Guiding Principles
In developing this guideline, the guiding principles for ideal survivorship care were taken into consideration as foundational to the delivery of equitable survivorship care that is personalized to the individual and their health and supportive care needs (44). These principles were further refined from those identified through consensus in our 2011 guideline (45). These principles are as follows:
Care should be tailored to the personal needs of survivors and be sensitive to issues of religious and spiritual values, culture/race/ethnicity, language, gender, age, disability, living circumstance, geographic (rural/remote), literacy, and structural vulnerability.
Multidisciplinary and collaborative, involving a range of oncology specialists, primary care providers, nursing and allied health staff, as well survivors and their families.
Continuing medical care and support to transition from the acute setting to the community, using effective communication strategies, planned and coordinated FU.
Family, as defined by survivors, should be included in survivorship services; and engaged as active participants and collaborators in planning survivorship care.
Survivorship care should start from diagnosis and extend through treatment, post-treatment remission and/or ongoing maintenance therapy for cancer control and/or living with advanced disease as a chronic illness, palliative and end of life care
Psychosocial and supportive care services involve a range of disciplines, but are not limited to, nurses, oncologists, psychiatrists, psychologists, social workers, dietitians, rehabilitation providers, spiritual care providers, and primary care providers.
Essential components of survivorship services are not limited to psychosocial and supportive care but include the prevention of and surveillance for recurrent and new cancers, as well as clinical management of other late effects.
Survivorship services should focus on empowering survivors, with the support of their caregivers, to adopt self-management strategies and other behaviours necessary to optimize health and well-being inclusive of coaching on health promotion/prevention.
Survivors should be prepared early in the disease course for transition to the appropriate model of post-treatment care based on needs and health risks and facilitated by use of survivorship care plans
Evidence-based using guidelines and research, quality survivorship frameworks for service delivery, health policy that is outcomes focused, cost-effective and sustainable.