More than 18.6 million Americans—over 5 percent of the population—are living after a cancer diagnosis, yet most do not receive the coordinated survivorship care they need. The gap stems from a long‑standing communication divide between oncologists and primary‑care clinicians.
Personal story underscores the problem
Kara Kenan of North Carolina finished treatment for advanced breast cancer nearly a decade ago. A routine blood test showed an elevated alkaline phosphatase level, which her primary‑care doctor dismissed. Trusting her own experience as a cancer‑advocacy professional, Kenan pressed for a follow‑up. An oncologist ordered a CT scan that revealed liver lesions, confirming that her cancer had returned.
Why survivorship care matters
Survivorship care is designed to monitor and manage the lingering effects of treatment—immune, gastrointestinal, endocrine and neurological damage—as well as the heightened risk of new health problems. Studies show cancer survivors have a 47 percent higher rate of cardiovascular disease than people who never had cancer, and they experience more pain, insomnia and psychosocial distress.
In addition to recurrence, survivors face a significant chance of developing second or third cancers. Patricia Ganz, associate director for population‑science research at UCLA Health’s Jonsson Comprehensive Cancer Center, notes that roughly one‑fifth of the 2 million people diagnosed each year will confront additional cancers later in life.
Historical context and current shortfalls
The National Coalition for Cancer Survivorship was founded in 1986, and the National Cancer Institute’s Office of Cancer Survivorship followed a decade later. A 2006 Institute of Medicine report, From Cancer Patient to Cancer Survivor: Lost in Transition, warned that many survivors were “lost in transition” after treatment ends. Yet a systematic, nationwide solution has never materialized.
Only about one‑third of patients who completed treatment five years or more ago report receiving survivorship care, according to a 2025 survey. Of those who are not receiving follow‑up, 58 percent say their doctor told them it was no longer needed.
Barriers to effective coordination
Both oncologists and primary‑care providers often lack training in long‑term survivorship issues. Ganz explains that many family doctors admit, “I don’t know anything about that. Go back to your oncologist.” This fragmented approach leaves patients to navigate complex health needs on their own.
Alex Adjei, chief of the Cleveland Clinic Cancer Institute, argues that after successful treatment, patients should be handed off to clinicians trained to manage chronic conditions such as hypertension and diabetes. Without that handoff, “it’s a disservice,” he says.
The National Cancer Institute recommends a shared‑responsibility model: primary‑care physicians manage chronic diseases and routine cancer screening, while oncologists focus on recurrence monitoring. In practice, coordination remains rare, leading to “fragmented care,” according to Michelle Mollica, director of survivorship care delivery at Hollings Cancer Center in Charleston, South Carolina.
Survivorship care plans: promise and pitfalls
The Institute of Medicine’s report advocated for a survivorship care plan—a detailed document handed to patients and their primary‑care doctors outlining expected follow‑up, mental‑health resources, physical‑therapy needs and screening schedules. For a brief period, the Commission on Cancer required such plans, but uptake was low.
Oncologists often balk at the unpaid effort required to compile comprehensive records, and many patients never receive a usable plan. Mollica describes the result as a “checkbox” rather than a meaningful conversation.
Innovations and hopeful models
Some cancer centers are making progress. At the Cleveland Clinic, Adjei’s team is developing a system that tailors survivorship care to each patient’s specific treatment history. Programs for adolescents and young adults address fertility preservation, while other clinics identify survivors with therapy‑induced genetic damage that raises long‑term heart disease risk.
These targeted approaches demonstrate that coordinated survivorship care is feasible when institutions commit resources and prioritize communication.
What patients and families can do
Survivors should proactively request a survivorship care plan and ensure their primary‑care physician is aware of their cancer history. Families can advocate for better coordination by asking providers about long‑term monitoring and supporting organizations that push for national standards.
As the survivor population is projected to exceed 22 million by 2035, the need for robust, patient‑centered survivorship care will only grow. Bridging the communication gap between oncologists and primary‑care clinicians is essential to protect the health and well‑being of millions of Americans who have already fought cancer.
Original reporting: KRDO (Colorado Springs metro) — read the source article.
