A scalable survivorship model for understaffed cancer programs—standardize pathways, shift routine care to shared models, and automate the repetitive work.
How to Build a Cancer Survivorship Program Without Additional Workforce
Cancer survivorship is growing faster than most oncology systems can absorb through visit-based follow-up alone. As of January 1, 2025, there were ~18.6 million cancer survivors in the U.S., projected to exceed 22 million by 2035.
At the same time, workforce capacity is under pressure. ASCO’s 2025 workforce reporting highlights that oncologist density relative to the aging population is decreasing—exactly the context that makes survivorship redesign urgent.
So the question many cancer programs are asking is practical: How do we build a survivorship program without hiring more staff?
The answer is not “do more.” It’s redesign delivery so survivorship becomes structured, repeatable, and partially shifted to the right setting (primary care/shared care) and the right format (group + digital + standardized pathways).
The core idea: survivorship capacity comes from redesign, not headcount
Leading survivorship literature has been explicit: traditional oncologist-led survivorship models are widely considered unsustainable at scale, and alternative models have been tested—including primary care–led, shared care, and nurse-led models.
NCI also emphasizes the importance of studying and implementing models of survivorship care, including risk-stratified approaches, because model design is central to making survivorship deliverable.
Translation into operations: You don’t need a bigger survivorship team first. You need a survivorship operating system.
The “No-New-Staff” Survivorship Program Blueprint
Step 1) Define your survivorship population and segment by risk/need
If everyone gets the same follow-up intensity, the system breaks. Start with a simple segmentation:
Low complexity / low recurrence risk → transition-ready, protocolized follow-up + clear escalation triggers
Moderate complexity → shared care (PCP + survivorship pathway) + periodic oncology touchpoints
High complexity / high late-effect risk or symptom burden → targeted survivorship clinic resources (nurse/APP-led) and specialty pathways
This is the foundation of risk-stratified survivorship care pathways.
Step 2) Standardize 3–5 survivorship pathways (instead of building a “clinic for everything”)
Without extra workforce, survivorship must be protocol-driven. Pick your highest-volume, highest-impact pathways first:
fatigue/sleep/distress screening → stepped-care referral
neuropathy/pain → rehab + symptom management pathway
cardiometabolic risk (when relevant by exposure) → PCP coordination + cardiology triggers
sexual health / menopause / fertility (as applicable) → structured referral pathway
nutrition/physical activity → group class + coaching + referral loop
The goal is not perfection. It’s a repeatable baseline that prevents survivors from becoming “lost after treatment.”
Step 3) Shift routine survivorship to shared care (and make handoffs auditable)
A shared care model for cancer survivors reduces oncology clinic load—but only if accountability is explicit.
Build a simple transition package:
treatment summary / key exposures
“what to monitor” list (late effects + red flags)
surveillance schedule and who owns it
referral triggers back to oncology
This is exactly the type of redesign emphasized across survivorship model discussions (shared care, primary care–led models).
Step 4) Use nurse/APP-led survivorship delivery for the “middle” of the pyramid
Oncologist time is the scarcest resource. A common scalability move is to create:
nurse/APP-led survivorship visits for moderate/high-need survivors
standardized templates for late-effect screening + referrals
oncologist escalation only when triggered
Alternative models specifically include nurse-led survivorship as a tested approach.
Step 5) Replace 1:1 education with group-based survivorship services
Group care is a capacity multiplier because one clinician-hour serves 10–30 survivors.
Examples of “group-first” survivorship services:
survivorship orientation class (what to expect after treatment)
fatigue/sleep program starter session
return-to-work / financial navigation workshop (with internal or partner resources)
physical activity/rehab intro (with referral routing)
Keep it simple: one recurring schedule, one intake pathway, one tracking method.
Step 6) Make technology do the repetitive work (screening, routing, documentation, reporting)
A technology-enabled survivorship program is not about “more tools.” It’s about removing administrative friction that consumes scarce staff time.
Technology can reliably handle:
post-treatment enrollment and check-ins
needs screening (symptoms, distress, functional status)
routing to pathways (rehab, nutrition, mental health, sexual health, PCP)
participation tracking and service utilization
generating program reports and closing referral loops
This aligns with the broader emphasis that survivorship models require supporting infrastructure, including information technology, to be seamless and scalable.
Step 7) Measure only what you need to manage (don’t build a research registry)
A survivorship program can be “real” with a small metric set:
eligible survivors vs enrolled
participation by service (group class, screening pathway, referrals)
referral completion rate
symptom burden trend (simple PROs)
oncology re-escalation triggers (volume + causes)
If you’re CoC-accredited (or pursuing it), this measurement discipline also maps cleanly to survivorship documentation expectations (e.g., identifying services and reporting participation annually under Standard 4.8).
The “No-New-Staff” Survivorship Program Checklist (copy/paste)
✅ Survivors segmented into low / moderate / high need (risk-stratified)
✅ 3–5 standardized survivorship pathways (screen → route → follow up)
✅ Shared-care handoff package for PCP with escalation triggers
✅ Nurse/APP-led survivorship delivery for moderate/high need
✅ Group education replaces most 1:1 survivorship education
✅ Technology-enabled screening + referral routing + participation tracking
✅ Minimal metric set tracked monthly (not annually)
✅ One quarterly review meeting to adjust pathways based on bottlenecks
Conclusion: the survivorship program you can build this quarter
You don’t need a new department to start. A survivorship program becomes real when you have:
segmented survivors,
standardized pathways,
a shared-care transition,
and a reliable system for screening + routing + tracking.
If your organization wants to expand survivorship support without adding major workload to already-stretched teams, we’d love to connect.
Book a demo to see how The After Cancer works in practice (what patients experience, how programs are structured, and how it fits into existing care pathways).
Or book a call with our team to discuss implementation pathways and partnerships.