Sustained Living: An JAMA-Aligned Psychosocial and Impairment-Driven Rehabilitation Model for Adult Oncology

Background: We provide a clinic-ready synthesis of psychosocial determinants in cancer care and operationalize a Sustained Living framework integrated with Lifelong Rehabilitation for routine practice. Methods: We conducted a narrative review emphasizing pragmatic evidence from guidelines and randomized or observational studies on distress screening (Distress Thermometer), brief mood measures (PHQ-4, HADS), patient-reported outcomes (EORTC QLQ-C30, PROMIS), financial toxicity (COST), rehabilitation and exercise, meaning-centered and dignity therapies, caregiver interventions, and electronic symptom monitoring. Themes were mapped to ethical principles: dignity, autonomy, and justice and translated into implementable ambulatory workflows with explicit thresholds, reassessment cadence (4–8 weeks), and role-based referrals. Findings: Distress is common and actionable; threshold-based screening (e.g., DT ≥4) supports stepped assessment and matched referral to psychology, rehabilitation, and navigation. Early multimodal psychosocial and rehabilitation interventions improve quality of life, reduce depression, and sustain participation. PRO-anchored monitoring lowers emergency use and may extend survival. Financial toxicity is measurable with COST and mitigable through benefits counseling and navigation. Figures and tables provide a triage algorithm, an impairment-driven rehabilitation pathway, core PRO domains/measures/actions, and a financial-toxicity toolkit to support rapid adoption in routine clinics. Implications for Practice: Embedding structured screening, targeted referral, and PRO-informed follow-up as standard work enables ambulatory oncology teams to deliver equitable, value-based care while centering dignity, autonomy, and functional recovery. The Sustained Living paradigm reframes advanced cancer care around living-normalizing rehabilitation, goal setting, and social reintegration from diagnosis through end of life, and aligning practice with what patients value most. We prioritized validated tools and high‑impact guidance for feasibility and implementation.