Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Overview of cancer survivorship care for primary care and oncology providers

Larissa Nekhlyudov, MD, MPH
Claire Snyder, PhD
Section Editor
Patricia A Ganz, MD
Deputy Editor
Sadhna R Vora, MD


The term "cancer survivor" has been used variably in the literature; most commonly, a cancer survivor refers to any person who has been diagnosed with cancer. Therefore, survivorship begins at the time of diagnosis and includes the periods of initial treatment with intent to cure, cancer-free survival, chronic or intermittent disease, and end of life care [1].

There are now over 15 million cancer survivors in the United States [2] and 32 million survivors worldwide [3]. This number is expected to grow due to improvements in cancer screening [4], increases in life expectancy following definitive cancer treatment [4,5], and the aging of the population [6,7].

Many studies report that cancer survivors often do not receive the appropriate oncology and primary care services, with evidence of overuse [8-11] and underuse of services [8,9,11-17]. For cancer survivors who are no longer in active treatment, health care needs include surveillance for recurrence, screening for the development of secondary cancers, monitoring and intervention for the long-term and late physical and psychologic effects of cancer and its treatment, management of comorbid medical conditions, as well as routine preventive and primary care. Unfortunately, there are few data available on how to best provide oncology and primary care in a coordinated and comprehensive fashion.

In this topic, we provide a broad overview of cancer survivorship care and address ways to enhance the care for cancer survivors. For this review, we will concentrate on the care of patients who have completed treatment with curative intent. A discussion on specific issues in cancer survivorship and topics related to patients with a specific diagnosis is addressed separately. Links to relevant topics are found at the end of this topic. (See 'Further cancer survivorship information' below.)


The number of individuals diagnosed with cancer has increased dramatically from approximately 3 million in the 1970s to over 15 million in 2016 [2,18]. The majority of survivors were diagnosed more than five years ago with 33, 23, 16, and 28 percent diagnosed 0 to <5, 5 to <10, 10 to <15, and 15 or more years previously [2].


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Aug 2017. | This topic last updated: Sep 13, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Hewitt, M, Greenfield, S, Stovall, E, et al. From cancer patient to cancer survivor: Lost in transition. (National Academies Press, Washington DC), 2006 http://www.iom.edu/Reports/2005/From-Cancer-Patient-to-Cancer-Survivor-Lost-in-Transition.aspx (Accessed on January 31, 2011).
  2. American Cancer Society. Cancer Treatment & Survivorship Facts & Figures, 2016-2017. American Cancer Society; Atlanta, GA 2016.
  3. Centers for Disease Control and Prevention (2015). Global Cancer Statistics. Available from: https://www.cdc.gov/cancer/international/statistics.htm (Accessed on April 13, 2017).
  4. Berry DA, Cronin KA, Plevritis SK, et al. Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med 2005; 353:1784.
  5. American Cancer Society. Cancer Treatment and Survivorship Facts & Figures 2012-2013. American Cancer Society; Atlanta, GA 2012.
  6. Smith BD, Smith GL, Hurria A, et al. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol 2009; 27:2758.
  7. Bluethmann SM, Mariotto AB, Rowland JH. Anticipating the "Silver Tsunami": Prevalence Trajectories and Comorbidity Burden among Older Cancer Survivors in the United States. Cancer Epidemiol Biomarkers Prev 2016; 25:1029.
  8. Elston Lafata J, Simpkins J, Schultz L, et al. Routine surveillance care after cancer treatment with curative intent. Med Care 2005; 43:592.
  9. Salloum RG, Hornbrook MC, Fishman PA, et al. Adherence to surveillance care guidelines after breast and colorectal cancer treatment with curative intent. Cancer 2012; 118:5644.
  10. Keating NL, Landrum MB, Guadagnoli E, et al. Surveillance testing among survivors of early-stage breast cancer. J Clin Oncol 2007; 25:1074.
  11. Cooper GS, Kou TD, Reynolds HL Jr. Receipt of guideline-recommended follow-up in older colorectal cancer survivors : a population-based analysis. Cancer 2008; 113:2029.
  12. Snyder CF, Earle CC, Herbert RJ, et al. Preventive care for colorectal cancer survivors: a 5-year longitudinal study. J Clin Oncol 2008; 26:1073.
  13. Snyder CF, Earle CC, Herbert RJ, et al. Trends in follow-up and preventive care for colorectal cancer survivors. J Gen Intern Med 2008; 23:254.
  14. Snyder CF, Frick KD, Kantsiper ME, et al. Prevention, screening, and surveillance care for breast cancer survivors compared with controls: changes from 1998 to 2002. J Clin Oncol 2009; 27:1054.
  15. Snyder CF, Frick KD, Peairs KS, et al. Comparing care for breast cancer survivors to non-cancer controls: a five-year longitudinal study. J Gen Intern Med 2009; 24:469.
  16. Snyder CF, Frick KD, Herbert RJ, et al. Preventive care in prostate cancer patients: following diagnosis and for five-year survivors. J Cancer Surviv 2011; 5:283.
  17. Keating NL, Landrum MB, Guadagnoli E, et al. Factors related to underuse of surveillance mammography among breast cancer survivors. J Clin Oncol 2006; 24:85.
  18. DeSantis CE, Lin CC, Mariotto AB, et al. Cancer treatment and survivorship statistics, 2014. CA Cancer J Clin 2014; 64:252.
  19. Ward E, DeSantis C, Robbins A, et al. Childhood and adolescent cancer statistics, 2014. CA Cancer J Clin 2014; 64:83.
  20. Doubeni CA, Field TS, Ulcickas Yood M, et al. Patterns and predictors of mammography utilization among breast cancer survivors. Cancer 2006; 106:2482.
  21. Grunfeld E, Hodgson DC, Del Giudice ME, Moineddin R. Population-based longitudinal study of follow-up care for breast cancer survivors. J Oncol Pract 2010; 6:174.
  22. Potosky AL, Han PK, Rowland J, et al. Differences between primary care physicians' and oncologists' knowledge, attitudes and practices regarding the care of cancer survivors. J Gen Intern Med 2011; 26:1403.
  23. Travis LB, Bhatia S, Allan JM, et al.. Second Primary Cancers. In: DeVita, Hellman, and Rosenberg's Cancer: Principles and Practice of Oncology, 9th, DePinho RA, Lawrence TS, Rosenberg SA, Weinberg RA (Eds), Lippincott Williams & Wilkins, Philadelphia 2011. p.2393-2410.
  24. Wood ME, Vogel V, Ng A, et al. Second malignant neoplasms: assessment and strategies for risk reduction. J Clin Oncol 2012; 30:3734.
  25. Henderson TO, Moskowitz CS, Chou JF, et al. Breast Cancer Risk in Childhood Cancer Survivors Without a History of Chest Radiotherapy: A Report From the Childhood Cancer Survivor Study. J Clin Oncol 2016; 34:910.
  26. Turcotte LM, Liu Q, Yasui Y, et al. Temporal Trends in Treatment and Subsequent Neoplasm Risk Among 5-Year Survivors of Childhood Cancer, 1970-2015. JAMA 2017; 317:814.
  27. Ng AK, Bernardo MP, Weller E, et al. Long-term survival and competing causes of death in patients with early-stage Hodgkin's disease treated at age 50 or younger. J Clin Oncol 2002; 20:2101.
  28. Aleman BM, van den Belt-Dusebout AW, Klokman WJ, et al. Long-term cause-specific mortality of patients treated for Hodgkin's disease. J Clin Oncol 2003; 21:3431.
  29. Chuang SC, Scelo G, Tonita JM, et al. Risk of second primary cancer among patients with head and neck cancers: A pooled analysis of 13 cancer registries. Int J Cancer 2008; 123:2390.
  30. Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 2007; 57:75.
  31. Children's Oncology Group: Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancer. Version 4.0, October 2013. http://www.survivorshipguidelines.org/pdf/LTFUGuidelines_40.pdf (Accessed on April 13, 2017).
  32. Oeffinger KC, Ford JS, Moskowitz CS, et al. Breast cancer surveillance practices among women previously treated with chest radiation for a childhood cancer. JAMA 2009; 301:404.
  33. Armstrong GT, Chen Y, Yasui Y, et al. Reduction in Late Mortality among 5-Year Survivors of Childhood Cancer. N Engl J Med 2016; 374:833.
  34. Children's Oncology Group. Long-term follow-up guidelines for survivors of childhood, adolescent and young adult cancers. Version 4.0, Children's Oncology Group; Arcadia, CA 2008.
  35. Bhatia S. Role of genetic susceptibility in development of treatment-related adverse outcomes in cancer survivors. Cancer Epidemiol Biomarkers Prev 2011; 20:2048.
  36. Yahalom J, Portlock CS. Toxicity. In: DeVita, Hellman, and Rosenberg's Cancer: Principles & Practice of Oncology, 9th, DePinho RA, Lawrence TS, Rosenberg SA, Weinberg RA (Eds), Lippincott Williams and Wilkins, Philadelphia 2011. p.2360-2368.
  37. Norian JM, Feinberg EC, DeCherney AH, Armstrong AY. Gonadal Dysfunction. In: De Vita, Hellman, and Rosenberg's Cancer: Principles & Practice of Oncology, 9th, DePinho RA, Lawrence TS, Rosenberg SA, Weinberg RA (Eds), Lippincott Williams & Wilkins, Philadelphia 2011. p.2372-2387.
  38. Stubblefield MD. Rehabilitation of the Cancer Patient. In: DeVita, Hellman, and Rosenberg's Cancer: Principles and Practice of Oncology, 9th, DePinho RA, Lawrence TS, Rosenberg SA, Weinberg RA (Eds), Lippincott Williams & Wilkins, Philadelphia 2011. p.2503-2509.
  39. Ruddy KJ, Partridge AH. Fertility (male and female) and menopause. J Clin Oncol 2012; 30:3705.
  40. Pachman DR, Barton DL, Swetz KM, Loprinzi CL. Troublesome symptoms in cancer survivors: fatigue, insomnia, neuropathy, and pain. J Clin Oncol 2012; 30:3687.
  41. Lenihan DJ, Cardinale DM. Late cardiac effects of cancer treatment. J Clin Oncol 2012; 30:3657.
  42. Bhakta N, Liu Q, Ness KK, et al. The cumulative burden of surviving childhood cancer: an initial report from the St Jude Lifetime Cohort Study (SJLIFE). Lancet 2017.
  43. Armenian SH, Xu L, Ky B, et al. Cardiovascular Disease Among Survivors of Adult-Onset Cancer: A Community-Based Retrospective Cohort Study. J Clin Oncol 2016; 34:1122.
  44. Mulrooney DA, Armstrong GT, Huang S, et al. Cardiac Outcomes in Adult Survivors of Childhood Cancer Exposed to Cardiotoxic Therapy: A Cross-sectional Study. Ann Intern Med 2016; 164:93.
  45. Ganz PA. Survivorship: adult cancer survivors. Prim Care 2009; 36:721.
  46. Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. JAMA 1995; 273:1450.
  47. Jessup M, Abraham WT, Casey DE, et al. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009; 119:1977.
  48. Nekhlyudov L, Aziz NM, Lerro C, Virgo KS. Oncologists' and primary care physicians' awareness of late and long-term effects of chemotherapy: implications for care of the growing population of survivors. J Oncol Pract 2014; 10:e29.
  49. Harrington CB, Hansen JA, Moskowitz M, et al. It's not over when it's over: long-term symptoms in cancer survivors--a systematic review. Int J Psychiatry Med 2010; 40:163.
  50. Brown LF, Kroenke K. Cancer-related fatigue and its associations with depression and anxiety: a systematic review. Psychosomatics 2009; 50:440.
  51. Institute of Medicine of the National Academies Board on Health Care Services. Cancer care for the whole patient: meeting psychosocial health needs. The National Academies Press; Washington, D.C., 2007.
  52. Foster C, Wright D, Hill H, et al. Psychosocial implications of living 5 years or more following a cancer diagnosis: a systematic review of the research evidence. Eur J Cancer Care (Engl) 2009; 18:223.
  53. Stanton AL. What happens now? Psychosocial care for cancer survivors after medical treatment completion. J Clin Oncol 2012; 30:1215.
  54. Carlson LE, Waller A, Mitchell AJ. Screening for distress and unmet needs in patients with cancer: review and recommendations. J Clin Oncol 2012; 30:1160.
  55. Jacobsen PB, Holland JC, Steensma DP. Caring for the whole patient: the science of psychosocial care. J Clin Oncol 2012; 30:1151.
  56. Weaver KE, Forsythe LP, Reeve BB, et al. Mental and physical health-related quality of life among U.S. cancer survivors: population estimates from the 2010 National Health Interview Survey. Cancer Epidemiol Biomarkers Prev 2012; 21:2108.
  57. Craft LL, Vaniterson EH, Helenowski IB, et al. Exercise effects on depressive symptoms in cancer survivors: a systematic review and meta-analysis. Cancer Epidemiol Biomarkers Prev 2012; 21:3.
  58. Mishra SI, Scherer RW, Snyder C, et al. Are exercise programs effective for improving health-related quality of life among cancer survivors? A systematic review and meta-analysis. Oncol Nurs Forum 2014; 41:E326.
  59. Yabroff KR, Dowling EC, Guy GP Jr, et al. Financial Hardship Associated With Cancer in the United States: Findings From a Population-Based Sample of Adult Cancer Survivors. J Clin Oncol 2016; 34:259.
  60. Zafar SY, Abernethy AP. Financial toxicity, Part I: a new name for a growing problem. Oncology (Williston Park) 2013; 27:80.
  61. Zafar SY, Abernethy AP. Financial toxicity, Part II: how can we help with the burden of treatment-related costs? Oncology (Williston Park) 2013; 27:253.
  62. Guy GP Jr, Ekwueme DU, Yabroff KR, et al. Economic burden of cancer survivorship among adults in the United States. J Clin Oncol 2013; 31:3749.
  63. Ekwueme DU, Yabroff KR, Guy GP Jr, et al. Medical costs and productivity losses of cancer survivors--United States, 2008-2011. MMWR Morb Mortal Wkly Rep 2014; 63:505.
  64. Azzani M, Roslani AC, Su TT. The perceived cancer-related financial hardship among patients and their families: a systematic review. Support Care Cancer 2015; 23:889.
  65. Narang AK, Nicholas LH. Out-of-Pocket Spending and Financial Burden Among Medicare Beneficiaries With Cancer. JAMA Oncol 2016.
  66. Chang S, Long SR, Kutikova L, et al. Estimating the cost of cancer: results on the basis of claims data analyses for cancer patients diagnosed with seven types of cancer during 1999 to 2000. J Clin Oncol 2004; 22:3524.
  67. Meropol NJ, Schulman KA. Cost of cancer care: issues and implications. J Clin Oncol 2007; 25:180.
  68. Langa KM, Fendrick AM, Chernew ME, et al. Out-of-pocket health-care expenditures among older Americans with cancer. Value Health 2004; 7:186.
  69. The USA Today/Kaiser Family Foundation/Harvard School of Public Health. National Survey of Households Affected by Cancer. 2006
  70. Himmelstein DU, Warren E, Thorne D, Woolhandler S. Illness and injury as contributors to bankruptcy. Health Aff (Millwood) 2005; Suppl Web Exclusives:W5.
  71. Weaver KE, Rowland JH, Bellizzi KM, Aziz NM. Forgoing medical care because of cost: assessing disparities in healthcare access among cancer survivors living in the United States. Cancer 2010; 116:3493.
  72. Nekhlyudov L, Madden J, Graves AJ, et al. Cost-related medication nonadherence and cost-saving strategies used by elderly Medicare cancer survivors. J Cancer Surviv 2011; 5:395.
  73. Ramsey S, Blough D, Kirchhoff A, et al. Washington State cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis. Health Aff (Millwood) 2013; 32:1143.
  74. Underwood JM, Townsend JS, Stewart SL, et al. Surveillance of demographic characteristics and health behaviors among adult cancer survivors--Behavioral Risk Factor Surveillance System, United States, 2009. MMWR Surveill Summ 2012; 61:1.
  75. Earle CC, Neville BA. Under use of necessary care among cancer survivors. Cancer 2004; 101:1712.
  76. Yu X, McBean AM, Virnig BA. Physician visits, patient comorbidities, and mammography use among elderly colorectal cancer survivors. J Cancer Surviv 2007; 1:275.
  77. Duffy CM, Clark MA, Allsworth JE. Health maintenance and screening in breast cancer survivors in the United States. Cancer Detect Prev 2006; 30:52.
  78. Snyder CF, Frick KD, Herbert RJ, et al. Quality of care for comorbid conditions during the transition to survivorship: differences between cancer survivors and noncancer controls. J Clin Oncol 2013; 31:1140.
  79. Moyer VA, U.S. Preventive Services Task Force. Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2012; 157:373.
  80. Centers for Disease Control and Prevention, National Center for Health Statistics. National Health Interview Survey, 1992–2015. https://progressreport.cancer.gov/after/obesity (Accessed on April 13, 2017).
  81. Klosky JL, Tyc VL, Garces-Webb DM, et al. Emerging issues in smoking among adolescent and adult cancer survivors: a comprehensive review. Cancer 2007; 110:2408.
  82. Mariotto AB, Rowland JH, Ries LA, et al. Multiple cancer prevalence: a growing challenge in long-term survivorship. Cancer Epidemiol Biomarkers Prev 2007; 16:566.
  83. U.S. Preventive Services Task Force. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med 2009; 150:551.
  84. Demark-Wahnefried W, Pinto BM, Gritz ER. Promoting health and physical function among cancer survivors: potential for prevention and questions that remain. J Clin Oncol 2006; 24:5125.
  85. Doyle C, Kushi LH, Byers T, et al. Nutrition and physical activity during and after cancer treatment: an American Cancer Society guide for informed choices. CA Cancer J Clin 2006; 56:323.
  86. Alcohol use and cancer. http://www.cancer.org/cancer/cancercauses/dietandphysicalactivity/alcohol-use-and-cancer (Accessed on March 06, 2013).
  87. Yabroff KR, Lawrence WF, Clauser S, et al. Burden of illness in cancer survivors: findings from a population-based national sample. J Natl Cancer Inst 2004; 96:1322.
  88. Barone BB, Yeh HC, Snyder CF, et al. Long-term all-cause mortality in cancer patients with preexisting diabetes mellitus: a systematic review and meta-analysis. JAMA 2008; 300:2754.
  89. Yancik R, Wesley MN, Ries LA, et al. Effect of age and comorbidity in postmenopausal breast cancer patients aged 55 years and older. JAMA 2001; 285:885.
  90. Wu AH, Kurian AW, Kwan ML, et al. Diabetes and other comorbidities in breast cancer survival by race/ethnicity: the California Breast Cancer Survivorship Consortium (CBCSC). Cancer Epidemiol Biomarkers Prev 2015; 24:361.
  91. Armenian SH, Bhatia S. Chronic health conditions in childhood cancer survivors: is it all treatment-related--or do genetics play a role? J Gen Intern Med 2009; 24 Suppl 2:S395.
  92. Halpern MT, Viswanathan M, Evans TS, et al. Models of Cancer Survivorship Care: Overview and Summary of Current Evidence. J Oncol Pract 2015; 11:e19.
  93. Nekhlyudov L, O'malley DM, Hudson SV. Integrating primary care providers in the care of cancer survivors: gaps in evidence and future opportunities. Lancet Oncol 2017; 18:e30.
  94. Nekhlyudov L, Lacchetti C, Davis NB, et al. Head and Neck Cancer Survivorship Care Guideline: American Society of Clinical Oncology Clinical Practice Guideline Endorsement of the American Cancer Society Guideline. J Clin Oncol 2017; 35:1606.
  95. Alfano CM, Ganz PA, Rowland JH, Hahn EE. Cancer survivorship and cancer rehabilitation: revitalizing the link. J Clin Oncol 2012; 30:904.
  96. Earle CC, Burstein HJ, Winer EP, Weeks JC. Quality of non-breast cancer health maintenance among elderly breast cancer survivors. J Clin Oncol 2003; 21:1447.
  97. Khan NF, Carpenter L, Watson E, Rose PW. Cancer screening and preventative care among long-term cancer survivors in the United Kingdom. Br J Cancer 2010; 102:1085.
  98. Snyder CF, Frick KD, Herbert RJ, et al. Comorbid condition care quality in cancer survivors: role of primary care and specialty providers and care coordination. J Cancer Surviv 2015; 9:641.
  99. Cheung WY, Neville BA, Cameron DB, et al. Comparisons of patient and physician expectations for cancer survivorship care. J Clin Oncol 2009; 27:2489.
  100. Kantsiper M, McDonald EL, Geller G, et al. Transitioning to breast cancer survivorship: perspectives of patients, cancer specialists, and primary care providers. J Gen Intern Med 2009; 24 Suppl 2:S459.
  101. Bober SL, Recklitis CJ, Campbell EG, et al. Caring for cancer survivors: a survey of primary care physicians. Cancer 2009; 115:4409.
  102. Mayer DK, Nekhlyudov L, Snyder CF, et al. American Society of Clinical Oncology clinical expert statement on cancer survivorship care planning. J Oncol Pract 2014; 10:345.
  103. Runowicz CD, Leach CR, Henry NL, et al. American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline. J Clin Oncol 2016; 34:611.
  104. Meyerhardt JA, Mangu PB, Flynn PJ, et al. Follow-up care, surveillance protocol, and secondary prevention measures for survivors of colorectal cancer: American Society of Clinical Oncology clinical practice guideline endorsement. J Clin Oncol 2013; 31:4465.
  105. El-Shami K, Oeffinger KC, Erb NL, et al. American Cancer Society Colorectal Cancer Survivorship Care Guidelines. CA Cancer J Clin 2015; 65:428.
  106. Skolarus TA, Wolf AM, Erb NL, et al. American Cancer Society prostate cancer survivorship care guidelines. CA Cancer J Clin 2014; 64:225.
  107. Resnick MJ, Lacchetti C, Bergman J, et al. Prostate cancer survivorship care guideline: American Society of Clinical Oncology Clinical Practice Guideline endorsement. J Clin Oncol 2015; 33:1078.
  108. Cohen EE, LaMonte SJ, Erb NL, et al. American Cancer Society Head and Neck Cancer Survivorship Care Guideline. CA Cancer J Clin 2016; 66:203.
  109. Majhail NS, Rizzo JD, Lee SJ, et al. Recommended screening and preventive practices for long-term survivors after hematopoietic cell transplantation. Hematol Oncol Stem Cell Ther 2012; 5:1.