dutch, German, Italian, Lithuanian and Spanish. At present, it is not possible to implement the Care intervention via the SurPass outside of Italy using only the materials in this manual. However, interested clinics or health systems can contact PanCare ( for more information on how to proceed if they are interested in using the SurPass.


PanCare strives to provide accurate and complete information that is up-to-date as of the date of publication.

No warranty or representation, expressed or implied, is made concerning the accuracy, reliability, completeness, relevance, or timeliness of this information.

The PanCare materials are free to use for anyone aiming to inform about late effects and long-term survivorship care. However, no financial advantage may be achieved. All communication should reference PanCare and link to the PanCare website.

1 Blaauwbroek R, et al. Family doctor-driven follow-up for adult childhood cancer survivors supported by a web-based survivor care plan. J Cancer Surviv. 2012;6(2):163-71.

2 van Kalsbeek RJ, et al. The PanCareFollowUp Care Intervention: A European harmonised approach to person-centred guideline-based survivorship care after childhood, adolescent and young adult cancer. European journal of cancer 2022;162:34-44.