The guiding principles of this clinical practice guideline emphasize a holistic, survivor-centered approach to cancer survivorship care. Key principles include tailored care that respects cultural, religious, linguistic, and personal needs, as well as the active involvement of families and caregivers in care planning. An interdisciplinary approach is essential, integrating professionals from various fields such as oncology, psychology, social work, rehabilitation, and spiritual care. Survivorship services must go beyond psychosocial support, encompassing cancer recurrence surveillance and management of long-term treatment effects. Additionally, empowering survivors through self-management strategies is a core objective, ensuring they receive the necessary tools and support for long-term well-being.

The expert panel developed this clinical practice guideline with a multidisciplinary team, comprised of interdisciplinary providers (nurses, radiation oncologist, medical oncologists, psychologist), administrative leaders in cancer care, and people with lived experience (patient partners) from across Canadian provinces and territories and cancer care and community organizations. The guideline development followed the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach, including for the prioritization of guideline questions and health outcomes, summarizing and assessing the certainty (or quality) of evidence, and the strength of recommendations. We conducted systematic reviews to identify available trials evaluating the various models of survivorship care. GRADE evidence profiles were developed to summarize the available research evidence about the effects of the models of survivorship care. In addition to conducting systematic reviews of model of survivorship care effects, we reviewed existing systematic reviews  for information related to patients’ values, costs, impact on health equity, feasibility and acceptability, and summarized available findings in GRADE evidence-to-decision frameworks.

The Results of the cancer survivorship care guideline highlight key findings on the organization and delivery of survivorship services. Various models of care—including survivorship clinics, shared care, and nurse-led follow-up—demonstrated no significant differences in recurrence rates, though nurse-led care showed higher patient satisfaction and emotional well-being. Primary care settings were associated with lower costs and increased satisfaction. An interdisciplinary team is recommended, integrating specialists such as nurses, dietitians, and psychologists. Psychosocial support, survivorship care plans, and patient education are essential for long-term well-being. Research should continue on engaging survivors in self-management and optimizing survivorship care delivery.