Effect of Social Determinants of Health on Receipt of Survivorship Care Plans

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Survivorship care plans are an important tool to help cancer survivors transition from active treatment to follow-up care, but a study published by Timsina et al in Supportive Care in Cancer has found that a number of vulnerable groups have a lower likelihood of receiving such plans. Cancer survivors with low educational achievement, a widowed/divorced/separated marital status, who were uninsured, and who were older than 65 years were less likely to receive a care plan.

A survivorship care plan is a formal treatment summary that includes information on actions needed to prevent and detect new and recurrent cancer, interventions for long-term effects from cancer and its therapies, and coordination of care between specialists and primary care providers.

Study Details

Researchers from Indiana University School of Medicine, Regenstrief Institute, and The Ohio State University analyzed data from the 2016 Behavioral Risk Factor Surveillance System’s (BRFSS) Survivorship modules, which are self-reported measures gathered via telephone survey by the U.S. Centers for Disease Control and Prevention, to determine the role that social determinants of health play in the reception of survivorship care plans. The researchers looked at a data set of 7,061 cancer survivors who were eligible for a survivorship care plan.

Data showed that factors associated with a lower chance of receiving a care plan were: 

  • Lower educational achievement (high school/some college: adjusted odds ratio [AOR] = 0.82, 95% confidence interval [CI] = 0.70–0.97, P = .02; less than high school: AOR = 0.68, 95% CI = 0.47–0.97, P = .03) compared to those with at least one college degree
  • Widowed/divorced/separated marital status (AOR = 0.72, 95% CI = 0.61–0.86, P < .01) vs those who were married/cohabiting
  • Being uninsured (AOR = 0.52, 95% CI = 0.0.34–0.80, P < .01) vs insured
  • Age older than 65 years (age 18–24 years: AOR = 6.62, 95% CI = 1.87–24.49, P < .01 vs age 65+ years).

“These groups often lack access to care or struggle with continuity of care, so they need these plans more than anyone,” said study coauthor David Haggstrom, MD, MAS, Director of the Regenstrief Center for Health Services Research, Associate Professor of Medicine at Indiana University School of Medicine, and a member of the Indiana University Melvin and Bren Simon Comprehensive Cancer Center. “Health care frequently struggles with transitions, so care plans are important to serve as support to the patient as they end active cancer treatment as well as help with coordination of care.”

“The findings of this study highlight the fact that when care plan dissemination is not universal, it can further widen the disparities and clinical outcomes of patients with cancer who already face roadblocks to care,” said first author Lava R. Timsina, MPH, PhD, Assistant Professor of Surgery at Indiana University School of Medicine. “Policy initiatives addressing patient education and access to these plans may be necessary to increase their delivery.” 

Reducing Barriers to Survivorship Care

Study authors recommend several steps to reduce barriers to plan delivery and encourage physician participation. They are: 

  • Including care plans as an accreditation requirement with the Commission on Cancer
  • Providing insurance reimbursement for creating the plan
  • Standardization of linguistically and culturally appropriate plans
  • Empowering patients to advocate to receive the plans 
  • Increasing the use of telehealth to deliver the plans. 

The data included patients from nine states and one U.S. territory: Indiana, Idaho, Kansas, Louisiana, Michigan, Missouri, Nebraska, South Dakota, Wisconsin, and the U.S. Virgin Islands. This is one of the only studies to take a national view of care plan dissemination among diverse populations. 

The study authors concluded, “Among cancer survivors, social determinants of health such as low educational achievement, widowed/divorced/separated marital status, and being uninsured were associated with a lower likelihood of receiving a survivorship care plan. Future studies should evaluate how omission of [survivorship care planning] in these patients influences the quality of care during the transition from oncologists to primary care.”

Disclosure: For full disclosures of the study authors, visit

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.