Survivorship care plans and the rest of the continuum
Care Continuum follows a patient from risk and screening through survivorship to the end of life. It is 14% of the scored OCN questions, down from 19% on the 2025 outline (the largest drop of any area), and it gained palliative care considerations from the old symptom area.
18 questions on survivorship, screening and end of life
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Care continuum
A primary care provider is taking over follow-up for a woman who survived lymphoma. Which treatment-summary detail best guides late-effect screening?
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Late-effect surveillance is set by exposure: the total anthracycline dose and the sites irradiated determine heart, thyroid, lung and second-cancer screening.
Antiemetics carry no long-term risks that need screening.
Past pain intensity is a symptom history, not an exposure that drives late-effect testing.
Ki-67 describes how fast the original tumor grew; it does not tell primary care which organs treatment put at risk.
Care continuum
Which benign biopsy finding most increases a woman's future breast cancer risk and may prompt discussion of risk-reducing medication?
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Atypical ductal or lobular hyperplasia raises lifetime breast cancer risk severalfold, enough to discuss risk-reducing endocrine medication.
A simple fibroadenoma is a benign growth that adds little or no risk.
Simple cysts are fluid-filled and do not raise cancer risk.
Fat necrosis is scarring after trauma or surgery and carries no added risk.
Care continuum
A survivor of allogeneic transplant who received total body irradiation and long-term steroids reports gradually blurred vision and glare. The nurse recognizes a likely late effect of:
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Detachment brings sudden flashes, floaters or a curtain over vision.
Macular degeneration is an age-related loss of central vision, not a typical transplant late effect.
Total body irradiation and long-term steroids both cloud the lens, which slowly dims vision and makes bright light dazzling years after transplant.
Acute angle closure comes on suddenly with eye pain, redness and headache, not gradual blur.
Care continuum
Which statement by a patient indicates correct understanding of advance directives?
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A person with capacity can revise or revoke an advance directive at any time; the newest version is the one that counts.
A directive guides care only when the person can no longer make or voice decisions.
Directives are not permanent; they can be updated as goals change.
Any adult can benefit from a directive, and planning works best before a crisis.
Care continuum
Per the American Cancer Society, an average-risk adult who chooses a multitarget stool DNA test should repeat it every:
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Ten years is the interval for a normal colonoscopy.
Five years is the interval for CT colonography or flexible sigmoidoscopy.
A yearly interval belongs to the fecal immunochemical test, not the stool DNA test.
For average-risk adults the ACS sets the multitarget stool DNA test at every 3 years, with colonoscopy after any positive result.
Care continuum
A screening test finds a cancer 2 years earlier than symptoms would have, yet the patient dies at the same age as without screening. Survival from diagnosis looks longer. This illustrates:
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Selection bias comes from who chooses to be screened, such as healthier volunteers.
Finding a cancer earlier adds time between diagnosis and death without changing when death occurs, so survival looks longer; that is why screening is judged by mortality.
Length-time bias means screening picks up more slow-growing tumors, not that the same tumor is found earlier.
Overdiagnosis is finding a cancer that would never have caused harm; this cancer did cause the death.
Care continuum
An oncology nurse is teaching a community group about modifiable cancer risk. Which factor accounts for the largest share of preventable cancer deaths in the United States?
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Smoking causes roughly 3 in 10 US cancer deaths, by far the largest preventable share.
Excess weight is the second-largest preventable contributor, well behind smoking.
UV exposure causes many skin cancers, but most are curable and it causes few cancer deaths.
Alcohol raises the risk of several cancers but accounts for far fewer deaths than tobacco.
Care continuum
A nurse is teaching sun safety at a community health fair. Which sunscreen instruction is consistent with American Academy of Dermatology guidance?
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SPF 15 once a day under-protects, and UV reaches the skin on cloudy days too.
The dermatology guidance is broad-spectrum, water-resistant SPF 30 or higher, reapplied about every 2 hours and after swimming or sweating.
A higher SPF filters more UV but wears off just as fast, so it still needs reapplying.
Most UV passes through clouds, so protection is still needed.
Care continuum
Which dietary item does the International Agency for Research on Cancer classify as a Group 1 (known) human carcinogen?
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Drinks above about 65 °C (149 °F) are Group 2A for esophageal cancer, not Group 1.
Unprocessed red meat is Group 2A, probably carcinogenic, a lower level of certainty.
Aspartame was placed in Group 2B, possibly carcinogenic, in 2023.
IARC lists processed meat such as bacon, ham and hot dogs in Group 1 because evidence that it causes colorectal cancer is sufficient.
Care continuum
A patient asks why their newly diagnosed rectal cancer will be presented at a multidisciplinary tumor board. Which explanation by the nurse is accurate?
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Surgeons, medical and radiation oncologists, radiologists, pathologists and nurses review the findings together and recommend a coordinated sequence of treatment.
Insurance authorization is handled separately by the payer.
Trial enrollment needs the patient's own informed consent; the board only suggests options.
Surgical consent is obtained by the surgeon with the patient, not by the board.
Care continuum
A patient receiving chemotherapy says she sees a different nurse and provider at every visit and feels no one knows her. Which action is most appropriate?
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Defending the schedule dismisses her concern and changes nothing.
Moving her care disrupts treatment to fix a problem the clinic can solve.
A complaint line records the problem but does not create the relationship she is missing.
A navigator gives continuity and one consistent person to call, which addresses her sense that no one knows her.
Care continuum
The family of an unresponsive, actively dying patient sits silently at the bedside, unsure whether he can still hear them. What should the nurse encourage?
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Familiar voices are a comfort, not a usual cause of agitation, and silence takes away the family's time to say goodbye.
Hearing is thought to be among the last senses lost, so families are encouraged to keep talking, say goodbye and touch the patient.
Limiting time with family is not needed for comfort and costs them time they cannot get back.
Many dying patients never wake again, so waiting risks missing the chance.
Care continuum
A 45-year-old completed adjuvant therapy for stage III colon cancer. Which lifestyle intervention has the strongest evidence for reducing recurrence?
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High-dose antioxidants have not lowered recurrence in trials.
Ketogenic diets have no evidence of preventing colon cancer recurrence.
Trials of high-dose vitamin D have not shown a clear reduction in colon cancer recurrence.
Physical activity has the most consistent link to better disease-free survival after colon cancer, and a randomized trial of structured exercise (CHALLENGE, 2025) reduced recurrence.
Care continuum
A 55-year-old breast cancer survivor scheduled for a routine annual mammogram describes new, persistent focal bone pain in her ribs. What is the priority nursing action?
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Treating the pain without evaluating it masks a symptom that needs a workup.
Waiting six months on a red-flag symptom delays the diagnosis of possible metastasis.
A screening mammogram images the breasts and cannot evaluate pain in the ribs.
New, persistent focal bone pain in a breast cancer survivor is a red flag for bone metastasis, so it moves her from routine surveillance to a diagnostic workup ordered by the provider.
Care continuum
Which modifiable factor most increases the risk of lymphedema after axillary lymph node dissection?
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Ordinary lifting has not been shown to raise lymphedema risk.
Higher body mass index is the strongest risk factor for lymphedema after node dissection that a patient can change; extent of surgery and nodal radiation also matter but cannot be changed.
Studies have not shown that flying raises lymphedema risk after node dissection.
Ordinary hot showers have not been shown to cause lymphedema after node dissection.
Care continuum
A patient with advanced cancer has just completed an advance directive naming a health care agent. What is the nurse's MOST important next action?
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A sealed document cannot be read in a crisis, when it is needed most.
Restating wishes aloud does not get the written directive to the agent or into the record.
A directive helps only if it can be found when needed, so copies go to the named agent, the medical record and other providers.
An attorney's office is rarely reachable during a hospital emergency, so the team would not see the directive.
Care continuum
A woman who survived cancer sees a new family physician, who orders routine blood tests that the oncology team drew last month. Which gap in the hand-off most likely caused the duplicate testing?
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A medication list does not show which labs were already drawn.
A scheduling mix-up would not lead a new clinician to reorder tests already done.
When the survivorship care plan and treatment summary are not sent to the primary care provider, tests the oncology team already ran get repeated.
Blaming the clinician skips the systems gap: the history never arrived.
Care continuum
A woman who finished chemotherapy for colon cancer wants to return to her job but will need a reduced schedule because of persistent fatigue. Which resource is most appropriate?
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A general group offers emotional support but no help planning a return to work.
Vocational rehabilitation helps a survivor plan a return to work with accommodations, adjusted schedules and strategies for managing fatigue on the job.
A disability claim assumes she cannot work, while she wants to go back.
Home nursing serves people who are homebound; it does not address returning to a job.
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I.A Health promotion and prevention: risky behaviors and the habits that lower risk.
I.B Screening and early detection.
I.C Navigation and care coordination.
I.D Palliative care considerations: new to this area in 2026.
I.E Advance care planning: advance directives and goals of care.
I.F Epidemiology: risk factors a person can change and those they cannot.
I.G Survivorship: rehabilitation, fear of recurrence, family and social strain, sexuality, discrimination, and late or delayed effects, second cancers and follow-up.
I.H End-of-life care: bereavement, hospice, caregiver support, the interprofessional team and comfort measures.
A treatment summary: the diagnosis and stage, the surgery, the drugs and radiation given, and serious complications.
A follow-up plan: who sees the patient for what, the surveillance schedule for that cancer, which late effects to look out for, and advice on health behaviors.
The American College of Surgeons Commission on Cancer once required accredited programs to hand a plan to a set share of patients. Its accreditation manual, Optimal Resources for Cancer Care (2020 Standards), replaced that rule with a requirement for a survivorship program, which is why practice varies.
Survivorship on the outline also means discrimination at work and in insurance. The Genetic Information Nondiscrimination Act (2008) protects genetic test results in health insurance and employment, but not in life, disability or long-term care insurance (NHGRI overview of genetic discrimination and GINA).
Screening, prevention and the three levels
Primary prevention stops cancer from starting (HPV vaccination, smoking cessation, sun protection). Secondary prevention finds it early in people without symptoms, which is what screening means. Tertiary prevention limits harm in people who already have cancer, such as cardiac follow-up after cardiotoxic treatment.
cytology every 3 years at 21–29; at 30–65, cytology every 3 years, an hrHPV test alone every 5 years, or cotesting every 5 years (2018; an update was in progress as of November 2026)
Lung
yearly low-dose CT at 50–80 with a 20 pack-year history, if still smoking or quit within 15 years (2021)
Prostate
PSA at 55–69 as an individual decision (2018; an update was in progress as of November 2026)
Those ages and intervals do not apply to carriers of a hereditary syndrome or to survivors of chest radiation, who follow their own, earlier schedules; inherited risk and germline testing are on cancer biology and staging. A fuller screening and prevention page is planned.
Navigation, advance directives and medical orders
Patient navigation began with Harold Freeman's program in Harlem in 1990 (Freeman and Rodriguez, “History and Principles of Patient Navigation” (2011)), aimed at the delays between an abnormal finding and treatment. Oncology nurse navigators now coordinate across the whole continuum: appointments, barriers such as transportation or cost, and the handoff between treating teams.
Advance care planning produces two different kinds of documents, easy to confuse:
Advance directives are written by the patient: a living will states wishes about treatment, and a health care proxy appointment (a durable health care power of attorney) names the person who decides if the patient cannot.
Portable medical orders (POLST, MOLST and similar forms) are signed by a clinician for a seriously ill patient and travel with them between settings, so EMS and other facilities can act on them.
The federal Patient Self-Determination Act (1990) requires hospitals and other Medicare and Medicaid providers to ask adults on admission whether they have an advance directive and to give them information about their rights (Social Security Act §1866(f), 42 U.S.C. 1395cc). Medicare pays for advance care planning conversations under CPT codes 99497 and 99498 (CMS MLN booklet on advance care planning (2026)).
Palliative care, hospice and bereavement
Palliative care can start at diagnosis and runs alongside treatment meant to cure or control the cancer. Hospice is palliative care for the end of life: under the Medicare hospice rules (42 CFR part 418), the hospice physician (with the attending physician, if there is one) certifies a life expectancy of six months or less if the disease follows its expected course, and the patient chooses comfort-focused care in place of treatment aimed at the terminal illness. The hospice team includes a physician, nurse, social worker and spiritual counselor, and the same rules require bereavement support for the family for up to a year after the death.
Here the outline stays practical: noticing when goals of care have changed, comfort measures with and without drugs, and support for caregivers. Hospice and palliative nursing in depth is the subject of separate certifications.
Continuum terms that get confused
Mix-ups in area I
Screening or early detection. Screening tests people without symptoms; a test ordered because of a lump or bleeding is diagnostic.
Hospice or a DNR order. Electing hospice does not require a do-not-resuscitate order, and a DNR order does not enroll anyone in hospice.
Advance directive or POLST. Only the medical order form is signed by a clinician and acted on by EMS.
Palliative care or hospice. Palliative care has no prognosis requirement and does not mean stopping treatment.
Survivor or patient. By NCI's definition the survivorship clock starts at diagnosis, not at the last treatment.
Area I next to the other topics
Fear of recurrence, distress after treatment and caregiver strain are on psychosocial care. Hereditary syndromes and how genetic testing works are on cancer biology and staging.
Domain IV · Symptom Management and Supportive Care25%
06Neutropenia and myelosuppressionAbsolute neutrophil count, neutropenic precautions, febrile neutropenia and the first hour of sepsis, growth factors, bleeding precautions, anemia and transfusion.
07Symptom management and supportive careNausea and vomiting, bowel changes, mucositis, neuropathy, fatigue, skin and hair changes, lymphedema and ostomies, nutrition and weight loss, pain, and complementary therapies.
Domain III · Treatment Modalities20%
03Chemotherapy, targeted therapy and immunotherapyDrug classes and how they work, checkpoint inhibitors, CAR T cells and bispecific antibodies, hormonal agents, oral therapy and adherence teaching, intrathecal and intravesical therapy, and recognizing immune-related toxicity.
04Safe chemotherapy administration and handlingOrder checks and independent double checks, dose and body surface area, hazardous drug handling and spills, protective equipment, infusion reactions, and first steps when a vesicant leaks.
05Radiation, surgery and transplantSurgical and procedural care, radiation principles and safety (time, distance, shielding; sealed and unsealed sources), common site effects, and an overview of autologous and allogeneic transplant.
Domain V · Oncologic Emergencies16%
08Oncologic emergencies: structural and treatment-relatedSuperior vena cava syndrome, spinal cord compression, cardiac tamponade, raised intracranial pressure, obstructions and pneumonitis, with a map of all sixteen Domain V emergencies.
09Tumor lysis syndrome and metabolic emergenciesTumor lysis syndrome, SIADH, hypercalcemia of malignancy, DIC and venous thromboembolism: who is at risk, the labs, and what the nurse does first.
Domain II · Oncology Nursing Practice15%
02Cancer biology, staging and practice standardsCarcinogenesis and immunology, genetic versus genomic testing, TNM staging and grading, performance status scales, clinical trial basics, ethics, advocacy and compassion fatigue.
10Psychosocial care in oncologyDistress screening, coping, body image, sexuality and fertility, learning needs, cultural and spiritual care, caregiver strain, crises, and the cost of cancer care.