In 2025, the five-year cancer survival rate in the U.S. reached 70% for the first time — a milestone that translates to about 18.6 million cancer survivors.
The growing cancer survivor population is pushing health systems to rethink what happens after active treatment ends.
“For many survivors the real distress begins the day their active treatment is over, they are left floundering without a roadmap,” Arash Asher, MD, director of cancer rehabilitation and survivorship at Los Angeles-based Cedars-Sinai, told Becker’s. “Health systems need to recognize that the story isn’t over.”
Becker’s asked 15 oncology leaders how their organization’s survivorship model is evolving and what they’ve learned about maintaining continuity of care.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: How is your organization’s survivorship model evolving as survival rates continue to improve?
Sudha Bommidi. Vice President of AdventHealth Cancer Institute (Altamonte Springs, Fla.): At AdventHealth Cancer Institute, we are working toward a survivorship model that delivers the same level of coordinated, whole-person support after treatment as patients receive during active oncology care. As we continue to build that model, we see opportunity to further strengthen the role of advanced practice providers, nurse navigators, social workers, rehabilitation specialists, primary care providers and other multidisciplinary team members in supporting long-term surveillance, symptom management, wellness and psychosocial needs. Over time, that kind of team-based approach can help broaden access while allowing oncologists to focus on patients with the most complex treatment needs.
One of the biggest lessons we have learned is that survivorship should not feel like a handoff. Our goal is to create more structured transitions, clearer care plans and more reliable follow-up pathways, with patients receiving better guidance on when to connect with oncology versus primary care. Navigation, education and proactive communication will remain essential as we work to improve continuity and help patients feel supported well beyond active treatment.
Mark Bonnen, MD, and Susan Parsons, MD. Physician Executive of the Cancer Service Line and Director of Cancer Survivorship for the Tufts Cancer Center, respectively, at Tufts Medicine (Burlington, Mass.): With the number of cancer survivors in the United States exceeding 18 million and projected to surpass 22 million by 2035, innovative and scalable approaches to survivorship care are urgently needed. Given the complexity of long-term survivorship care and the need for effective care coordination, we and others have successfully partnered with advanced practice providers to deliver comprehensive clinical survivorship care. APPs are uniquely qualified for this role because their training emphasizes patient-centered care, health promotion, chronic disease management, patient education and interdisciplinary coordination — core elements of survivorship practice.
Cancer is predominantly a disease of aging, and the growing population of older adults, combined with improved survival across many cancer types, will continue to drive increases in the number of survivors. Traditional models of survivorship care — ranging from discharging patients back to primary care clinicians with limited specialist involvement to the increasingly untenable practice of retaining patients indefinitely within oncology clinics — are insufficient to meet the complexity of survivors’ needs or the scale of the growing survivor population.
As in many areas of medical specialization, cancer survivors have unique health concerns that are best addressed by clinicians with focused expertise in survivorship care. Survivors face risks and challenges beyond cancer recurrence, including late and long-term treatment effects, secondary malignancies, psychosocial concerns, functional decline and complex health promotion needs. Effective management requires familiarity with evolving treatment paradigms, surveillance recommendations, cancer genetics and specialized survivorship resources that may not be readily available to clinicians who do not routinely care for this population.
APP-led and APP-staffed survivorship programs offer a scalable and sustainable model for meeting growing demand while ensuring survivors have access to clinicians with the expertise and resources needed to optimize long-term health and well-being.
Rebekah Branco. Senior Director of Cancer Services at Montefiore Einstein Comprehensive Cancer Center (New York City): At Montefiore Einstein Comprehensive Cancer Center, we are proud to support our patients during each stage of their cancer journey. Just as our scientists enable us to evolve our treatment options, our Survivorship Program continues to lead the way in ensuring we’re meeting each patient’s current and future needs.
Today, as our patients transition away from active treatment and back to their lives, our multidisciplinary team has expanded to include APPs, social workers, dietitians, psychiatry, rehab medicine, gynecologic care, oncofertility experts and more.
We’ve also created a nurse practitioner-driven Survivorship Clinic that is separate from all other clinical areas. From the moment patients enter this serene space, decorated with calming décor, we are aiming to both physically and mentally move them to a new phase of care. In this setting we move beyond active surveillance to comprehensive post-cancer treatment support. This includes streamlined referrals to services such as cardio-oncology to ensure we’re monitoring for late treatment effects. There is also cancer rehabilitation to focus on overall health and wellness, as well as manage any chronic pain resulting from cancer treatment.
The end of active cancer cannot be the end of caring for the “whole person.” Our survivorship mission is to bring every patient at least back to the physical and emotional status they enjoyed before their cancer diagnosis. On the road to wellness, there are many paths — at MECCC, we’re continuing to lay the groundwork to make each easier to cross.
Rondeep Brar, MD. Chief Medical Officer of Cancer Care at Stanford Medicine and the Ann and John Doerr Medical Director of the Stanford Cancer Center (Palo Alto, Calif.): Since 2017, Stanford has implemented a patient-centered, clinically integrated survivorship care model embedded within disease-specific clinical care programs. Advanced practice providers play a central role in delivering survivorship care and have received specialized training to develop the competencies required for survivorship visits. More recently, oncology nurse navigators have been increasingly integrated into this model, enhancing care coordination, patient education, and support across transitions in care.
Rather than using fixed transition points for discharge to primary care, Stanford employs a flexible approach tailored to individual patient needs, treatment complexity and available local resources. This approach is further strengthened by a growing emphasis on partnerships with primary care providers, supporting co-management and ensuring continuity of care as survivors transition beyond active treatment. This model recognizes the diverse circumstances of survivors, including the large number of patients who travel considerable distances to access specialized cancer care at Stanford.
Erica Doubleday, NP. Director of Advanced Practice Providers for the Cancer Service Line at Ochsner MD Anderson Cancer Center (New Orleans): At Ochsner MD Anderson Cancer Center, our survivorship model is evolving to reflect both the growing population of cancer survivors and the need for more coordinated, longitudinal care. We have expanded the role of advanced practice providers in leading survivorship visits, developing individualized care plans and serving as a consistent point of contact as patients transition out of active oncology treatment.
Our model emphasizes multidisciplinary collaboration — integrating oncology, primary care, behavioral health and supportive services — to address not only surveillance, but also the long-term physical and psychosocial effects of cancer. We are increasingly standardizing survivorship care plans, embedding symptom management and psychosocial support, and strengthening collaboration with cardio-oncology, integrative oncology, women’s wellness and more to ensure long-term follow-up is both accessible and comprehensive.
One of our key learnings has been the importance of maintaining timely access while avoiding fragmentation. Dedicated survivorship pathways, often APP-led, allow oncologists to focus on active treatment while ensuring survivors have consistent, relationship-driven follow-up. Clear communication and shared care models are critical to continuity, particularly as patient needs shift from disease management to prevention and quality of life.
From a patient experience standpoint, survivors value clarity, accessibility and continuity. Programs that emphasize education, navigation support, and proactive symptom management have been most effective in sustaining satisfaction and engagement throughout the transition beyond active oncology care.
Michelle Gulbrandson, MSN, APRN. Manager of Advanced Practice Providers – Oncology at Nebraska Medicine’s Fred & Pamela Buffett Cancer Center (Omaha): At the Fred & Pamela Buffett Cancer Center, we are actively transitioning survivorship care back to the advanced practice providers on the disease-based teams. We believe this model supports a more seamless, longitudinal approach to survivorship discussions, allowing these conversations to occur naturally across the continuum of care. By leveraging the established relationships between patients and their provider teams, we anticipate improved engagement, trust and overall patient experience. In parallel, we are strengthening our partnership with primary care colleagues to support a more shared management of survivorship needs, with ongoing guidance from our oncology teams to ensure continuity, quality and coordination of care.
Blake Herring, MSN, RN. Associate Chief Service Lines for Cancer Services at UVA Comprehensive Cancer Center (Charlottesville, Va.): At UVA Health, we are working hard to strengthen our survivorship program, and we believe survivorship starts at diagnosis, not when treatment ends. We want to help patients find a “new normal” after cancer by not just surveillance and recurrence monitoring, but also the physical, emotional, psychosocial and financial effects of their cancer journey.
To facilitate this growing population, we are expanding the role of our APPs, nurse navigators and multidisciplinary supportive care teams in post-treatment survivorship care. One of the biggest lessons we are learning is that survivors still need a strong connection with their oncology team, even as they transition away from active treatment. The success of this approach is dependent on clear care plans, strong collaboration between oncology and primary care and patients knowing where to turn when new concerns arise. When done well, that will help to improve access for new patients entering the system, as well as continuity, patient satisfaction and confidence through the survivorship journey.
Melinda Hsu, MD. Medical Oncologist and Director of Survivorship at University Hospitals Seidman Cancer Center (Cleveland): As the population of cancer survivors grows, thanks to advances in screening and therapies, there are a variety of unmet needs across multiple domains of survivorship care that we have identified. A multidisciplinary approach to improving the quality of life of our survivors of cancer continues to be the backbone of our survivorship model. At University Hospitals Seidman Cancer Center, we are expanding collaborations to meet our survivors where they are in their cancer journey, while building toward a risk-stratified model of survivorship care.
Dori Klemanski, DNP, APRN. Chief of Advanced Practice Providers at The Ohio State University Comprehensive Cancer Center — Arthur G. James Cancer Hospital and Richard J. Solove Research Institute (Columbus): APPs have been a central component of survivorship care from the beginning. Their role remains a tenet of care, whether in treatment clinics discussing care plans or embedded within survivorship clinics.
At our institution, APPs are integral from providing survivorship care during and after treatment with APP-led clinics in survivorship, psychiatric oncology care, oncofertility and sexual health, and working in tandem with physicians in palliative care. They provide holistic care addressing ongoing sequelae and psychosocial care by connecting survivors to cancer rehabilitation, counseling, art and music therapy, support groups, peer mentorship and supportive classes. The survivor’s wellbeing is the sole focus of this team.
Zoe Larned, MD. Director of Ochsner MD Anderson Cancer Center and System Chair of Hematology/Oncology at Ochsner Health (New Orleans): At Ochsner MD Anderson Cancer Center, we have been intentional in developing survivorship care models that are proactive, multidisciplinary and continuously evolving to meet the needs of cancer survivors across varied diagnoses, demographics and regions. These models have allowed us to maintain access to care for our patients during active treatment and in the years beyond.
APP-led survivorship clinics have been critical in supporting this growing population of survivors. These providers focus on subspecialty expertise to monitor and manage any late or chronic side effects, coordinate follow-up care based on national surveillance guidelines and manage referrals and communication with the patient’s primary care physician.
Integrative care providers are another essential element of our survivorship care models, helping us address needs beyond traditional medical care and support patients living well beyond their cancer diagnoses. They offer services and tools such as acupuncture, yoga, tai chi, massage and mindfulness. We have also embedded primary care physicians in our clinics to assist with early identification of support needs while patients are on active treatment, allowing us to bridge them more safely into survivorship. Our teams also include nutritionists, patient care navigators, psychologists, social workers and other staff resources to support the patient through their care needs.
Our supportive care model is also designed to reach patients equitably, regardless of distance, income or access to local resources. Patients who live far from our cancer centers or who have demanding work schedules can access virtual care services and digital home monitoring support. Telehealth visits with APPs, integrative care providers, nutritionists, psychologists and social workers allow patients to receive high-quality supportive care without the burden of travel, missed work or transportation costs. These tools help us identify concerns early and intervene before issues escalate.
Overall, our survivorship models continue to evolve and innovate as we meet the long-term support needs of our patients during this exciting time in oncology.
Ashley Martinez, PhD, DNP, APRN. Director of Advanced Practice Programs at University of Texas MD Anderson Cancer Center (Houston): Our survivorship model is evolving rapidly as survival rates improve, with exponential growth even just over the past three years. We are seeing a steady rise in initial survivorship visits, driven by patients who are increasingly seeking cancer-specific survivorship care and guidance beyond active treatment.
To meet this demand, we are expanding survivorship services across our Houston-area community locations. This helps patients transition more easily while staying connected to a coordinated care model closer to home.
Operationally, a key focus has been standardizing how we identify patients ready for survivorship. We implemented a survivorship indicator in the EHR that flags eligible patients and aligns them with the appropriate cancer-specific survivorship program, improving consistency and reducing missed referrals. In parallel, we developed cancer-specific eligibility registries that will eventually allow proactive tracking and support timely transitions into survivorship pathways.
We now support more than 20,000 survivorship-related patient encounters annually, which has required expanding the roles of APPs, nurses and multidisciplinary teams. These team-based approaches have been essential in maintaining access while ensuring high-quality, consistent care.
What we have learned is that continuity and patient satisfaction depend on intentional design. Clear eligibility criteria, embedded workflows and community-based access points create a more seamless transition. Survivorship is no longer a handoff, but a continuation of comprehensive oncology care.
Lindsay Peterson, MD. Medical Oncologist at WashU Medicine and Start Strong Survivorship Program Director at Siteman Cancer Center (St. Louis): At Siteman Cancer Center, survivorship care is an integrated, team-based model that begins at the time of diagnosis. Through our START Strong program, physicians and APPs partner with oncology-trained physical therapists and registered dietitians, with referrals to social work and psychology as needed, to proactively address fatigue, physical function, nutrition, emotional well-being and healthy lifestyle behaviors.
One of our biggest lessons has been that survivors value continuity and connection. Rather than feeling “graduated” from oncology care, patients benefit from a gradual transition in which roles are clearly defined and survivorship principles are introduced early. Expanding the role of APPs and multidisciplinary providers has improved access and scalability while maintaining high patient satisfaction by ensuring survivors continue to feel supported, heard and connected to their cancer care team as their needs evolve.
Johnny Rollins, MSN, APRN. Associate Director of Advanced Practice, Survivorship at University of Texas MD Anderson Cancer Center (Houston): I’d like to specifically comment on how data has helped us to expand survivorship care regarding adding APP positions, services and clinics.
Eligibility registries have helped us gather the data necessary to provide additional clinic space and increased APP positions. Over the last year, we have successfully opened or expanded 17 survivorship clinics. During the same time frame, we have supported the departments with justification to add five full-time APP positions dedicated to survivorship.
We continue to see about 1,600 patients every 90 days that meet criteria for transition to a disease-specific survivorship clinic. That alone justifies two full-time APP positions and two clinics operating Monday through Friday, and that is based on only 90 days of data. We are predicting 5,000-plus patients over the next 12 months that could possibly be transitioned to a survivorship clinic.
Angela Usher, PhD. Manager of Supportive Oncology at UC Davis Comprehensive Cancer Center (Sacramento, Calif.): As survival rates improve, our survivorship model has evolved to focus not only on surveillance and follow-up care, but also on optimizing quality of life, health behaviors and recovery after treatment. We have found that survivors are highly motivated to improve their health, address treatment-related side effects and restore physical functioning.
Our Survivorship Clinic utilizes an interdisciplinary model in which patients receive coordinated care from multiple specialists during a single visit. In addition to medical follow-up from an experienced APP, patients may be seen by a registered dietitian, physical therapist, licensed clinical social worker and certified sexual health therapist and RN navigator. Together, the team addresses nutrition, physical reconditioning, lymphedema prevention, psychosocial concerns, fear of recurrence, fatigue, sexual health and survivorship care planning.
One of our most important lessons has been that access and patient satisfaction improve when supportive services are integrated into survivorship care rather than delivered through multiple referrals. By providing coordinated, team-based care, we reduce barriers, improve continuity and help survivors navigate the transition from active treatment with greater confidence.
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