# Survivorship care plans generated automatically from the treatment record

Source: https://onco.cc/ideas/idea-acc-auto-generated-survivorship-plans/  
OnCo record `idea-acc-auto-generated-survivorship-plans` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Every patient finishing treatment should get a clear document listing what they had, what to watch for, and when to be checked. Software can write it from the record so it actually happens.

## Summary

Survivorship care plans are recommended by every oncology guideline body but are produced for a minority of patients because writing them by hand takes an hour. Structured treatment data (regimens, cumulative doses, radiation fields, surgery) can be mapped by rules to late-effect risks and evidence-based surveillance schedules (for example, the Children's Oncology Group long-term follow-up guidelines) and rendered for patient and family doctor automatically, with clinician review.

## Fields

- Kind: Idea
- Last checked: 2026-09-08
- Hypothesis: Automated generation will raise survivorship plan delivery from under 30% to above 90% of eligible patients and increase adherence to recommended surveillance (echocardiography after anthracyclines, breast MRI after chest radiotherapy) by at least 25 percentage points.
- Rationale: The knowledge is codified in guidelines; the failure is purely one of labour, which software removes.
- Proposed test: Implement in three centres and measure plan delivery, surveillance adherence at two years, and primary care physician awareness of late-effect risks.
- Maturity: early-clinical
- Actor: data

## Notes

- Not graded as a protocol upgrade. The randomised trial of survivorship care plans in 408 women with early breast cancer found no difference in cancer-related distress or any patient-reported secondary outcome (Grunfeld, 2011), and the United States accreditation requirement was later replaced with a broader survivorship programme standard (see `rejuv-access-survivorship-care-us`). Generating plans automatically would make them cheaper to produce; whether a plan of any kind changes outcomes is the question a trial of this idea would have to answer.

## Sources

- Grunfeld et al., Evaluating survivorship care plans: results of a randomized clinical trial of patients with breast cancer (J Clin Oncol 2011): https://doi.org/10.1200/JCO.2011.36.8373
- Children's Oncology Group long-term follow-up guidelines: http://www.survivorshipguidelines.org/

## Connected records

- ideas: [A machine-readable treatment summary handed to every patient and readable by any hospital](https://onco.cc/ideas/idea-acc-portable-treatment-summary/), [Make the treatment exposure record machine-readable, so surveillance can be computed](https://onco.cc/ideas/idea-rejuv-exposure-record-a-machine-can-read/)
- technologies: [After treatment in the United States: the survivorship care plan, and what the trial found](https://onco.cc/technologies/rejuv-access-survivorship-care-us/), [Getting psychological help after cancer: the stepped-care model, and what is actually commissioned](https://onco.cc/technologies/rejuv-mind-access-to-psychological-care/), [Survivorship care and late-effects surveillance](https://onco.cc/technologies/survivorship-care-plan/), [The Children's Oncology Group Long-Term Follow-Up Guidelines](https://onco.cc/technologies/rejuv-paed-cog-ltfu-guidelines/), [The handover from children's to adult services, where follow-up falls away](https://onco.cc/technologies/rejuv-paed-transition-to-adult-care/)
- bottlenecks: [Fragmented care and guideline gaps](https://onco.cc/bottlenecks/b-care-fragmentation/), [Nobody owns the follow-up once the oncology clinic lets go](https://onco.cc/bottlenecks/rejuv-agenda-nobody-owns-the-follow-up/), [Survivorship and late effects are neglected](https://onco.cc/bottlenecks/b-survivorship/)
- roadmaps: [Recovery and rejuvenation roadmap: cure is not enough → survivorship gets a name → the cohorts that measured the cost → exercise proven as treatment → biological ageing measured and sold → repair, if anyone funds it](https://onco.cc/roadmaps/rejuvenation-roadmap/), [Supportive care and survivorship roadmap: making treatment bearable → proving it extends life → caring for tens of millions afterwards](https://onco.cc/roadmaps/survivorship-roadmap/)

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