I am a medical oncologist who has finally seen the light — the dim one in the corner, obscured by various company booths at every major conference. That is a joke. It is also, somewhat, not a joke. That light is survivorship. And I will confess that, like many of my colleagues, I focused on the treatment of cancer, not fully emphasizing the importance of survivorship in parallel. This is the story of why, and how I changed my mind.
Survivorship care has often been an afterthought. This is difficult to acknowledge but to understand the indifference, you have to understand the psychology of a medical oncologist. At our heart, we are interventionists. We do not hold a scalpel or a scope — we prescribe. The work of translating scientific discovery into treatments that cure cancer is as close to a miracle as this atheist oncologist is going to get. It is secondary to this mindset that we do not necessarily consider ourselves experts in exercise or behavioral health counseling, the things typically associated with survivorship work.
When a patient is undergoing anti-cancer treatments, we consider ourselves the quarterbacks of their care. We claim full ownership of a patient's clinical course, but only up to a certain stopping point. The problem is that oncologists feel our mandate ends at a very specific finish line: keep the patient alive, keep them cancer-free, return them to their daily lives. Once those boxes are checked, the job feels done, but the blind spot begins where active treatment ends.
For most of oncology's history, that finish line made sense when we thought about cancer as a battle and victory bell to be rung at the end of treatment. But the landscape has changed dramatically and quickly. More patients are surviving cancer than ever before, and we use more therapies than ever before. The finish line is much less clear because active treatment is less defined. Is a patient considered in active treatment when they are on maintenance therapy? If a drug does not eradicate a patient’s cancer but keeps it from growing, how do we categorize this patient's disease state? Do oncologists even know how best to define a cancer survivor?
In today's world of sophisticated drug development, it is difficult to articulate when a medical oncologist’s expertise is no longer needed and patients can be safely discharged from their care. The issue is that the treatments may end, but the consequences do not always come to light right away. Consider checkpoint inhibitors, for example. Unlike chemotherapy, whose toxicities tend to declare themselves during or shortly after treatment, immunotherapy side effects can emerge years after the last dose. A patient’s family physician may not connect the clinical picture to a drug marked inactive in the chart. Even when a drug is still mentioned on a patient’s medication list, knowledge gaps regarding a drug’s toxicities are common even to medical oncologists. The FDA issued more than 50 oncology approvals in 2025, with 20 of those coming in the final quarter alone. Staying current and up to date on new therapies is incredibly challenging.
An obvious solution would be to have long-term cancer survivors continue to follow up with their medical oncologist indefinitely. Unsurprisingly, this is not a viable option due to the medical oncology workforce shortage. There are fewer of us doing this work relative to the patients who need it. Although the number of oncologists billing Medicare increased from 2014 to 2024, the number per 100,000 population aged 55 and older actually decreased. The science is moving faster than the systems built to support it, and we are doing more with less.
Without the appropriate support in place for oncology clinicians, attempting to triage multiple things can quickly lead to burnout. Every hour requires a ranking: which call gets returned first, whose symptom warrants an urgent visit, which scan gets reviewed before the next patient walks in — it is exhausting. There is only a finite amount of mental and empathic reserve an oncologist can give. When we run on empty, we focus our energy on only the most urgent priority. And unfortunately, survivorship has existed just outside the focus circle, and has been shadowed ever since.
I told myself someone else was handling it. No one was handling it.
The question is why survivorship keeps getting triaged to the back of the line. Part of the answer starts with the word itself. To a medical oncologist, "survivorship" carries the wrong associations. It sounds like it belongs to social work or wellness, which are disciplines we respect but do not consider our lane. "Survivor" implies the hard part is over, so "survivorship care" reads as epilogue rather than intervention. It signals nothing urgent, nothing measurable, nothing ours. And so it gets pushed to the periphery, because there is a mismatch between what the word implies and what the work actually is.
Eventually, I realized that survivorship is more than a simple add-on to the anti-cancer drugs I prescribe. My aha moment arrived when I was trying to solve a practical problem. I was working to improve referrals to a cancer survivorship program and could not understand why medical oncologists were not sending patients. When I asked clinicians why they were not placing referrals the answer was consistently: “My patient did not have any survivorship issues.”
That was the instance where everything clicked.
Oncologists were not referring for survivorship care because they genuinely did not believe their patients qualified. This presumption is incorrect on two counts. First, after active treatment, oncologists are not good at surfacing the traditional survivorship issues such as cancer-related fatigue, sexual dysfunction, and fear of recurrence. These common complaints do not appear on our radar unless we spend the time to ask a patient directly. Second, the oncology community was not thinking about survivorship as the next phase of cancer care, as a place where we can still make an important impact on a patient's overall survival. I, like many of my colleagues, did not emphasize exercise, tobacco cessation, weight management, and metabolic health. We have forgotten that these are not simply lifestyle suggestions, but important anti-cancer interventions that reduce recurrence and help patients live longer. And when seen through that lens, every cancer patient has a survivorship issue and needs dedicated survivorship care.
After that moment, I saw the light: the spotlight focusing on the critical survivorship interventions that improve overall survival and disease-free survival. I realized that these interventions should not be ignored, and instead represent an important opportunity to fully complete our patients' cancer journeys. If we accept the severe toxicities of chemotherapy, stem cell transplants, and immunotherapy because the survival benefit justifies the cost, why would we not do the same for exercise or tobacco cessation? I have spent my career chasing incremental gains in hazard ratios as I squint my eyes to see if the Kaplan-Meier curves ever separate. Meanwhile, survivorship interventions that impact my cancer patients' disease-free survival remained in the background and I was not prescribing them nearly as often as I should have been.
Survivorship interventions are not soft medicine, and the data simply can no longer be ignored. For example: tobacco cessation closer to the time of cancer diagnosis increases overall survival. Exercise in colon cancer patients improves both disease-free and overall survival at rates comparable to adjuvant chemotherapy — a finding from the CHALLENGE trial that truly caught my eye when I first read it. And cardiovascular disease is the leading cause of non‐cancer death in cancer survivors. Each of these interventions, outside of traditional anti-cancer therapies, has potential to move the survival needle on its own.
What is even more striking is what happens when you stack them. Oncologists understand stacking intuitively because this is how we built modern adjuvant therapy in breast cancer. We started with doxorubicin-based regimens, added taxanes, then immunotherapy. Each layer improved the survival curves a little more. The survivorship data suggests the same logic applies. Non-smoking cancer survivors who adhere to the full American Cancer Society survivorship guidelines of physical activity, weight management, diet, and alcohol reduction may have up to a 24% lower risk of all-cause mortality and a 21% lower risk of cancer-specific mortality compared to those who do not. These are not lifestyle suggestions. They are evidence-based interventions with effect sizes that rival our best adjuvant therapies.
So let's reframe the word entirely. If it is not a peripheral or add-on service, then what does survivorship mean? True survivorship care is a multidisciplinary clinical model, delivered by trained clinicians, that proactively addresses cancer recurrence, the late effects of treatment, metabolic health, and behavioral medicine. The addition of these interventions to traditional cancer therapies such as surgery, radiation, and anti-cancer drugs has the potential to fully complete a patient’s cancer care. But if the current oncology model does not have the capacity to deliver this comprehensive approach, we need to think outside the box of our traditional training to create a solution.
Ultimately, the oncologist's job is not to provide every phase of cancer care personally, but to ensure that every phase gets implemented. The answer is not to simply pile survivorship work onto an already overstretched system. I propose a dedicated clinical partner of specially trained clinicians for whom this phase of cancer care is the primary mission. The oncology community cannot do it alone; we need a survivorship collaborator to prescribe these interventions with the same conviction and expectation of compliance that we bring to our anti-cancer drugs. If our primary focus is to keep patients alive and cancer-free, we need to brainstorm ways to deliver these important survivorship interventions. When we finally prioritize survivorship for our patients, a partnership of this type can move the needle on overall survival in ways we have not yet fully measured.
Let’s not abandon our patients before we have done all we can to help them live longer, fuller lives. For too long, survivorship sat in the dim corner, obscured by the brighter lights of drug development and clinical trials. It is time for all of us to turn the lights on.
The author would like to thank Catherine Alfano, PhD and Justin Grischkan, MD for their thoughtful editorial suggestions to this manuscript.
