{"entity":{"id":"idea-moon-survivor-lifelong-care-model","kind":"idea","name":"Risk-stratified lifelong care for tens of millions of survivors, automated and shared with primary care","aka":[],"tldr":"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.","summary":"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.","asOf":"2026-09-08","links":[{"label":"Bottleneck evidence (Survivorship and late effects are neglected): NCI Office of Cancer Survivorship statistics","url":"https://cancercontrol.cancer.gov/ocs/statistics"}],"tags":[],"related":[],"cancers":[],"sections":[],"technologies":["cardio-oncology"],"targets":[],"drugs":[],"companies":[],"institutions":[],"pathways":[],"terms":[],"trials":[],"people":[],"bottlenecks":["b-survivorship","b-care-fragmentation"],"keyPapers":[],"journals":[],"dependsOn":[],"notes":[],"hypothesis":"The model maintains or improves guideline-concordant surveillance and late-effect detection while reducing oncology follow-up visits by half and improving survivor-reported unmet needs.","rationale":"Stratified follow-up trials in breast and colorectal cancer show primary care-led or patient-initiated follow-up is safe for low-risk survivors; automation and payment make it scalable.","test":"Regional implementation trial comparing the model with standard follow-up on surveillance completion, late-effect detection, visits and patient-reported outcomes over five years.","maturity":"early-clinical","actor":"policy","cost":"medium","horizonYears":4},"route":"/ideas/idea-moon-survivor-lifelong-care-model/","neighbours":{"technology":[{"id":"cardio-oncology","kind":"technology","name":"Cardio-oncology","route":"/technologies/cardio-oncology/"},{"id":"rejuv-mind-depression-after-cancer","kind":"technology","name":"Depression during and after cancer: the interview-based prevalence, and the care model that works","route":"/technologies/rejuv-mind-depression-after-cancer/"},{"id":"rejuv-mind-fear-of-recurrence","kind":"technology","name":"Fear that the cancer will come back: how common it is, and when it stops being ordinary worry","route":"/technologies/rejuv-mind-fear-of-recurrence/"},{"id":"rejuv-mind-traumatic-stress-after-cancer","kind":"technology","name":"Post-traumatic stress after cancer: what is measured, and how much of it is measurement","route":"/technologies/rejuv-mind-traumatic-stress-after-cancer/"},{"id":"rejuv-paed-transition-to-adult-care","kind":"technology","name":"The handover from children's to adult services, where follow-up falls away","route":"/technologies/rejuv-paed-transition-to-adult-care/"},{"id":"rejuv-mind-fear-of-recurrence-treatment","kind":"technology","name":"Treating fear of recurrence: the randomised trials, their effect sizes, and where the treatment is available","route":"/technologies/rejuv-mind-fear-of-recurrence-treatment/"}],"bottleneck":[{"id":"b-care-fragmentation","kind":"bottleneck","name":"Fragmented care and guideline gaps","route":"/bottlenecks/b-care-fragmentation/"},{"id":"b-survivorship","kind":"bottleneck","name":"Survivorship and late effects are neglected","route":"/bottlenecks/b-survivorship/"}],"roadmap":[{"id":"survivorship-roadmap","kind":"roadmap","name":"Supportive care and survivorship roadmap: making treatment bearable → proving it extends life → caring for tens of millions afterwards","route":"/roadmaps/survivorship-roadmap/"}]}}