# Risk-stratified lifelong care for tens of millions of survivors, automated and shared with primary care

Source: https://onco.cc/ideas/idea-moon-survivor-lifelong-care-model/  
OnCo record `idea-moon-survivor-lifelong-care-model` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Cancer survivors are a huge and growing population with specific long-term risks. Give each a plan matched to their risk, run automatically and shared with their family doctor.

## Summary

Survivors face recurrence, second cancers, cardiovascular and endocrine late effects, and psychosocial and financial harm, but follow-up is either oncologist-heavy and unsustainable or absent. The proposal is a national survivorship model: an automated, treatment-specific survivorship care plan generated from the record at end of treatment, risk-stratified pathways (self-managed, primary care-led, shared care, specialist), scheduled surveillance triggered by the record, patient-reported outcome check-ins, and re-entry routes to oncology, with primary care paid for its role.

## Fields

- Kind: Idea
- Last checked: 2026-09-08
- Hypothesis: The model maintains or improves guideline-concordant surveillance and late-effect detection while reducing oncology follow-up visits by half and improving survivor-reported unmet needs.
- Rationale: Stratified follow-up trials in breast and colorectal cancer show primary care-led or patient-initiated follow-up is safe for low-risk survivors; automation and payment make it scalable.
- Proposed test: Regional implementation trial comparing the model with standard follow-up on surveillance completion, late-effect detection, visits and patient-reported outcomes over five years.
- Maturity: early-clinical
- Actor: policy

## Sources

- Bottleneck evidence (Survivorship and late effects are neglected): NCI Office of Cancer Survivorship statistics: https://cancercontrol.cancer.gov/ocs/statistics

## Connected records

- technologies: [Cardio-oncology](https://onco.cc/technologies/cardio-oncology/), [Depression during and after cancer: the interview-based prevalence, and the care model that works](https://onco.cc/technologies/rejuv-mind-depression-after-cancer/), [Fear that the cancer will come back: how common it is, and when it stops being ordinary worry](https://onco.cc/technologies/rejuv-mind-fear-of-recurrence/), [Post-traumatic stress after cancer: what is measured, and how much of it is measurement](https://onco.cc/technologies/rejuv-mind-traumatic-stress-after-cancer/), [The handover from children's to adult services, where follow-up falls away](https://onco.cc/technologies/rejuv-paed-transition-to-adult-care/), [Treating fear of recurrence: the randomised trials, their effect sizes, and where the treatment is available](https://onco.cc/technologies/rejuv-mind-fear-of-recurrence-treatment/)
- bottlenecks: [Fragmented care and guideline gaps](https://onco.cc/bottlenecks/b-care-fragmentation/), [Survivorship and late effects are neglected](https://onco.cc/bottlenecks/b-survivorship/)
- roadmaps: [Supportive care and survivorship roadmap: making treatment bearable → proving it extends life → caring for tens of millions afterwards](https://onco.cc/roadmaps/survivorship-roadmap/)

---
JSON: https://onco.cc/api/v1/entities/idea-moon-survivor-lifelong-care-model.json