Methodology

Guideline Expert Panel and COI Management

The expert panel was comprised of interdisciplinary providers (nurses, radiation oncologist, medical oncologists, psychologist), administrative leaders in cancer care, and people with lived experience (patient partners) and was representative across Canadian provinces and territories and cancer care and community organizations. The guideline panel developed and graded the recommendations and evaluated the certainty of supporting research evidence using the GRADE approach (48,49). The guideline-development process included expert panel formation, management of any potential conflicts of interest, internal and external review, and organizational approval, and was guided by CAPO policies and procedures.

Selection of Questions and Outcomes of Interest

Through consensus discussion the expert panel prioritized guideline questions to assess nurse-led, primary care-led, shared-care, and patient-led models of survivorship care. The panel then selected outcomes of interest for each question a priori, brainstorming possible outcomes for the guideline questions and through discussions reached consensus on the critical outcomes for decision making. Prioritized clinical outcomes included: detection of cancer recurrence, time to detection of recurrence, detection of secondary (new) cancers, mortality, and person-centered outcomes including physical functioning and/or disability, long-term physical symptoms (including cognitive function), occurrence of new medical comorbidities, quality of life, psychosocial distress/mental health symptoms, sexual health/intimacy, healthy lifestyle behaviours, and patient satisfaction.

Evidence Reviews

We followed the general methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions for conducting systematic reviews of intervention effects. In addition to conducting systematic reviews of intervention effects, we reviewed existing systematic reviews for information related to patients’ values, costs, impact on health equity, feasibility and acceptability, and summarized available findings within GRADE evidence-to-decision (EtD) frameworks. Subsequently, the certainty in the body of evidence was assessed for each effect estimate of the outcomes following the GRADE approach based on the following domains: risk of bias, imprecision, inconsistency, indirectness of the evidence, risk of publication bias. The overall certainty of evidence was then categorized into 4 levels ranging from very low to high.

Search Strategy and Inclusion of Studies

We searched medical literature databases, including Medline, Embase, PsycInfo, CINAHL, and Cochrane Central Register of Controlled Trials for existing systematic reviews and primary studies on models of care from inception to December 17, 2024. The search strategy was developed to focus on the inclusion of systematic reviews/meta-analyses and randomized controlled trials. The keywords for the search strategy were informed based on evidence from existing literature and feedback from the guideline expert panel. We also cross-referenced the reference lists from relevant systematic reviews in search and hand-searched grey literature to identify possible missing citations or potential primary studies of interest. Any additional references identified were included in forward reference searching

For the systematic review of implementation strategies we searched the following databases: Medline (OVID: 2009 through November 2024); Embase (OVID: 2009 through November 2024), PsycInfo (OVID: 2009 through November 2024), the Cochrane Central Register (OVID: 2009 through November 2024) and CINAHL (EBSCO: 2009 through November 2024). Reference lists and systematic review articles were scanned for additional citations.

We used COVIDENCE (56) and DistillerSR (57) platforms to screen the identified literature. Systematic review team members screened titles and abstracts of identified articles, followed by full texts, independently and in duplicate. A third independent reviewer with expertise in the guideline topic and systematic review methods resolved the conflicts. We considered studies with adult cancer survivors (18 years or older) after primary treatment for cancer and disease-free (i.e. adjuvant but may be on continued maintenance therapies (i.e. hormonal therapy) and/or completed first-line treatment for any phase of cancer). Across these potentially relevant studies, we considered any model of care for post-treatment follow-up relevant to the prevention and surveillance of recurrence and new cancers, surveillance and management of physical or psychosocial effects, surveillance and management of chronic medical conditions, health promotion, and/or disease prevention. We included studies that assessed alternate models of survivorship care compared to usual care (i.e. oncologist specialist-led care).

Decision-Making on Recommendations

During online conference calls and communications, the expert panel developed recommendations based on the evidence summarized in the GRADE EtD frameworks. Consensus meetings were preceded by independently pre-voting on the judgements and providing comments for each EtD criterion using the GRADEpro software. For each recommendation, the expert panel used a population perspective and reached consensus via discussions and voting on the following: the balance of benefits and harms of the management options, the certainty in the evidence, and the considerations about patients’ values and preferences associated with the health outcomes. The guideline panel also considered the extent of resource use associated with alternative management options as well as costs and cost-effectiveness. The panel agreed on the recommendations, including direction and strength, remarks, and justification by consensus. The panel’s deliberations, additional considerations, and details about justification for each recommendation are provided in the linked EtD frameworks.

Interpretation of Strong and Conditional Recommendations

The strength of a recommendation is expressed as either strong ("the guideline panel recommends..."), or conditional ("the guideline panel suggests…") and based on the interpretation outlined in the Table as per the GRADE approach (50):

Implications for:	Strong recommendation	Conditional recommendation
Patients	Most individuals in this situation would want the recommended course of action, and only a small proportion would not.	The majority of individuals in this situation would want the suggested course of action, but many would not. Decision aids may be useful in helping patients to make decisions consistent with their individual risks, values, and preferences.
Clinicians	Most individuals should follow the recommended course of action. Formal decision aids are not likely to be needed to help individual patients make decisions consistent with their values and preferences.	Different choices will be appropriate for individual patients; clinicians must help each patient arrive at a management decision consistent with his or her values and preferences. Decision aids may be useful in helping individuals to make decisions consistent with their individual risks, values, and preferences.
Policy makers	The recommendation can be adopted as policy in most situations. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator.	Policy decision making will require substantial debate and involvement of various stakeholders. Performance measures should assess if decision-making is appropriate.
Researchers	The recommendation is supported by credible research or other convincing judgements that make additional research unlikely to alter the recommendation. On occasion, a strong recommendation is based on low or very low certainty of the evidence. In such instances, further research may provide important information that alters the recommendations.	The recommendation is likely to be strengthened (for future updates or adaptation) by additional research. An evaluation of the conditions and criteria (and the related judgements, research evidence, and additional considerations) that determined the conditional (rather than strong) recommendation will help identify possible research gaps.