Cancer Survivorship Care Falls Short of National Standards in the American Southeast

More than 18 million people in the United States are living with a history of cancer, and that number is climbing as the population ages and treatment advances keep more patients alive for longer. Yet the care these survivors receive after treatment ends remains fragmented, inconsistent, and often suboptimal. A new study published in the Journal of Cancer Survivorship offers one of the most detailed looks yet at how a large, real-world health system in the American Southeast measures up against the National Standards for Cancer Survivorship Care, a consensus blueprint developed by the National Cancer Institute to guide health systems on the essential policies, processes, and quality evaluations that survivorship care should include. The findings reveal a system that is trying, but one where the reach and consistency of survivorship services depend heavily on where a patient happens to receive care.

The research team, led by Shirley M. Bluethmann of Wake Forest University School of Medicine and Atrium Health Wake Forest Baptist Comprehensive Cancer Center, used a qualitatively dominant convergent mixed-methods design to assess perceived alignment with the National Standards across a health system whose catchment area spans urban and rural parts of North and South Carolina as well as parts of Georgia and Virginia. Quantitative data came from an electronic survey distributed through REDCap to 51 key informants representing oncology practices within the system, including clinical champions and team leaders. In parallel, the team gathered rich qualitative data from four representative practices, two large main-campus oncology practices and two smaller regional ones, through four clinic observations and twelve semi-structured interviews. The qualitative work was guided by the Consolidated Framework for Implementation Research, or CFIR, a widely used lens for understanding what helps or hinders the adoption of new practices in healthcare settings.

The survey instrument was adapted from the Organizational Assessment Tool in the NCI National Standards for Cancer Survivorship Care Toolkit, with refinements informed by a Survivorship Insights Council that included project champions, community outreach leaders, supportive oncology researchers, healthcare providers, and a cancer patient advocate. The survey posed ten questions each in three domains: Health System Policy, covering the organizational policies that establish and structure survivorship care; Health System Processes, covering how that care is actually delivered; and Health System Evaluation, covering how systems collect data on the effects of survivorship care. The team added nuanced response options, such as distinguishing between processes performed routinely and those performed only sometimes, and follow-up questions on practical and social effects of cancer and referral pathways for caregivers.

The response numbers tell their own story about the burden of competing demands in clinical settings. Of the 51 informants contacted, 16 consented and only 10 completed at least one survey item. Those who did respond represented practices seeing anywhere from 217 to 6,459 new cancer patients annually, with patient populations ranging from nearly entirely urban to almost entirely rural, and from 3.4 percent to 36.4 percent Black patients. On average, informants reported meeting 55.4 percent of the National Standards at least some of the time. The strongest performance came in the Health System Processes domain, where 91 percent of respondents said standards were met at least sometimes. By contrast, the policy and evaluation domains showed striking gaps: 88 percent of informants reported having no policy for collecting longitudinal data on survivors’ experiences and patient-reported outcomes, and no informant reported having a process to collect data on survivors’ return to work or other productive activities. Fully 86 percent said they had no process for tracking how many health professionals at their practice were trained to provide survivorship care.

The qualitative strand of the study filled in the texture behind those numbers. Clinic observations, rooted in focused ethnography principles, ranged from roughly four to six hours per site and included staff huddles, informal conversations, and observation of patient visits lasting from about thirty minutes to an hour. Interviews averaged 27.5 minutes and captured administrators, nurse managers, social workers, program managers, and advanced practice providers. Most partners had little to no familiarity with the National Standards outside the context of the study itself, yet they shared largely positive perceptions of what the standards could accomplish, viewing them as beneficial for improving and standardizing care across the system.

Across the CFIR domains, a consistent set of facilitators and barriers emerged. Within Intervention Characteristics, partners found the National Standards difficult to understand, describing them as too vague in some places and too broad in others, and questioning why policy and process were separated when the distinction was hard to operationalize. One partner noted that patients do not exist in an oncology vacuum, pointing out that the standards do not accommodate social needs assessment that already happens in primary care, such as screening for food insecurity or safety at home. Within the Outer Setting, partners described transportation challenges, food insecurity, financial strain, inadequate housing, and limited health literacy among their patients, all of which contribute to missed or delayed appointments. Rural patients often cannot do virtual visits from home because of poor internet or cellular connectivity, and many are reluctant to travel to the main campus at all. Partners also argued that the National Standards would be nearly impossible to prioritize without linkage to incentives or accreditation requirements, pointing to the American College of Surgeons Commission on Cancer as the most plausible lever for driving adoption.

The Inner Setting domain exposed perhaps the most consequential disparities. Access to survivorship care and supportive oncology services was markedly more extensive at main-campus locations than at regional practices, where survivorship visits might be limited to once per week or less and supportive services were offered in person only on a limited basis or via telehealth. One regional partner described patients as getting the bare minimum when it came to survivorship, with follow-up visits focused narrowly on the treated organ rather than on broader preventive needs like colonoscopies and lung screenings. Crucially, partners emphasized that the problem was often not a lack of resources but a lack of knowledge about what resources exist elsewhere in the system. They called for more navigators, social workers, and mental health counselors, better tracking of survivorship care, improved health-related social needs screening, and more training for staff on what survivorship care involves. One partner suggested an electronic medical record template that would give patients information about the purpose of a survivorship visit before they arrive, so the visit is understood as more than a box being checked.

The Process domain highlighted who needs to be at the table. Partners identified clinicians responsible for identifying and referring patients, along with administrators and leaders with authority over hiring, as essential to implementation. One interviewee noted that providers would support expanded supportive oncology, but that administration would need to budget the full-time positions needed to staff regional sites. The mixed-methods integration, presented as a joint display, showed that while partners generally believed they were meeting survivorship care standards and addressing survivors’ needs, implementation was inconsistent, with barriers including unclear policy language, limited resources and staffing, time constraints, and gaps in communication and education, particularly in regional settings.

The authors are candid about the study’s limitations. The low survey response rate raises the likelihood of response bias, since informants who chose to respond may have been more engaged in survivorship care than those who did not, meaning the reported alignment figures may overstate the true picture. The team suggests that future efforts could simplify the standards, improve timing around competing clinical demands, and secure stronger leadership communication about the survey’s importance. They also point toward more objective assessments using electronic health record data, and toward asking explicitly about the feasibility of addressing each identified barrier.

Still, the study’s implications reach well beyond one health system. It demonstrates a systematic, replicable approach for assessing alignment with the National Standards and for surfacing the contextual factors that determine whether national guidance translates into bedside reality. The authors conclude that a model combining standardized survivorship services with the flexibility to meet local population needs may help close gaps in care, promote equitable access to supportive resources, and improve outcomes for the growing population of cancer survivors across diverse settings. As the silver tsunami of aging survivors swells, the study is a reminder that standards on paper only matter as much as the staffing, infrastructure, incentives, and local knowledge that carry them into practice.

Subject of Research: Assessment of health system alignment with National Standards for Cancer Survivorship Care in the American Southeast

Article Title: Contextual assessment of perceived health system alignment with National Standards for Cancer Survivorship Care in the American Southeast

Article References: Bluethmann, S. M., Bunch, S., Nightingale, C., Willis, A. R., York, B., Fisher, B., Birken, S. A., Zimmer, R., Strom, C., Strahley, A., Zakrzewski, S., & Sohl, S. J. (2026). Contextual assessment of perceived health system alignment with National Standards for Cancer Survivorship Care in the American Southeast. Journal of Cancer Survivorship. https://doi.org/10.1007/s11764-026-02123-0

Image Credits: AI Generated

DOI: 10.1007/s11764-026-02123-0

Keywords: cancer survivorship, National Standards, health system alignment, implementation science, CFIR, supportive oncology, rural health disparities, mixed methods, Commission on Cancer, patient-reported outcomes, health-related social needs, care delivery