What Is a Cancer Survivorship Care Program? A Practical Guide

How oncology practices can turn survivorship guidelines into repeatable services: surveillance, late effects pathways, prevention, psychosocial care, and SCP delivery.

What Is a Cancer Survivorship Care Program? A Practical Guide

Cancer survivorship is now a core part of oncology care, not an optional “nice-to-have.” The reason is simple: the survivor population is large, growing, and many survivors carry ongoing needs that traditional follow-up models don’t consistently address. As of January 1, 2025, there were ~18.6 million people in the United States living with a history of cancer, and projections suggest this will exceed 22 million by 2035.

Survivors don’t just need recurrence surveillance. Many experience persistent symptoms, late effects, and psychosocial challenges that can last for years—often requiring coordinated care across oncology, primary care, and multiple specialties. Major frameworks and guidelines recognize survivorship as its own phase of care and outline what “good survivorship care” should include.

In this article, you’ll learn:

What survivorship care is—and what a survivorship care program adds in real-world operations
The guideline-defined core components of survivorship care (what programs should include)
How survivorship care plans (SCPs) fit in as the personalized “blueprint” for follow-up

Survivorship care vs survivorship program: what’s the difference?

Survivorship care is the clinical work that needs to happen for survivors after primary treatment and often alongside long-term or maintenance therapies. It goes beyond “follow-up visits” and focuses on prevention, early detection of problems, symptom management, and quality of life.

A cancer survivorship care program is the system your cancer center or oncology practice builds to deliver survivorship care reliably and at scale—with defined workflows, accountable roles, and measurable services.

In other words:

Survivorship care = what survivors need
Survivorship program = how your organization makes that care repeatable

This distinction matters because without a program, survivorship care often becomes inconsistent: some survivors receive intensive follow-up while others are lost between settings or left to navigate late effects on their own.

Why survivorship programs accelerated (and why SCPs became a core deliverable)

Survivorship became a major oncology priority after the 2005 Institute of Medicine (IOM) report From Cancer Patient to Cancer Survivor: Lost in Transition, which framed survivorship as a distinct phase of care and called for structured follow-up planning. The report emphasized an actionable survivorship framework—often summarized as prevention, surveillance, intervention, and coordination—and promoted the treatment summary + follow-up care plan (what many teams refer to as the survivorship care plan) as a concrete deliverable at the end of primary treatment.

Since then, organizations such as NCCN and ASCO have expanded survivorship guidance into more detailed recommendations and resources for real-world implementation.

Core components of a structured cancer survivorship care program

Survivorship care isn’t a collection of “nice resources.” NCCN Survivorship Guidelines outline a broad set of survivorship domains (late/long-term effects, psychosocial concerns, preventive health, physical activity, second cancers, and more). A survivorship program is how a cancer center converts these guideline domains into repeatable workflows so care is delivered consistently—rather than only when someone happens to remember.

Below is a practical summary of the components most survivorship frameworks consistently emphasize.

1) Surveillance for recurrence and risk-based follow-up

Recurrence surveillance is not one-size-fits-all. It varies by cancer type, stage, biology, and treatment exposure. A survivorship program typically standardizes:

Follow-up cadence: who is seen, when, and by whom
Escalation triggers: what symptoms or findings return a survivor to oncology or specialty services
Symptom monitoring: “red flag” pathways that require urgent evaluation
Care coordination rules: oncology vs primary care vs subspecialists

Why this matters: Without a defined approach, surveillance becomes inconsistent—some survivors are over-followed in oncology clinics while others are under-monitored or lost between settings.

2) Screening for second primary cancers

For many survivors, recurrence is not the only long-term risk. Survivors may also face higher risk of subsequent new primary cancers, which NCCN includes within survivorship guidance.

A survivorship program operationalizes this by defining:

what screening is needed based on survivor history and exposures,
how screening is coordinated after transition to primary care,
prevention supports (e.g., tobacco cessation, weight and metabolic risk management).

3) Monitoring and management of long-term and late effects

NCCN Survivorship guidance addresses a wide range of late/long-term problems (physical and psychosocial), including topics like fatigue, cognitive function, pain, sleep disorders, sexual health, lymphedema, and treatment-related cardiac toxicity.

A guideline-aligned survivorship program turns “known risks” into action through:

standardized screening for common long-term and late effects,
defined referral pathways (rehab, cardiology, sexual health, mental health, nutrition, etc.),
clear “who owns what” rules (oncology vs PCP vs specialty clinics).

Why this matters: Survivorship is where patients may live with symptoms for years. Without pathways, issues are treated as isolated complaints rather than predictable, monitorable outcomes of therapy.

4) Prevention, health promotion, and recurrence-risk reduction

Survivorship guidelines emphasize prevention and healthy lifestyles as part of long-term wellness, including domains like nutrition, weight management, and physical activity.

A survivorship program typically builds practical workflows around:

healthy weight and metabolic risk management,
physical activity and functional restoration (often via rehab + coaching),
nutrition quality and symptom-informed eating strategies,
alcohol and tobacco risk reduction,
sleep and stress regulation supports.

5) Psychosocial care and “life after cancer” needs

Survivorship care is incomplete if it stops at surveillance. NCCN survivorship guidance includes psychosocial and functional domains (e.g., distress, return to work, sleep, sexual health), reinforcing the need for structured screening and referral pathways.

A survivorship program often includes:

distress screening with stepped-care referral,
fear of recurrence support,
sexual health, menopause, fertility, intimacy support,
return-to-work and financial navigation pathways when available,
caregiver/family support when relevant.

Why this matters: These needs are common drivers of reduced quality of life—and they are often under-detected unless systematically screened.

6) Survivorship care plans (SCPs): the personalized blueprint that ties it all together

A Survivorship Care Plan (SCP) is the individualized output that translates past treatment into a practical follow-up roadmap. The IOM report explicitly called for a comprehensive care summary and follow-up plan, and ASCO maintains survivorship care plan resources and templates used in practice.

A strong SCP typically includes:

diagnosis and stage,
treatments received (surgery, chemo, radiation, targeted therapy, immunotherapy, endocrine therapy),
known risks for late/long-term effects,
ongoing symptoms and psychosocial needs,
preventive care and screening needs,
clear accountability: who does what and when.

Operational takeaway: SCPs are most effective when they are not a one-time PDF, but a programmatic workflow—created, delivered, and connected to referrals and follow-up processes.

A practical implementation model (built for real clinics)

If you’re building or refining a survivorship care program, this simple structure helps teams move from “ideas” to operations:

Define your survivor population (e.g., post–first-course treatment; risk tiers)
Choose 3–5 program services you can deliver consistently (not one-off)
Standardize screening + referral pathways for the most common needs
Decide where SCPs live in the workflow (who creates, delivers, updates)
Measure participation + outcomes (even basic metrics are a start)

This keeps survivorship scalable—especially when staffing is limited.

Conclusion

Survivorship care is no longer a “future” initiative—it’s today’s capacity and quality challenge. With millions of survivors and growing unmet needs, survivorship programs are how oncology practices turn guidelines into something real: consistent, measurable support that extends care beyond the treatment endpoint.

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.

What Is a Cancer Survivorship Care Program? A Practical Guide