Models of survivorship care

An increasing number of Australians are surviving cancer due to advances in early detection, treatment, and the aging population. There are several models of follow-up (survivorship) care, some are described below. 

Guiding frameworks 

Clinical Oncology Society of Australia (COSA) Model of Survivorship Care 

The COSA Model of Survivorship Care (2016) is a guide for quality survivorship care in Australia. In 2019 COSA released their position statement on cancer survivorship care, summarising the critical components of the model. It includes these key recommendations: 

  1. Healthcare teams should implement a multidisciplinary, systematic approach to enhance coordinated and integrated survivorship care 
  2. Personalised stratified pathways of care are required, meaning that care should be tailored based on individual needs and determined by factors such as type of cancer and treatment, current symptoms and concerns and risk of long-term and late effects 
  3. In addition to surveillance and managing treatment-related symptoms and late effects, survivorship care should support wellness, healthy lifestyle, and primary and secondary prevention 
  4. At transition to follow-up care, healthcare teams should develop a treatment summary and survivorship care plan 
  5. Survivors require equitable and timely access to services, while minimising unnecessary use of healthcare services and resources 

The principles underpinning the COSA model are that care should be: 

  1. Survivor centred, enabling individuals to participate in decision-making, engaging individuals to motivate positive health choices and empowering individuals to seek information and support 
  2. Integrated across all service levels, at every time point 
  3. Coordinated across all services 
  4. Accessible and equitable 
  5. Promote wellbeing, prevent illness and manage symptoms and problems 


Cancer Australia Principles of Survivorship Care 

Cancer Australia’s national framework provides a guide to planning, policy, and health system responses to cancer survivorship.  

It includes five key principles, which promote personalised care, self-management and health and wellbeing during and after cancer treatment: 

  1. Consumer involvement in person-centred care 
  2. Support for living well 
  3. Evidence-based care pathways 
  4. Coordinated and integrated care 
  5. Data-driven improvement and investments in research 


Optimal Care Pathways 

The Optimal Care Pathways outline specific steps and expected standards for optimal, quality cancer care in Australia. They map the patient's journey from prevention and early detection to end-of-life care. Survivorship and follow-up guidance are specifically addressed in the pathway’s fifth step: Care after initial treatment and recovery. The National Cancer Expert Reference Group, Cancer Australia and Cancer Council Australia have endorsed the Optimal Care Pathways. 



Models of care 


Mode of delivery