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<p>The exponential growth of cancer survivors represents a major healthcare challenge, with more than 23 million people in Europe and 2.2 million in Spain requiring long-term specialized follow-up. Five-year survival has reached 60% in our country, creating&#xa0;a growing population of long-term survivors who need comprehensive care beyond the stage of active oncological treatment. This consensus document between oncology and primary care professionals establishes a care framework based on shared management for the follow-up of cancer survivors. The proposed model is based on the principles of continuity and ongoing communication, equity in access, and efficiency in resource use, recognizing that the needs of these patients go beyond purely medical aspects to encompass physical, psychological, social, and functional dimensions. This proposal defines a dynamic risk stratification that enables the identification of high-risk patients, who will continue to receive preferential hospital follow-up, and low-risk patients, whose care can be led by primary care with the support of other specialists. Specific roles are established for each level of care, along with bidirectional communication pathways and multidisciplinary coordination tools that include shared medical records, agreed protocols, and rapid referral channels.</p>

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Consensus document between oncology and primary care for the follow-up of cancer survivors

  • 期刊论文

  • 出版模式：

    开放获取

  • 发表日期：

    2026年1月23日

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  • Rosario Vidal-Tocino,
  • Rafael Manuel Micó Pérez,
  • María Hernández Miguel,
  • Yolanda Ginés,
  • Raúl Hernanz,
  • Lourdes Martinez-Berganza Asensio,
  • Ruth Vera García,
  • Fátima Santolaya Sardinero,
  • Elena Brozos Vázquez,
  • Jacinto Batíz Cantera,
  • Cruz Bartolomé-Moreno

摘要

The exponential growth of cancer survivors represents a major healthcare challenge, with more than 23 million people in Europe and 2.2 million in Spain requiring long-term specialized follow-up. Five-year survival has reached 60% in our country, creating a growing population of long-term survivors who need comprehensive care beyond the stage of active oncological treatment. This consensus document between oncology and primary care professionals establishes a care framework based on shared management for the follow-up of cancer survivors. The proposed model is based on the principles of continuity and ongoing communication, equity in access, and efficiency in resource use, recognizing that the needs of these patients go beyond purely medical aspects to encompass physical, psychological, social, and functional dimensions. This proposal defines a dynamic risk stratification that enables the identification of high-risk patients, who will continue to receive preferential hospital follow-up, and low-risk patients, whose care can be led by primary care with the support of other specialists. Specific roles are established for each level of care, along with bidirectional communication pathways and multidisciplinary coordination tools that include shared medical records, agreed protocols, and rapid referral channels.