The Survivorship Gap: Why the Rapid Growth in Cancer Survivors Requires New Care Models

A practical look at the capacity mismatch driving survivorship shortfalls—and the care models health systems are adopting to deliver survivorship at scale.

The Survivorship Gap: Why the Rapid Growth in Cancer Survivors Requires New Care Models

Cancer survivorship in the United States is growing faster than most oncology systems were built to support. As of January 1, 2025, about 18.6 million people in the U.S. were living with a history of cancer—projected to exceed 22 million by 2035.

At the same time, survivorship is not a brief “aftercare” period. For many people, it becomes a long, clinically active phase marked by persistent symptoms, late effects, and psychosocial and practical needs that require coordinated follow-up and services—often across oncology, primary care, and multiple specialties.

This mismatch—rapid survivor growth + complex needs + limited delivery capacity—is what many hospital teams experience as the survivorship gap in cancer care.

In this article, we break down:

what is driving the survivorship gap,
why “more guidelines” hasn’t automatically translated into scalable survivorship services, and
why leading organizations increasingly emphasize the need for new survivorship care models (risk-stratified, shared care, and technology-enabled).

What is the survivorship gap in cancer care?

The survivorship gap is the space between:

what survivorship standards and guidelines say survivors need (surveillance, late effects management, prevention, psychosocial care, coordinated transitions), and
what most systems can reliably deliver at scale inside real-world staffing, visit templates, and fragmented care transitions.

It’s not a lack of awareness. It’s an implementation and capacity problem.

Cancer survivorship is growing fast—and so is post-treatment care demand

The survivor population is rising because more people are living longer after cancer. ACS highlights survivorship growth driven by an aging population and advances in early detection and treatment. And this isn’t a population treated “long ago.” About half of cancer survivors were diagnosed within the past decade, which means millions are still in the high-need window when late and long-term effects, monitoring needs, and recovery challenges are most active.

Operational reality: A larger survivor population does not mean “routine surveillance only.” Survivors frequently need structured assessment, referral pathways, and ongoing support beyond traditional follow-up visit models—especially for late effects that appear months or years after treatment.

Survivorship is a success story—but it creates a second wave of clinical need that most follow-up systems were never designed to deliver.

Why hospitals and cancer centers struggle to meet survivorship demand

In most systems, the survivorship gap isn’t about clinicians “not caring.” It’s about implementation friction: survivorship standards are well-described, but converting them into reliable, scalable services is hard inside real-world oncology operations. The same barriers show up repeatedly across survivorship literature and implementation work.

A) Capacity constraints: survivorship work doesn’t fit inside standard visit templates

Survivorship care includes longitudinal assessment, education, symptom management, prevention counseling, referrals, and coordination. That work requires time and structure—yet many programs try to “add it on” to already packed follow-up visits.

A concrete example: survivorship care planning has been reported to take ~45–90 minutes per patient, often as unreimbursed time—an immediate scalability barrier when clinics are already operating at capacity.

B) Fragmented transitions: survivors fall between oncology and primary care

Survivorship is the phase where handoffs matter most—and where systems often struggle most.

The landmark Lost in Transition report emphasized survivorship as a distinct phase of care and pushed survivorship care planning partly because post-treatment transitions were a major vulnerability in care.

Common breakdown points include:

unclear ownership of late and long-term effects (oncology vs PCP vs subspecialists),
inconsistent use of treatment summaries / survivorship care plans as a shared reference, and
weak bidirectional communication, making it hard for PCPs to know what to monitor and hard for oncology teams to see what’s happening after transition.

C) Limited staffing: survivorship demand is rising faster than workforce capacity

Even well-designed survivorship pathways require people to deliver them—navigators, APPs, nurses, rehab, psychosocial support, and care coordination. But survivorship work competes with increasing treatment complexity and clinic volume.

This is one reason many programs move toward nurse/APP-led survivorship pathways, shared care, and technology-enabled models: they’re capacity multipliers.

D) “No single best model”: guidelines exist, but delivery models are still evolving

Guidelines and frameworks have clarified what survivorship should include, but many publications emphasize that models of care must still evolve, and that infrastructure (including information technology) is critical to making survivorship seamless and scalable.

Why “more guidelines” hasn’t automatically closed the survivorship gap

Over the past two decades, organizations have done the hard conceptual work of defining “good survivorship care” and its deliverables:

NCCN outlines survivorship as a package of services spanning surveillance, screening for new cancers, management of late/long-term effects, health promotion, and care coordination.
ASCO curates survivorship guidelines, care plan templates, and implementation resources to support clinical practice.
LIVESTRONG convened stakeholders to define “essential elements” that survivorship programs should provide directly or via referral—explicitly focusing on implementable components.
ESMO has emphasized core survivorship components and the need for organized survivorship approaches (internationally).

But guidelines don’t build workflows. And survivorship fails in predictable places: time, staffing, transitions, data capture, referral loops, and measurement.

The case for new survivorship care models (what leading organizations are emphasizing)

When demand outpaces capacity and guideline-level care can’t be delivered consistently, the solution isn’t “more follow-up visits” or “more documents.” It’s new delivery pathways that make survivorship scalable, measurable, and sustainable.

1) Risk-stratified survivorship care pathways

Risk-stratified approaches allocate intensity of follow-up based on recurrence risk, treatment exposure, comorbidities, and symptom burden—so high-need survivors get high-touch services, while lower-risk survivors transition appropriately with clear monitoring plans.

NCI’s Office of Cancer Survivorship has explicitly supported initiatives focused on models of survivorship care, including risk-stratified care, to improve survivorship care delivery and outcomes.

2) Shared-care models (oncology + primary care, with clear accountability)

Shared-care models aim to reduce “handoff failure” by defining responsibilities across oncology and primary care, supported by treatment summaries, survivorship care plans, and escalation triggers.

3) Nurse/APP-led survivorship and team-based clinics

Programs increasingly use nurse/APP-led survivorship visits, group survivorship models, and structured referral pathways to expand capacity—especially when oncologists must prioritize active treatment complexity.

4) Technology-enabled survivorship programs

Technology-enabled models can standardize needs screening, automate parts of care planning, support referrals, and continuously capture participation and outcomes—reducing the administrative load that breaks survivorship at scale.

This is consistent with broader calls that current survivorship models are often unsustainable and need improvement through redesigned care pathways.

Conclusion: why new survivorship care models are no longer optional

The survivorship gap is the result of three forces colliding:

Demand is rising fast (and survivorship is not “simple follow-up”).
Most systems weren’t built for long-term survivorship delivery at scale.
Guidelines aren’t the problem—implementation is.

That’s why the field is moving toward new survivorship care models—especially risk-stratified care, shared-care models, and technology-enabled programs—to make survivorship care scalable, measurable, and sustainable.

If your organization is thinking about how to support the growing population of cancer survivors 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.

Or book a call with our Team.

The Survivorship Gap: Why the Rapid Growth in Cancer Survivors Requires New Care Models