Many assumptions around patient needs and support guide current oncology practice and cancer survivorship care in the digital era. Addressing these assumptions and providing smarter, holistic, tech-enabled follow-up models are essential for truly effective and sustainable person-centered care.

Citation: Hegarty J, Toygar I, Clara MI, Pawlowska E (2026) The cancer survivorship paradox in the digital era. PLoS Med 23(7): e1005174. https://doi.org/10.1371/journal.pmed.1005174

Published: July 27, 2026

As populations in high‑income countries grow older and cancer survival improves, the number of people living with and beyond cancer will rise markedly. A key priority is to quantify how the size and demographic and clinical profile and needs of this population will evolve over time.

Advances in treatment are both expanding survival and leading to greater long‑term needs, especially among older adults with multimorbidity, frailty, and diverse backgrounds. Children and adolescents face distinct challenges as they transition to adult care. Precision medicine adds further demands for monitoring, toxicity management, and coordinated care, while late effects can persist for decades. As specialist-led follow-up becomes less sustainable, there is growing focus on alternative survivorship models that better match care to patients’ changing needs. To ensure survivorship supportive‑care models remain evidence‑based, equitable, and responsive to the diverse and evolving needs of cancer survivors, it is crucial to critically re‑examine the assumptions underpinning current practice. Here, we address four such assumptions.

Survivorship supportive care cannot sustainably be contained or facilitated within specialist oncology services. Instead, its future lies in a shared and stratified model of care that involves multiple providers and actively engages patients as partners in their care. Survivorship supportive care must be initiated within oncology settings, yet its sustained delivery depends on a coordinated, multi‑sector model that extends well beyond specialist services. Put simply, survivors need different levels of follow‑up. Some patients can be safely supported in shared‑care models with clear escalation points, while others require more intensive specialist oversight due to higher recurrence risk, symptom burden, or treatment‑related effects. Specialist oncology teams retain a crucial role for survivors with complex treatment effects, high recurrence risk, or specialized monitoring needs, but not for every survivor indefinitely.

Across Oncokompas, eSMART, and LYSA, common barriers included clinician workload, workflow disruption, reliance on research infrastructure, and variable organizational readiness. Digital and human factors, such as uneven digital literacy, usability challenges, and the need for sustained professional engagement, further constrained reach, scalability, and sustainability, despite demonstrated clinical benefit.

Viewing cancer as a chronic illness, the chronic care model emphasizes active survivor involvement and ongoing partnerships with providers, requiring improved planning and coordination. In response, risk-stratified, shared, and integrated survivorship models, led by primary care, nursing, allied health, or hybrid teams, are emerging as more sustainable, person-centered approaches. These are supported by navigation services and digital tools, often guided by frameworks like the pyramid of care, where most survivors need low-intensity support and fewer require more specialized care.

Despite innovation, barriers limit routine adoption. The discussion in this paper reflects high-resource settings; in lower-resource contexts, challenges differ substantially, with access to basic cancer care remaining a major barrier. Even in well-resourced systems, fee-for-service models may incentivize specialist-led follow-up and reinforce inequities, while publicly funded systems may better support community-based care. Without deliberate redesign, disparities may widen, with underserved groups continuing to receive fragmented care, which remains a key issue. Oncology services often cannot meet long-term needs, and primary care may lack cancer-specific expertise; addressing this requires several system-level changes.

First, stratified care must be embedded in routine workflows. Digital tools can enable symptom monitoring, self-assessment, and risk flagging, but without interoperable data, standardized measures, and decision support, stratification remains aspirational. Evidence for the effectiveness of stratified care is still uneven, particularly around validated risk prediction tools and cost-effectiveness. This is therefore a key research priority, particularly in resource-constrained systems. For example, the National Cancer Institute has called for R01 studies (the National Institute of Health’s grant program for independent research projects) to better understand and evaluate risk‑stratified survivorship care and its impact on care quality, outcomes, and healthcare use.

Second, digital systems must support continuity and accountability across care transitions. As survivorship pathways span oncology, primary care, and community services, digital platforms can reduce loss to follow‑up through coordinated referrals, appropriate care routing, and clear accountability. These functions, however, require organizational alignment, workforce capability, and governance structures that define roles, data ownership, and escalation pathways.

Third, large-scale implementation requires policy leadership and infrastructure investment, including national pathways, aligned reimbursement, and interoperable systems. AI‑enabled decision support and stratification may improve scalability if integrated within frameworks prioritizing equity, safety and person‑centered care. Implementation barriers must be anticipated and addressed.

Overall, the promise of digital and stratified survivorship models lies not in new tools alone, but in the deliberate alignment of research findings, policy, infrastructure, and clinical practice to deliver proactive, equitable supportive care across the cancer continuum.