Risk-stratified lifelong care for tens of millions of survivors, automated and shared with primary care
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.
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.
- Survivorship and late effects are neglected · Tens of millions of people live after cancer with heart damage, infertility, second cancers and fear, and few services.
- Fragmented care and guideline gaps · Patients fall between specialists, wait for referrals and often do not get the treatment guidelines say they should.