Transitional care planning helps the patient’s cancer care continue without interruption through different phases of the cancer experience.

Transition means passage from one phase to another. Transitional care planning is the bridge between two phases of care. As the cancer patient's treatment goals change or the place of care changes, the patient may encounter problems during the transition. Patients will need to make decisions that balance disease status and treatment options with family needs, finances, employment, spiritual or religious beliefs, and quality of life. There may be practical problems such as finding an appropriate rehabilitation center, obtaining special equipment, or paying for needed care. There may be mental health problems such as depression or anxiety. Transitional care planning helps identify and manage these problems so the transition can go smoothly, without interruption of care. This can reduce stress on the patient and family and improve the patient’s health outcome.

See the following PDQ summaries for more information:

• Anxiety Disorder ¹
• Depression ²
• Pain ³

Transitional care planning may include support and education for the patient and family and referral to resources. Ideally, it involves a team approach by the patient's health care providers. It is important that there be close communication between members of the team and that this communication include the patient and family.

Goals of cancer care may change as the disease changes.

Each type of cancer requires different care and the goals of a patient’s treatment may change as his or her disease gets better or worse. Cancer care may include any of the following:

• Active treatment: Treatment given to cure the cancer.
• Supportive care: Care given to prevent or treat as early as possible the symptoms of the disease; side effects caused by treatment of the disease; and psychological, social, and spiritual problems related to the disease or its treatment.
• Palliative therapy: Treatment given to relieve symptoms and improve the patient's quality of life. Palliative therapy may be given along with other cancer treatments or when treatment is no longer curative, to make the patient comfortable at the end of life.

Transitional care planning can help the patient and family with medical, practical, and emotional issues that arise as they adjust to these different levels and goals of care.

A patient may receive care in several different settings during the course of the illness.

Most of the care received by people with cancer is provided in places other than a hospital. The place where the patient receives treatment may change several times during the course of the illness. Patients may go from receiving care in a hospital or as an outpatient to receiving care at home, in a nursing home, at a rehabilitation center (a place for special training, such as help in regaining strength or movement), or from a hospice team for end-of-life care. When a patient moves from one place of care to another, the process of planning for the move is often called discharge planning. This may involve a case manager who acts on the patient's behalf when dealing with the hospital, visiting nurses, health care companies, rehabilitation facilities, nursing homes, and other groups that provide the care needed. The case manager is a link to resources and services in the community and can arrange for the provision of services, including patient and family education and referrals.

Glossary Terms

Feelings of fear, dread, and uneasiness that may occur as a reaction to stress. A person with anxiety may sweat, feel restless and tense, and have a rapid heart beat. Extreme anxiety that happens often over time may be a sign of an anxiety disorder.

A term for diseases in which abnormal cells divide without control. Cancer cells can invade nearby tissues and can spread to other parts of the body through the blood and lymph systems. There are several main types of cancer. Carcinoma is cancer that begins in the skin or in tissues that line or cover internal organs. Sarcoma is cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue. Leukemia is cancer that starts in blood-forming tissue such as the bone marrow, and causes large numbers of abnormal blood cells to be produced and enter the blood. Lymphoma and multiple myeloma are cancers that begin in the cells of the immune system. Central nervous system cancers are cancers that begin in the tissues of the brain and spinal cord.

To heal or restore health; a treatment to restore health.

A mental condition marked by ongoing feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life. Other symptoms of depression include feelings of worthlessness and hopelessness, loss of pleasure in activities, changes in eating or sleeping habits, and thoughts of death or suicide. Depression can affect anyone, and can be successfully treated. Depression affects 15-25% of cancer patients.

A program that provides special care for people who are near the end of life and for their families, either at home, in freestanding facilities, or within hospitals.

A place that gives care to people who have physical or mental disabilities and need help with activities of daily living (such as taking a bath, getting dressed, and going to the bathroom) but do not need to be in the hospital.

A patient who visits a health care facility for diagnosis or treatment without spending the night. Sometimes called a day patient.

Treatment given to relieve the symptoms and reduce the suffering caused by cancer and other life-threatening diseases. Palliative cancer therapies are given together with other cancer treatments, from the time of diagnosis, through treatment, survivorship, recurrent or advanced disease, and at the end of life.

PDQ is an online database developed and maintained by the National Cancer Institute. Designed to make the most current, credible, and accurate cancer information available to health professionals and the public, PDQ contains peer-reviewed summaries on cancer treatment, screening, prevention, genetics, complementary and alternative medicine, and supportive care; a registry of cancer clinical trials from around the world; and directories of physicians, professionals who provide genetics services, and organizations that provide cancer care. Most of this information, and more specific information about PDQ, can be found on the NCI's Web site at http://www.cancer.gov/cancertopics/pdq. Also called Physician Data Query.

Having to do with how the mind works and how thoughts and feelings affect behavior.

The overall enjoyment of life. Many clinical trials assess the effects of cancer and its treatment on the quality of life. These studies measure aspects of an individual’s sense of well-being and ability to carry out various activities.

In medicine, a process to restore mental and/or physical abilities lost to injury or disease, in order to function in a normal or near-normal way.

A problem that occurs when treatment affects healthy tissues or organs. Some common side effects of cancer treatment are fatigue, pain, nausea, vomiting, decreased blood cell counts, hair loss, and mouth sores.

Having to do with deep, often religious, feelings and beliefs, including a person’s sense of peace, purpose, connection to others, and beliefs about the meaning of life.

An indication that a person has a condition or disease. Some examples of symptoms are headache, fever, fatigue, nausea, vomiting, and pain.