The 18 million cancer survivors living in the United States represent a growing and underserved population with complex long-term health needs — yet survivorship care remains one of the most under-resourced areas of oncology program administration. The Commission on Cancer (CoC) requires that accredited cancer programs provide survivorship care plans (SCPs) to patients completing curative-intent treatment, but compliance rates remain low: a 2023 survey by ASCO found that only 46% of cancer programs reported providing SCPs to more than 75% of eligible patients. Late-effects monitoring programs, primary care co-management coordination, and patient-reported outcome tracking add further administrative layers that survivorship clinic staff cannot absorb alone. Virtual assistants (VAs) trained in survivorship program operations are providing the infrastructure these programs need to operate at scale.
Survivorship Care Plan Generation
ASCO's survivorship care plan templates — including the Cancer Treatment Summary and Survivorship Care Plan — provide a standardized format for documenting treatment history, surveillance recommendations, late-effects risks, and follow-up provider assignments. Completing an individualized SCP requires pulling chemotherapy regimen, radiation dose and field, surgical procedures, and hormonal therapy data from the medical record; populating NCCN-concordant surveillance schedules based on cancer type and stage; identifying relevant late-effects risks; and routing the completed plan to the physician for review, signature, and transmission to the patient and primary care provider.
VAs handle the document preparation layer: extracting treatment data from the EHR, populating SCP templates using ASCO or Journey Forward tools, generating the surveillance schedule, and routing the draft to the survivorship provider for final review. After approval, VAs send the SCP to the patient and transmit a copy to the primary care provider with documentation of transmission. For programs generating 20 or more SCPs per month, VA-driven preparation reduces provider drafting time from 20 to 30 minutes to 3 to 5 minutes of review per SCP.
Late-Effects Monitoring Coordination
Cancer survivors face well-defined late effects based on their treatment exposure: anthracycline-treated patients require echocardiographic surveillance for cardiomyopathy, platinum-treated patients need audiological monitoring, radiation-exposed patients require thyroid function monitoring and breast surveillance for radiation field exposures, and immunotherapy-treated patients may have long-term autoimmune sequelae requiring endocrine and pulmonary monitoring. ASCO has published late-effects screening guidelines for each major treatment category, and CoC accreditation standards require that survivorship programs demonstrate systematic late-effects monitoring.
VAs coordinate late-effects monitoring by maintaining a registry of patients with specific treatment exposures, generating annual recall lists for required monitoring studies, scheduling surveillance tests, and documenting completion. For programs using Epic's survivorship module or Navigating Cancer's survivorship platform, VAs operate within these systems to ensure monitoring activities are tracked against the patient's defined late-effects risk profile.
Primary Care Co-Management Referral Coordination
ASCO's survivorship guidelines recommend a shared care model in which the oncology team transitions well patients to primary care co-management, with the oncologist serving as a consultant for cancer-specific follow-up. Implementing this transition requires identifying patients who are appropriate for co-management, communicating the SCP and transition summary to the primary care provider, confirming the PCP is willing to assume surveillance responsibilities, and scheduling a transition visit. Many patients — particularly those who established PCP care before diagnosis — require reconnection to primary care after years of oncology-focused care.
VAs manage the transition coordination workflow: identifying eligible patients based on treatment completion date and disease status, drafting co-management letters for physician signature, confirming PCP availability and acceptance of the transition, and scheduling transition visits. For programs in geographically underserved areas where PCP access is limited, VAs also identify and coordinate referrals to federally qualified health centers or community health workers.
PRO-CTCAE and LIVESTRONG Outcome Tracking
Patient-reported outcomes (PROs) are increasingly integrated into survivorship programs to capture symptom burden, functional status, and quality of life data that are not captured in clinical documentation. The NCI's PRO-CTCAE instrument and LIVESTRONG's validated SCP tools provide structured frameworks for collecting and tracking these outcomes over time. CoC's quality improvement standards increasingly reference PRO collection as a program quality metric.
VAs coordinate PRO collection by sending PRO-CTCAE or LIVESTRONG survey links to patients at defined follow-up intervals, tracking response completion, entering paper surveys into the data collection system when patients cannot complete electronically, and aggregating outcome data for program quality reporting. Clinically concerning PRO scores — particularly elevated pain, fatigue, or depression scores — are flagged for immediate survivorship provider review.
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Sources
- American Society of Clinical Oncology. "ASCO Survivorship Care Plan Survey." 2023.
- Commission on Cancer. "CoC Survivorship Accreditation Standards." facs.org. 2024.
- National Cancer Institute. "PRO-CTCAE Instrument Overview." ctep.cancer.gov.
- LIVESTRONG Foundation. "LIVESTRONG Care Plan Tool." livestrong.org.