RECORDING – CAPO Recommendations for Survivorship Models of Follow-Up Care: 2025 Best Models for Adults Post-Treatment

RECORDING – CAPO Recommendations for Survivorship Models of Follow-Up Care: 2025 Best Models for Adults Post-Treatment

Recorded on Wednesday, April 9

Hosted by: Dr. Doris Howell

According to the Canadian Cancer Society, at the beginning of 2018, over 1.5 million people in Canada were living with or beyond cancer. The Institute of Medicine (IOM), From Cancer Patient to Cancer Survivor: Lost in Transition (2006), and many other subsequent reports have called for improvement in the quality of care provided to cancer survivors and for comprehensive, coordinated, and tailored follow-up care. 

Based on consensus of experts, four components of survivorship care were identified in the IOM report including: 

1. Prevention of new (primary and recurrent cancers and other late effects; 
2. Surveillance for recurrence or new cancers; 
3. Interventions for illnesses secondary to cancer and cancer treatment (medical and physical consequences and/or long term symptom, psychological distress/mental health problems experienced by survivors and caregivers, and concerns related to employment, insurance and disability; and 
4. Coordination between specialists and primary care providers (PCPs) to ensure attention to other health needs and/or comorbid conditions.

Cancer survivorship care is not a “one-size” fits all model. Many factors are shown to influence the organization and structure of survivorship models of care such as the number and types of survivors being served, services and financial/human resources, risk of recurrence, cancer treatment exposures and resulting long-term symptoms and late effect risks, geographic location and care setting, and patient preferences for type of follow-up care. Types of survivorship care models include community-based shared-care models, academically based comprehensive survivor program models, nurse practitioner–led shared care, and multidisciplinary programs for high-risk populations. Survivorship has various definitions extending from early survivorship (diagnosis and acute cancer treatment) to post-treatment and long-term medical care and for those living with advanced cancer as a chronic illness. For this guidance document, we have defined a model of survivorship care as a program for cancer survivors that addresses two or more of the IOM components for survivorship care. Additionally, we focus only on individuals who have completed active cancer treatment and are transitioning from acute to more long-term medical care and follow-up services. 

The purpose of this guideline is to provide recommendations to inform the optimal organization and structure of survivorship care and the outcomes associated with differing follow-up models of care for adults’ cancer survivors who have completed primary treatment for cancer. Through engagement of key stakeholders, we will also develop considerations to address issues of equity and equitable access to survivorship follow-up care for diverse and vulnerable populations and for implementation of survivorship models of care. 

This guideline is targeted for:

1. Health professionals who are responsible for the care of adults with cancer who are clinically disease free after receiving primary cancer treatment.
2. Administrative and system leaders responsible for implementing high-quality evidence informed survivorship models of care and service components for adults.

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