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Annual Review of Medicine

Volume 76, 2025

Care Models for Cancer Survivors

Abstract

The population of cancer survivors is on the rise due to an increase in cancer incidence and a decline in cancer mortality. This growing survivor population creates a number of challenges. Although there have been improvements in care planning for cancer survivors, our healthcare system still lacks the delivery of coordinated care between primary care physicians and specialists. Understanding the needs of cancer survivors can help improve the current care models. In this review we describe existing survivorship care models. We also describe emerging models using some programs at the Cleveland Clinic to highlight various potential approaches.

Keyword(s): cancer prevention, cancer survivorship, care models, early detection, posttreatment care, survivorship programs
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2025-01-27
2025-06-23
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Literature Cited

  1. 1.
    Sung H, Ferlay J, Siegel RL, et al. 2021.. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. . CA Cancer J. Clin. 71:(3):209–49
     [Google Scholar]
  2. 2.
    Sedeta E, Sung H, Laversanne M, et al. 2023.. Recent mortality patterns and time trends for the major cancers in 47 countries worldwide. . Cancer Epidemiol. Biomarkers Prev. 32:(7):894–905
     [Google Scholar]
  3. 3.
    Allemani C, Matsuda T, Di Carlo V, et al. 2018.. Global surveillance of trends in cancer survival 2000–14 (CONCORD-3): analysis of individual records for 37 513 025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries. . Lancet 391:(10125):1023–75
     [Google Scholar]
  4. 4.
    Siegel RL, Miller KD, Wagle NS, Jemal A. 2023.. Cancer statistics, 2023. . CA Cancer J. Clin. 73:(1):17–48
     [Google Scholar]
  5. 5.
    Natl. Cancer Inst. 2023.. Statistics and graphs. Stat., Off. Cancer Surviv., Div. Cancer Control Popul. Stud., Natl. Cancer Inst., Bethesda, MD:. https://cancercontrol.cancer.gov/ocs/statistics#stats
    [Google Scholar]
  6. 6.
    Jiang C, Deng L, Karr MA, et al. 2022.. Chronic comorbid conditions among adult cancer survivors in the United States: results from the National Health Interview Survey, 2002–2018. . Cancer 128:(4):828–38
     [Google Scholar]
  7. 7.
    Mullan F. 1985.. Seasons of survival: reflections of a physician with cancer. . N. Engl. J. Med. 313:(4):270–73
     [Google Scholar]
  8. 8.
    Aziz NM. 2002.. Cancer survivorship research: challenge and opportunity. . J. Nutr. 132:(11):3494S–503S
     [Google Scholar]
  9. 9.
    Park ER, Peppercorn J, El-Jawahri A. 2018.. Shades of survivorship. . J. Natl. Compr. Cancer Netw. 16:(10):1163–65
     [Google Scholar]
  10. 10.
    Miller K, Merry B, Miller J. 2008.. Seasons of survivorship revisited. . Cancer J. 14:(6):369–74
     [Google Scholar]
  11. 11.
    Dirven L, van de Poll-Franse LV, Aaronson NK, Reijneveld JC. 2015.. Controversies in defining cancer survivorship. . Lancet Oncol. 16:(6):610–12
     [Google Scholar]
  12. 12.
    Denlinger CS, Carlson RW, Are M, et al. 2014.. Survivorship: introduction and definition. Clinical practice guidelines in oncology. . J. Natl. Compr. Cancer Netw. 12:(1):34–45
     [Google Scholar]
  13. 13.
    Moser EC, Meunier F. 2014.. Cancer survivorship: a positive side-effect of more successful cancer treatment. . Eur. J. Cancer Suppl. 12:(1):1–4
     [Google Scholar]
  14. 14.
    Kuzmanovic T, Horvath D, Slaughter M, et al. 2023.. Identification and management of clonal hematopoiesis of indeterminate potential (CHIP) in cancer survivors: The Cleveland Clinic experience. . J. Clin. Oncol. 41:(16_Suppl.):7010
     [Google Scholar]
  15. 15.
    Singh A, Mencia-Trinchant N, Griffiths EA, et al. 2022.. Mutant PPM1D- and TP53-driven hematopoiesis populates the hematopoietic compartment in response to peptide receptor radionuclide therapy. . JCO Precision Oncol. 6::e2100309
     [Google Scholar]
  16. 16.
    Mayer DK, Nasso SF, Earp JA. 2017.. Defining cancer survivors, their needs, and perspectives on survivorship health care in the USA. . Lancet Oncol. 18:(1):e11–18
     [Google Scholar]
  17. 17.
    Hewitt M, Greenfield S, Stovall E, eds. 2006.. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC:: Natl. Acad. Press
     [Google Scholar]
  18. 18.
    Emery J, Butow P, Lai-Kwon J, et al. 2022.. Management of common clinical problems experienced by survivors of cancer. . Lancet 399:(10334):1537–50
     [Google Scholar]
  19. 19.
    Lai-Kwon J, Heynemann S, Hart NH, et al. 2023.. Evolving landscape of metastatic cancer survivorship: reconsidering clinical care, policy, and research priorities for the modern era. . J. Clin. Oncol. 41:(18):3304–10
     [Google Scholar]
  20. 20.
    Harrison JD, Young JM, Price MA, et al. 2009.. What are the unmet supportive care needs of people with cancer? A systematic review. . Support. Care Cancer 17:(8):1117–28
     [Google Scholar]
  21. 21.
    Harrington CB, Hansen JA, Moskowitz M, et al. 2010.. It's not over when it's over: long-term symptoms in cancer survivors—a systematic review. . Int. J. Psychiatry Med. 40:(2):163–81
     [Google Scholar]
  22. 22.
    Lisy K, Langdon L, Piper A, Jefford M. 2019.. Identifying the most prevalent unmet needs of cancer survivors in Australia: a systematic review. . Asia Pac. J. Clin. Oncol. 15:(5):e68–78
     [Google Scholar]
  23. 23.
    Jacobsen PB, Nipp RD, Ganz PA. 2017.. Addressing the survivorship care needs of patients receiving extended cancer treatment. . Am. Soc. Clin. Oncol. Educ. Book 37::674–83
     [Google Scholar]
  24. 24.
    Ben-Ari E. 2022.. Meeting cancer survivors' psychological health needs: a conversation with Dr. Patricia Ganz. . Cancer Currents Blog, June 7. https://www.cancer.gov/news-events/cancer-currents-blog/2022/psychosocial-cancer-survivors-patricia-ganz
    [Google Scholar]
  25. 25.
    Mols F, Husson O, Roukema JA, van de Poll-Franse LV. 2013.. Depressive symptoms are a risk factor for all-cause mortality: results from a prospective population-based study among 3,080 cancer survivors from the PROFILES registry. . J. Cancer Surviv. 7:(3):484–92
     [Google Scholar]
  26. 26.
    Mullen L, Signorelli C, Nekhlyudov L, Jacobsen PB, et al. 2023.. Psychosocial care for cancer survivors: a global review of national cancer control plans. . Psycho-Oncology 32:(11):1684–93
     [Google Scholar]
  27. 27.
    Chaput G, Med CP, Sussman J. 2019.. Integrating primary care providers through the seasons of survivorship. . Curr. Oncol. 26:(1):48–54
     [Google Scholar]
  28. 28.
    Shapiro CL, Jacobsen PB, Henderson T, Hurria A, et al. 2016.. ReCAP: ASCO Core Curriculum for Cancer Survivorship Education. . J. Oncol. Pract. 12:(2):145
     [Google Scholar]
  29. 29.
    Ownby KK. 2019.. Use of the distress thermometer in clinical practice. . J. Adv. Pract. Oncol. 10:(2):175–79
     [Google Scholar]
  30. 30.
    Hahn EE, Munoz-Plaza CE, Pounds D, et al. 2022.. Effect of a community-based medical oncology depression screening program on behavioral health referrals among patients with breast cancer: a randomized clinical trial. . JAMA 327:(1):41–49
     [Google Scholar]
  31. 31.
    Chan RJ, Crawford-Williams F, Crichton M, et al. 2023.. Effectiveness and implementation of models of cancer survivorship care: an overview of systematic reviews. . J. Cancer Surviv. 17:(1):197–221
     [Google Scholar]
  32. 32.
    Taylor K, Chan RJ, Monterosso L. 2015.. Models of survivorship care provision in adult patients with haematological cancer: an integrative literature review. . Support. Care Cancer 23:(5):1447–58
     [Google Scholar]
  33. 33.
    Schmidt RL. 2021.. Advancing survivorship care through program development. Natl. Compr. Cancer Netw., Plymouth Meeting, PA:. https://education.nccn.org/node/89900#group-tabs-node-course-default1
    [Google Scholar]
  34. 34.
    Mollica MA, Mayer DK, Oeffinger KC, et al. 2020.. Follow-up care for breast and colorectal cancer across the globe: survey findings from 27 countries. . JCO Glob. Oncol. 6::1394–411
     [Google Scholar]
  35. 35.
    Halpern M, Mollica MA, Han PK, Tonorezos ES. 2024.. Myths and presumptions about cancer survivorship. . J. Clin. Oncol. 42:(2):134–39
     [Google Scholar]
  36. 36.
    Alfano CM, Oeffinger K, Sanft T, Tortorella B. 2022.. Engaging TEAM medicine in patient care: redefining cancer survivorship from diagnosis. . Am. Soc. Clin. Oncol. Educ. Book 42::921–31
     [Google Scholar]
  37. 37.
    Tan SY, Dhillon HM, Mak C, et al. 2023.. Utility of survivorship care plans: a mixed-method study exploring general practitioners' and cancer specialists' views. Asia Pac. . J. Clin. Oncol. 20:(1):128–37
     [Google Scholar]
  38. 38.
    Sanft TB, Epstein L, Capozza S, et al. 2015.. Distress in cancer survivors attending a multidisciplinary survivorship clinic. . J. Clin. Oncol. 33::9575
     [Google Scholar]
  39. 39.
    Natl. Cancer Inst. 2024.. Improving the Management of symPtoms during And following Cancer Treatment (IMPACT). . National Cancer Institute. https://healthcaredelivery.cancer.gov/impact/
    [Google Scholar]
  40. 40.
    Smith J, Essery R, Yardley L, et al. 2024.. Experiences of using a supported digital intervention for cancer survivors in primary care: a qualitative process evaluation. . J. Cancer Surviv. 18:(1):144–56
     [Google Scholar]
  41. 41.
    Ekman I, Swedberg K, Taft C, et al. 2011.. Person-centered care—ready for prime time. . Eur. J. Cardiovasc. Nurs. 10:(4):248–51
     [Google Scholar]
  42. 42.
    McCabe MS, Bhatia S, Oeffinger KC, et al. 2013.. American Society of Clinical Oncology statement: achieving high-quality cancer survivorship care. . J. Clin. Oncol. 31:(5):631–40
     [Google Scholar]
  43. 43.
    McCabe MS, Partridge AH, Grunfeld E, Hudson MM. 2013.. Risk-based health care, the cancer survivor, the oncologist, and the primary care physician. . Semin. Oncol. 40:(6):804–12
     [Google Scholar]
  44. 44.
    Loonen JJ, Blijlevens NM, Prins J, et al. 2018.. Cancer survivorship care: person centered care in a multidisciplinary shared care model. . Int. J. Integr. Care 18:(1):4
     [Google Scholar]
  45. 45.
    Goetz P, Klemp JR. 2018.. Transition to survivorship. . J. Oncol. Navig. Surviv. 9::7
     [Google Scholar]
  46. 46.
    Menichetti J, Libreri C, Lozza E, Graffigna G. 2016.. Giving patients a starring role in their own care: a bibliometric analysis of the on-going literature debate. . Health Expect. 19:(3):516–26
     [Google Scholar]
  47. 47.
    Epstein RM, Fiscella K, Lesser CS, Stange KC. 2010.. Why the nation needs a policy push on patient-centered health care. . Health Aff. 29:(8):1489–95
     [Google Scholar]
  48. 48.
    Olsson LE, Jakobsson Ung E, Swedberg K, Ekman I. 2013.. Efficacy of person-centred care as an intervention in controlled trials—a systematic review. . J. Clin. Nurs. 22:(3–4):456–65
     [Google Scholar]
  49. 49.
    Oeffinger KC, Argenbright KE, Levitt GA, et al. 2014.. Models of cancer survivorship health care: moving forward. . Am. Soc. Clin. Oncol. Educ. Book 34:(1):205–13
     [Google Scholar]
  50. 50.
    Nekhlyudov L, O'malley DM, Hudson SV. 2017.. Integrating primary care providers in the care of cancer survivors: gaps in evidence and future opportunities. . Lancet Oncol. 18:(1):e30–38
     [Google Scholar]
  51. 51.
    Choi Y, Parrillo E, Wenzel J, et al. 2023.. Optimizing cancer survivorship in primary care: patient experiences from the Johns Hopkins Primary Care for Cancer Survivors clinic. . J. Cancer Surviv. 17:(5):1286–94
     [Google Scholar]
  52. 52.
    Høeg BL, Bidstrup PE, Karlsen RV, et al. 2019.. Follow-up strategies following completion of primary cancer treatment in adult cancer survivors. . Cochrane Database Syst. Rev. 2019:(11):CD012425
     [Google Scholar]
  53. 53.
    Howell D, Hack TF, Oliver TK, et al. 2012.. Models of care for post-treatment follow-up of adult cancer survivors: a systematic review and quality appraisal of the evidence. . J. Cancer Surviv. 6:(4):359–71
     [Google Scholar]
  54. 54.
    Browall M, Forsberg C, Wengström Y. 2017.. Assessing patient outcomes and cost-effectiveness of nurse-led follow-up for women with breast cancer—have relevant and sensitive evaluation measures been used?. J. Clin. Nurs. 26:(13–14):1770–86
     [Google Scholar]
  55. 55.
    Monterosso L, Platt V, Bulsara M, Berg M. 2019.. Systematic review and meta-analysis of patient reported outcomes for nurse-led models of survivorship care for adult cancer patients. . Cancer Treat. Rev. 73::62–72
     [Google Scholar]
  56. 56.
    Lai XB, Ching SSY, Wong FKY. 2017.. Nurse-led cancer care: a scope review of the past years (2003–2016). . Int. J. Nurs. Sci. 4:(2):184–95
     [Google Scholar]
  57. 57.
    Bitterman DS, Downing A, Maués J, Lustberg M. 2024.. Promise and perils of large language models for cancer survivorship and supportive care. . J. Clin. Oncol. 42::1607–611
     [Google Scholar]
  58. 58.
    Freije JM, MacDonald NJ, Steeg PS. 1998.. Nm23 and tumour metastasis: basic and translational advances. . Biochem. Soc. Symp. 63::261–71
     [Google Scholar]
  59. 59.
    Billman E, Steele N, Servino K, et al. 2024.. Developing “The Health After Cancer Podcast” to amplify cancer survivors' voices through digital storytelling. . Patient Educ. Couns. 123::108194
     [Google Scholar]
  60. 60.
    Ayyoubzadeh SM, Shirkhoda M, Niakan Kalhori SR, et al. 2022.. A smartphone remote monitoring app to follow up colorectal cancer survivors: requirement analysis. . JMIR Cancer 8:(1):e18083
     [Google Scholar]
  61. 61.
    Chow R, Drkulec H, Im JHB, et al. 2024.. The use of wearable devices in oncology patients: a systematic review. . Oncologist 29:(4):e419–30
     [Google Scholar]
  62. 62.
    Xiao C, Polomano R, Bruner DW. 2013.. Comparison between patient-reported and clinician-observed symptoms in oncology. . Cancer Nurs. 36:(6):E1–16
     [Google Scholar]
  63. 63.
    Falchook AD, Green R, Knowles ME, et al. 2016.. Comparison of patient- and practitioner-reported toxic effects associated with chemoradiotherapy for head and neck cancer. . JAMA Otolaryngol. Head Neck Surg. 142:(6):517–23
     [Google Scholar]
  64. 64.
    Basch E, Jia X, Heller G, et al. 2009.. Adverse symptom event reporting by patients versus clinicians: relationships with clinical outcomes. . J. Natl. Cancer Inst. 101:(23):1624–32
     [Google Scholar]
  65. 65.
    Corcoran S, Thom B, Decker K. 2018.. Electronic patient-reported outcomes (ePRO) in survivorship practice. . J. Clin. Oncol. 36:(7_Suppl.):79
     [Google Scholar]
  66. 66.
    Zebrack BJ. 2011.. Psychological, social, and behavioral issues for young adults with cancer. . Cancer 117:(Suppl. 10):2289–94
     [Google Scholar]
  67. 67.
    Tonorezos ES, Barnea D, Cohn RJ, et al. 2018.. Models of care for survivors of childhood cancer from across the globe: advancing survivorship care in the next decade. . J. Clin. Oncol. 36:(21):2223–30
     [Google Scholar]
  68. 68.
    Woodruff TK. 2010.. The Oncofertility Consortium—addressing fertility in young people with cancer. . Nat. Rev. Clin. Oncol. 7:(8):466–75
     [Google Scholar]
  69. 69.
    Puckrin R, Jamani K, Jimenez-Zepeda VH. 2024.. Long-term survivorship care after CAR-T cell therapy. . Eur. J. Haematol. 112:(1):41–50
     [Google Scholar]
  70. 70.
    Martin T, Usmani SZ, Berdeja JG, et al. 2023.. Ciltacabtagene autoleucel, an anti-B-cell maturation antigen chimeric antigen receptor T-cell therapy, for relapsed/refractory multiple myeloma: CARTITUDE-1 2-year follow-up. . J. Clin. Oncol. 41:(6):1265–74
     [Google Scholar]
  71. 71.
    Baum RP, Kulkarni HR, Singh A, et al. 2018.. Results and adverse events of personalized peptide receptor radionuclide therapy with 90Yttrium and 177Lutetium in 1048 patients with neuroendocrine neoplasms. . Oncotarget 9:(24):16932
     [Google Scholar]
  72. 72.
    Brabander T, van der Zwan WA, Teunissen JJ, et al. 2017.. Long-term efficacy, survival, and safety of [177Lu-DOTA0, Tyr3] octreotate in patients with gastroenteropancreatic and bronchial neuroendocrine tumors. . Clin. Cancer Res. 23:(16):4617–24
     [Google Scholar]
  73. 73.
    Sabet A, Ezziddin K, Pape U-F, et al. 2013.. Long-term hematotoxicity after peptide receptor radionuclide therapy with 177Lu-octreotate. . J. Nuclear Med. 54:(11):1857–61
     [Google Scholar]
  74. 74.
    Bergsma H, van Lom K, Raaijmakers MH, et al. 2018.. Persistent hematologic dysfunction after peptide receptor radionuclide therapy with 177Lu-DOTATATE: incidence, course, and predicting factors in patients with gastroenteropancreatic neuroendocrine tumors. . J. Nuclear Med. 59:(3):452–58
     [Google Scholar]
  75. 75.
    Sonbol MB, Halfdanarson TR, Hilal T. 2020.. Assessment of therapy-related myeloid neoplasms in patients with neuroendocrine tumors after peptide receptor radionuclide therapy: a systematic review. . JAMA Oncol. 6:(7):1086–92
     [Google Scholar]
  76. 76.
    Csizmar CM, Saliba AN, Swisher EM, Kaufmann SH. 2021.. PARP inhibitors and myeloid neoplasms: a double-edged sword. . Cancers 13:(24):6385
     [Google Scholar]
  77. 77.
    de Boer RA, Aboumsallem JP, Bracun V, et al. 2021.. A new classification of cardio-oncology syndromes. . Cardio-Oncology 7:(1):24
     [Google Scholar]
  78. 78.
    Scott LC, Yang Q, Dowling NF, Richardson LC. 2021.. Predicted heart age among cancer survivors—United States, 2013–2017. . MMWR Morb. Mortal. Wkly. Rep. 70:(1):1–6
     [Google Scholar]
  79. 79.
    Heuser M, Thol F, Ganser A. 2016.. Clonal hematopoiesis of indeterminate potential. . Dtsch. Arztebl. Int. 113:(18):317–22
     [Google Scholar]
  80. 80.
    Jaiswal S, Natarajan P, Silver AJ, et al. 2017.. Clonal hematopoiesis and risk of atherosclerotic cardiovascular disease. . N. Engl. J. Med. 377::111–21
     [Google Scholar]
  81. 81.
    Marnell CS, Bick A, Natarajan P. 2021.. Clonal hematopoiesis of indeterminate potential (CHIP): linking somatic mutations, hematopoiesis, chronic inflammation and cardiovascular disease. . J. Mol. Cell. Cardiol. 161::98–105
     [Google Scholar]
  82. 82.
    AACR (Am. Assoc. Cancer Res.). 2024.. AACR cancer disparities progress report. Rep., AACR, Philadelphia, PA:. https://cancerprogressreport.aacr.org/wp-content/uploads/sites/2/2024/05/AACR_CDPR__2024.pdf
    [Google Scholar]
  83. 83.
    Manz CR, Schrag D. 2021.. Racial disparities in colorectal cancer recurrence and mortality: equitable care, inequitable outcomes?. J. Natl. Cancer Inst. 113:(6):656–57
     [Google Scholar]
  84. 84.
    Lindstrom L. 2021.. Racial and ethnic disparities in rates of invasive secondary breast cancer among women with ductal carcinoma in situ in Hawai‘i. . JAMA Netw. Open 4:(10):e2130925
     [Google Scholar]
  85. 85.
    Mazor M, Wisnivesky JP, Goel M, et al. 2021.. Racial and ethnic disparities in post-traumatic stress and illness coherence in breast cancer survivors with comorbid diabetes. . Psychooncology 30:(10):1789–98
     [Google Scholar]
  86. 86.
    Yamamoto T, Koshima I. 2014.. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. . Plast. Reconstr. Surg. 133:(6):887e–88e
     [Google Scholar]
  87. 87.
    Yoshida Y, Schmaltz CL, Jackson-Thompson J, Simoes EJ. 2019.. The effect of metabolic risk factors on cancer mortality among blacks and whites. . Transl. Cancer Res. 8:(Suppl. 4):S389–96
     [Google Scholar]
  88. 88.
    Noyd DH, Yasui Y, Li N, et al. 2021.. Disparities in cardiovascular risk factors by race/ethnicity among adult survivors of childhood cancer: a report from the Childhood Cancer Survivorship Study (CCSS). . J. Clin. Oncol. 39::10017
     [Google Scholar]
  89. 89.
    Burnett C, Lyerly R, Jesdale BM. 2024.. Overall satisfaction with cancer care among sexual and gender minority people and their utilization of identity-tailored health education materials. . LGBT Health 11:(6):475–83
     [Google Scholar]
  90. 90.
    Weaver KE, Geiger AM, Lu L, Case LD. 2013.. Rural-urban disparities in health status among US cancer survivors. . Cancer 119:(5):1050–57
     [Google Scholar]
  91. 91.
    Hajra K, Tripathi D, Maity D. 2024.. Multicancer early detection tests for cancer diagnosis. . J. Explor. Res. Pharmacol. 9:(1):23–33
     [Google Scholar]
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Care Models for Cancer Survivors
Annual Review of Medicine 76, 225 (2025); https://doi.org/10.1146/annurev-med-042423-044004
/content/journals/10.1146/annurev-med-042423-044004
/content/journals/10.1146/annurev-med-042423-044004
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