This Cancer 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] Please note
this is not an actual patient, and the care team names have been removed for confidentiality.
***This is strictly an example of the care plan format that I have worked on throughout the
semester***

Care Plan
Prepared by:

Paige on 4/7/2016 at Oncology department

General Information
Patient Name

John Smith

Date of birth

1/1/1964

Support contact

Care team
Hematologist/oncologist
Surgeon
Radiation oncologist
Primary care physician
Nurse/nurse practitioner
Mental health/social worker

v6.0.620
Printed 4/25/2016

www.JourneyForward.org

Background Information
Symptoms/signs

Chronic sore throat

Family history/predisposing conditions

father had throat cancer, diabetes

Other health concerns

Anemia, Hypertension

Tobacco use-past

Yes

Tobacco use-current

No

Cancer type/location

T2T2 N0 M0 squamous cell carcinoma of the right posterior

pharyngeal wall

Diagnosis date

1/1/2015

New or recurrent cancer diagnosis

New

Surgery

Diagnosis only

Surgical procedure & findings

Direct laryngoscopy and excisional biopsy with debulking revealed

a 4cm x 3cm mass along the right posterior superior pharyngeal
wall just posterior to the right tonsillar pillar and extending up to
the nasopharynx and hypopharynx. Half the mass was removed in
a debulking procedure

Tumor type/histology/grade

stage 2

Staging study

Date

MRI orbit face, neck

1/30/2015

T stage

T2

N stage

N0

M stage

M0

Stage

II

Findings
Mass posterior to the palate on right side near
the junction of the naso-and oropharynx

Treatment Plan & Summary

Patient's height

70 in

Pre-Treatment

Post-Treatment

Patient's weight

193 lb

176 lb

Patient's BSA

2.08 m

1.99 m

Patient's BMI

27.7

25.3

ECOG performance status

0-1

1 (Symptomatic but completely

ambulatory)

v6.0.620
Printed 4/25/2016

www.JourneyForward.org

Cisplatin, Lasix

Regimen

Treatment on clinical trial

Chemotherapy agents

No
Route

Dose

Schedule

# cycles

Cisplatin

100mg

every 3 weeks

Lasix

40mg

every 3 weeks

Non-chemotherapy agents

Route

Purpose/goal

Chemotherapy intent

Control of metastatic disease

Chemotherapy treatment period

5/10/2015-

Reason for stopping treatment

Completed therapy

Response to treatment

Complete

Treatment-related hospitalization

No

Ongoing toxicities

No

Radiation therapy

2gy, Administered, to Neck

% dose
reduction

Comments

Follow-up Care
Follow-up care

When/How often?

Medical oncology visits

3-6 months

Lab tests

at visits

Imaging

Every 6 months or less

Potential late effects of treatment

weight loss, trouble swallowing

Coordinating provider
Dr. Colvin

Needs or concerns
Prevention & wellness

changing roles and responsibilities, withdrawing from you, too

much attention, being nosy or confusing expectations are issues
that may be expected and dealt with.

Genetic risk

n/a

Emotional or mental health

tell your doctor if you have loss of interest in activities, crying

spells, problems sleeping, feelings of hopelessness, problem with
concentration, suicidal feelings or long-lasting changes in eating
habits

Personal relationships

changing roles and responsibilities, withdrawing from you, too

much attention, being nosy or confusing expectations are issues

v6.0.620
Printed 4/25/2016

www.JourneyForward.org

that may be expected and dealt with.

Fertility

n/a

Financial advice or assistance

the Nat'l Coalition for Cancer and the American Cancer Society
have open communications with their partners about their fears
and concerns. Cancer and Careers is a resource for all things
employment related.

sexuality

men in committed relationships should have open communication

with their partners about their fears and concerns. Concerns can
include erectile dysfunction and decreased libido. Acknowledge
problems and seek help of a urologist as needed.

Referrals provided
Smoking cessation counselor

Fit to Quit @ 788-1697

Physical therapist/exercise specialist

if you find yourself weak or deconditioned, contact STAR

(Survivorship Rehab Program)

Psychiatrist

ask your Oncologist or Nurse Navigator for a referral

Comments

It is important to live a Healthy Lifestyle!

For some cancer survivors, the experience is the impetus to
making healthy lifestyle changes. It may seem insignificant, but
these changes have been shown to reduce the risk of cancer
coming back or a new cancer developing. Below are some tips on
adopting a healthier lifestyle.
- Do not use tobacco in any form
- Maintain a healthy weight. Many studies have found that excess
weight plays an important role in cancer development and
recurrence. While maintaining a healthy weight is important in
cancer prevention, it cannot be easily separated from the
importance of physical activity and eating a healthy diet. Strive to
incorporate all three pieces of the puzzle: healthy weight, balanced
diet, and regular exercise.
- Talk to your healthcare team about what a healthy weight is for
you and take steps to maintain that weight.
- Expert recommend at least 30 minutes of moderate to vigorous
activity per day, 5 days per week.
- Eat healthy, including plenty (a rainbow) of fruits and vegetables
daily. Strive to have 2/3rds of your plate be vegetables, fruits,
whole grains, and beans, while 1/3rd or less should be animal
product. Chose fish (3x per week) and chicken, while limiting red
meat and processed meats.
- Limit how much alcohol you drink (if you drink alcohol at all)

v6.0.620
Printed 4/25/2016

www.JourneyForward.org

- Have regular check-ups by a healthcare professional

- Keep up-to-date on general health screening tests, including
cholesterol, blood pressure, and glucose levels
- Get an annual influenza vaccine (aka. Flu shot)
- Get vaccinated with the pneumococcal vaccine, which prevents a
type of pneumonia and re-vaccinated as determined by your
healthcare team
- Dont forget dental and eye health!

v6.0.620
Printed 4/25/2016

www.JourneyForward.org

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 individuals 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.

v6.0.620
Printed 4/25/2016

www.JourneyForward.org