OnCo
ideasIdea

Risk-stratified lifelong care for tens of millions of survivors, automated and shared with primary care

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.

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.

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.
What would test it
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
Who has to act
policy
Cost to try
Medium ($1M to $50M)
Years to first evidence
4
Bottlenecks it attacks

Connected

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