A Real-World Model of Multidisciplinary Survivorship Care: Clinical Pathways, Patient-Reported Outcomes, and Implementation Challenges

Abstract PURPOSE: Cancer survivorship care is increasingly recognized as a core component of oncology, yet its real-world organization remains heterogeneous. This study aimed to characterize a multidisciplinary survivorship care model and examine the structure of patient-reported survivorship needs. METHODS: We conducted a retrospective, practice-based evaluation at a tertiary academic cancer center. The analysis combined structured mapping of clinical services with quantitative assessment of routinely collected patient-reported outcomes. Survivorship concerns were assessed using the National Comprehensive Cancer Network (NCCN) Problem List, and psychological distress was measured before and after clinic visits using the NCCN Distress Thermometer. A network analysis based on smoothed tetrachoric correlations and EBICglasso was used to examine conditional associations among concerns. RESULTS: Survivorship care was delivered through coordinated multidisciplinary clinics, individualized care planning, and an integrated network of specialized services. Most patients (91.9%) reported at least one concern, with a median of five concerns per visit, spanning physical, emotional, social, practical, and spiritual domains. Distress scores decreased significantly following the clinic visit (median 4 [IQR 2–6] vs 1 [IQR 0–3], p < 0.001). Network analysis revealed structured interrelationships among concerns, with emotional issues forming a central cluster linked to physical and functional domains. Highly connected nodes included self-management, work, loneliness, and perceived burden. CONCLUSION: Survivorship care can be effectively operationalized in routine practice; however, patient needs are interconnected rather than isolated. Network-informed approaches may support more integrated and patient-centered survivorship care.