Recommendations

Following deliberations and voting consensus of our interdisciplinary expert panel that included representation of jurisdictions across Canada and people with lived experience of cancer (patient partners) we have developed our recommendations for these five alternate models of survivorship care for follow-up of adult cancer survivors based on evidence of effects on outcomes in comparison to oncologist specialist led-care models of care. A condensed version of the recommendations summarized based on the EtD frameworks is shown in Table 4. Brief Summary of Recommendations.

  
      Table 4: Brief Summary of Recommendations
    
        Model of Care
        Recommendation and Remarks
      
        Shared-Care Model
        
          Recommendation: The panel recommends that shared care models of survivorship care are appropriate to be used for many adult cancer survivors who have completed cancer treatment. 
          (Strong recommendation, based on low certainty in the evidence)

          Remarks: Shared care must be recognized as a formalized arrangement with core elements in place to address essential components of quality survivorship care (surveillance, health promotion/prevention, psychosocial support, symptom management, etc.). Integration across care sectors is crucial for seamless survivor and provider experience.
        
        Primary Care Physician Led-Care
        
          Recommendation: The panel recommends that primary care-led survivorship models of care are appropriate to be used for many adult cancer survivors who have completed cancer treatment. 
          (Strong recommendation, based on moderate certainty in the evidence)

          Remarks: Compared to oncologist-led care, primary care-led models showed trivial to small differences in health effects. They are favorable for many survivors, but oncologist-led models may be needed for patients with complex symptoms, high risk of recurrence, or specific preferences.
        
        Nurse-Led Care Model
        
          Recommendation: The panel recommends that nurse-led survivorship models of care are appropriate to be used for many adult cancer survivors who have completed cancer treatment. 
          (Strong recommendation, based on moderate certainty in the evidence)

          Remarks: Similar to primary care-led models, nurse-led models showed small differences in outcomes compared to oncologist-led care. Suitable for many, but some patients may require specialist-led follow-up depending on their needs.
        
        Patient-Initiated / Self-Management Models
        
          Recommendation: The panel suggests that patient-led survivorship models of care are appropriate for low-risk patients who have completed cancer treatment. 
          (Conditional recommendation, based on very low certainty in the evidence)

          Remarks: Rapid access back to oncologist-led care is critical to the success of this model.

Table 4: Brief Summary of Recommendations
Shared-Care Model	Recommendation: The panel recommends that shared care models of survivorship care are appropriate to be used for many adult cancer survivors who have completed cancer treatment. (Strong recommendation, based on low certainty in the evidence) Remarks: Shared care must be recognized as a formalized arrangement with core elements in place to address essential components of quality survivorship care (surveillance, health promotion/prevention, psychosocial support, symptom management, etc.). Integration across care sectors is crucial for seamless survivor and provider experience.
Primary Care Physician Led-Care	Recommendation: The panel recommends that primary care-led survivorship models of care are appropriate to be used for many adult cancer survivors who have completed cancer treatment. (Strong recommendation, based on moderate certainty in the evidence) Remarks: Compared to oncologist-led care, primary care-led models showed trivial to small differences in health effects. They are favorable for many survivors, but oncologist-led models may be needed for patients with complex symptoms, high risk of recurrence, or specific preferences.
Nurse-Led Care Model	Recommendation: The panel recommends that nurse-led survivorship models of care are appropriate to be used for many adult cancer survivors who have completed cancer treatment. (Strong recommendation, based on moderate certainty in the evidence) Remarks: Similar to primary care-led models, nurse-led models showed small differences in outcomes compared to oncologist-led care. Suitable for many, but some patients may require specialist-led follow-up depending on their needs.
Patient-Initiated / Self-Management Models	Recommendation: The panel suggests that patient-led survivorship models of care are appropriate for low-risk patients who have completed cancer treatment. (Conditional recommendation, based on very low certainty in the evidence) Remarks: Rapid access back to oncologist-led care is critical to the success of this model.

Funnel Communication 2025-03-06 Funnel Communication 2025-03-06

Organization and Care Delivery Structure of Survivorship

The following recommendations are based on the expert consensus of the Cancer Journey Survivorship Expert Panel, informed by a systematic review of the evidence current to December 2009. The body of evidence includes clinical practice guidelines, systematic reviews and randomized controlled trials. Each recommendation was developed with the consideration of the expected health benefits balanced with the potential harms, side effects or risks associated with the guidance offered. Tactics for guideline implementation across various healthcare jurisdictions or health models are offered and can be used as part of auditing or monitoring of survivorship services. Final and formal approval of the document was obtained through an online vote by the members of the Cancer Journey Survivorship Expert Panel. Where recommendations were taken directly or adapted from any of the identified practice guidelines, the source document is listed after the recommendation. While there is a great volume of data on the topic, unless otherwise stated, recommendations should be considered consensus-based and informed by the evidence.

Funnel Communication 2025-03-03 Funnel Communication 2025-03-03

Psychosocial and Supportive Care Interventions

The psychosocial and supportive care interventions for cancer survivors emphasize healthy lifestyle behaviors, including exercise, nutrition, and smoking cessation, tailored to individual needs. Programs should be based on behavior change theories to sustain long-term benefits. Survivors experiencing psychosocial distress should have access to cognitive behavioral therapy and psychoeducational support. Routine follow-up should monitor symptoms, late effects, and physiological concerns through a shared-care approach. Additionally, survivors should receive support for sexual health, fatigue management, vasomotor symptoms, and sleep disturbances, integrating multicomponent cognitive behavioral therapy and targeted interventions to enhance overall quality of life.