A major new effort is underway to change that. In a special section of the Journal of Cancer Survivorship, researchers led by Kimberly A. Miller of the University of Southern California, Vida A. Passero of the VA National TeleOncology program and the University of Pittsburgh, and Michelle A. Mollica of the Medical University of South Carolina present an overview of the National Standards for Cancer Survivorship Care, early lessons from their real-world testing, and a roadmap for what must come next. The standards, developed by the National Cancer Institute in partnership with the Department of Veterans Affairs and several Health and Human Services agencies as part of the Biden Cancer Moonshot and Cancer Cabinet initiatives, are designed as recommendations for health systems rather than mandates for individual clinicians. Together they form a nationally relevant blueprint of essential health policies, care delivery processes, and evaluation indicators intended to guide the creation and strengthening of survivorship programs across wildly different care settings.

The development process was deliberately structured and consensus-driven. Drawing on methods used to build the Victorian Quality Cancer Survivorship Framework in Australia, the team began with a comprehensive landscape review of survivorship and cancer-specific clinical guidelines, the Commission on Cancer survivorship standard, existing quality frameworks, state cancer control plans, and the peer-reviewed literature. NCI and the VA then convened three iterative virtual meetings with national and international survivorship experts to prioritize candidate indicators by importance and feasibility. The result was a final set of 30 indicators organized across three domains—health system policies, care delivery processes, and assessment and evaluation—with 10 indicators in each. The architecture is intentionally practical: it asks health systems to examine what they promise survivors, how they actually deliver care, and how they measure whether that care works.

Knowing whether a blueprint survives contact with reality required testing it in the field. In 2024, NCI released an administrative supplement funding opportunity inviting current grantees to examine or improve survivorship care in alignment with the new standards. Eighteen demonstration projects were funded across the United States, spanning NCI-designated comprehensive cancer centers, children’s hospitals, integrated health systems, and community oncology programs. The portfolio covered the full implementation continuum, from readiness assessment and mapping of existing services to strategic planning, program implementation, and evaluation of care quality and outcomes. It also reached a striking diversity of survivor populations, including pediatric and adolescent and young adult survivors, older adults, rural communities, underserved groups, and survivors of specific cancer types, underscoring both the breadth of survivorship needs and the adaptability of the standards across contexts.

The early findings are sobering in places and encouraging in others. One study evaluating a large regional health system in the American Southeast found that practices met only about half of the indicators on average, revealing multilevel barriers and facilitators that will shape any national rollout. A team at a rural comprehensive cancer center characterized patient experiences with digital survivorship services, suggesting that telehealth and portal-based programming can meaningfully extend the reach of survivorship care to patients who might otherwise never access it. Researchers analyzing electronic health record data for head and neck cancer patients in their first year after diagnosis identified persistent gaps between what the standards call for and what clinical practice delivers, particularly when comparing rural and urban locations. Survivor-reported evaluations at a comprehensive cancer center found stronger alignment on physical and emotional concerns than on financial and practical needs, pointing to financial navigation as a critical weak link in the survivorship experience.

Several projects zeroed in on populations whose needs standard models often miss. The Adolescent and Young Adult National Standards Consortium drew on insights from nine healthcare systems to map the challenges of aligning AYA survivorship care with the new framework, while a mixed-methods study of an AYA survivorship clinic documented strikingly low utilization and identified limited awareness and weak referral patterns as key barriers. Caregivers emerged as another underserved group: one study found substantial unmet emotional, social, and health needs among cancer caregivers that must be addressed if standards covering their care are to be met. Meanwhile, a new Cancer Survivorship Maturity Model offers institutions a structured way to stage their readiness across survivorship domains, revealing heterogeneous maturity even among engaged organizations and providing a practical path for implementation planning.

Across all 18 projects, several cross-cutting themes crystallized. Organizational readiness consistently proved to be the foundational determinant of implementation. Health systems with existing survivorship leadership, defined roles, and dedicated infrastructure were far better positioned to engage in strategic planning, pilot testing, and measurement, while settings with limited staffing or fragmented accountability often had to focus first on readiness assessment and capacity building. In one multi-site health system, main campuses with dedicated survivorship infrastructure met more standards, whereas regional clinics with constrained staffing and time delivered what researchers described as only a bare minimum of survivorship care. The standards, in other words, function not just as a quality framework but as a diagnostic tool that exposes variation in institutional preparedness and highlights where foundational investment is most needed.

A second theme was definitional variability. Projects differed in who they counted as survivors, when survivorship care should begin, and what services fell under the survivorship umbrella—whether post-treatment specialty visits alone or care from diagnosis through advanced disease spanning oncology and primary care. This heterogeneity complicated standardization, particularly for adolescents and young adults, people living with metastatic disease, and patients whose care crosses multiple settings, but it also demonstrated the flexibility of the standards to accommodate diverse models of care. A third theme involved the hard technical work of workflow integration. Translating standards into referrals, assessments, documentation, and follow-up required alignment with existing clinical roles and data systems, and teams repeatedly ran into limited structured data, uneven electronic health record functionality, and reliance on manual processes. Innovative responses included maturity models to stage infrastructure, standardized EHR templates for symptom and distress screening, and embedded telehealth and digital navigation that extended survivorship processes beyond in-person visits.

The practical lessons emerging from this early implementation are clear at every level of the system. At the systems level, improving alignment is tightly linked to leadership engagement, clear ownership, and dedicated survivorship infrastructure, while the absence of structured EHR data to capture survivorship indicators forced many sites into manual workarounds—evidence that sustainable implementation requires coordinated investments in leadership, governance, and data infrastructure. At the clinical level, survivorship care proved most feasible when woven into existing oncology and primary care workflows through structured care pathways, standardized assessments, and formalized referral processes, though gaps in psychosocial, financial, and supportive care needs persist. At the patient level, survivors continue to report unmet needs in symptom management, psychosocial support, financial burden, and care coordination, and barriers such as limited awareness, access challenges, and navigation complexity continue to limit the reach of even well-designed programs. The consistent message is that standardized frameworks must be paired with population-specific adaptation for adolescents and young adults, rural survivors, caregivers, and other groups whose needs do not fit a single template.

The authors frame the standards as a foundation for a more consistent, equitable, and accountable national approach to survivorship care, and they lay out distinct agendas for research, practice, and policy. Future research should identify which of the 30 indicators are most sensitive to change, refine measurement strategies, and apply implementation science methods to understand how organizational context shapes uptake and sustainability. Health systems seeking to scale survivorship services will need to invest in leadership engagement, workforce training, data infrastructure, and cross-disciplinary coordination, embedding the standards into team-based care and EHR optimization. On the policy front, harmonizing the standards with existing accreditation requirements such as the Commission on Cancer’s Survivorship Standard 4.8, quality reporting initiatives, and payer priorities could accelerate adoption and reduce fragmentation, particularly for underserved populations and resource-limited settings. What began as a conceptual blueprint is now being stress-tested in real-world settings, and the early evidence suggests that with sustained partnership among health systems, researchers, clinicians, survivors, caregivers, and policymakers, the national standards could transform survivorship from a set of discrete, unevenly distributed services into a coordinated, system-level function of American cancer care.

Subject of Research: Development and early implementation of the National Standards for Cancer Survivorship Care in United States health systems

Article Title: Advancing the national standards for cancer survivorship care: overview, early implementation insights, and future directions

Article References: Miller, K. A., Passero, V. A., & Mollica, M. A. (2026). Advancing the national standards for cancer survivorship care: overview, early implementation insights, and future directions. Journal of Cancer Survivorship. https://doi.org/10.1007/s11764-026-02122-1

Image Credits: AI Generated

DOI: 10.1007/s11764-026-02122-1

Keywords: cancer survivorship, National Cancer Institute, health care standards, care coordination, survivorship care quality, implementation science, electronic health records, adolescent and young adult survivors, telehealth, health policy, psychosocial support, health systems

The analysis identified 14,940,581 US survivors who had experienced one malignancy, alongside 2,191,482 people who had experienced two. An additional 379,897 survivors had been diagnosed with three malignancies, while 110,859 had experienced four or more. These figures do not describe a cancer that has returned or spread from its original site. Instead, an SMN generally refers to a new primary cancer arising independently, often in a different tissue and sometimes years after the first diagnosis. That distinction matters clinically: a recurrence reflects residual or re-emerging disease, whereas a subsequent primary malignancy can result from inherited susceptibility, environmental exposures, aging, treatment-related injury, or a combination of these forces.

To produce the estimates, Emily S. Tonorezos and colleagues used data collected from 1975 through 2021 by the National Cancer Institute’s Surveillance, Epidemiology, and End Results program. SEER is a network of population-based cancer registries covering selected US regions and demographic groups. It records diagnoses, tumor sites, and other characteristics, allowing researchers to track cancer patterns over time in large populations. The investigators calculated the number and proportion of survivors with one or more subsequent malignancies, examining how risk varied with age at the first diagnosis, the amount of time since that diagnosis, and the type of initial cancer. They also used standardized incidence ratios, or SIRs, to compare the observed number of subsequent cancers in survivors with the number expected among people without a previous cancer diagnosis.

The overall SIR was 1.19, meaning that survivors experienced about 19 percent more new malignancies than would be expected in a comparable population with no cancer history. The estimate was accompanied by a 95 percent confidence interval of 1.19 to 1.19, reflecting the enormous size of the underlying dataset. An SIR above 1 does not mean that every survivor faces the same excess risk, nor does it predict an individual’s fate. It is a population-level comparison that combines people with widely differing ages, treatments, genetic backgrounds, behaviors, and medical histories. The study’s more striking pattern emerged when researchers examined age at first diagnosis: survivors who had been diagnosed before age 40 had the highest relative risk, with an SIR of 1.78, or approximately 78 percent above the expected level.

Several biological explanations could contribute to that age-related pattern. Children and young adults have more years ahead in which a second cancer can develop, increasing the opportunity for a late effect to become clinically visible. Their tissues may also be more vulnerable to DNA damage caused by radiation or certain chemotherapies, particularly when treatment occurs during periods of active growth. Some young patients carry inherited variants in genes involved in DNA repair, cell-cycle control, or tumor suppression, raising the likelihood of multiple primary cancers. A first cancer at a young age can also be a marker of an underlying predisposition rather than a purely sporadic event. In addition, some childhood and adolescent cancer treatments used historically exposed developing organs to radiation or high doses of DNA-damaging drugs, although modern treatment strategies increasingly seek to reduce those late risks.

Treatment is only one part of the explanation. Cancer survivors may share exposures that contributed to both malignancies, including tobacco use, ultraviolet radiation, alcohol consumption, obesity, or other factors that influence inflammation, hormone signaling, and DNA damage. A person who develops melanoma, for example, may have a pattern of intense ultraviolet exposure or a biological susceptibility that increases the likelihood of another skin cancer. Survivors may also undergo more frequent medical examinations and imaging than people without a cancer history, making additional tumors more likely to be detected. This surveillance effect can inflate the apparent incidence, especially soon after the first diagnosis, although it is unlikely to explain the entire long-term pattern. The researchers found that the proportion with an SMN was particularly high among survivors whose first cancer was melanoma, bladder cancer, or Hodgkin lymphoma.

The association with Hodgkin lymphoma is consistent with decades of evidence showing that some survivors face elevated risks of breast, lung, gastrointestinal, and other cancers long after treatment. Radiation can injure DNA directly and can also alter the tissue environment in ways that promote malignant transformation years later. Certain chemotherapy agents, including some alkylating drugs and topoisomerase inhibitors, can create DNA cross-links or strand breaks; in rare cases, those changes contribute to later solid tumors or blood cancers. Bladder cancer survivors may have both field effects—where a broad region of the urinary tract has been exposed to carcinogens—and treatment-related risks. Melanoma survivors may be more likely to develop additional melanomas because of ultraviolet exposure, inherited susceptibility, or a combination of both. The study does not, however, assign individual cases to a particular cause or estimate how many were directly produced by treatment.

The numerical burden revealed by the analysis is partly a consequence of success. The United States now has a large and aging population of cancer survivors because screening, surgery, radiation, targeted drugs, immunotherapies, and supportive care have improved survival. As survivors live longer, the chances of developing any later disease—including an unrelated cancer—naturally increase. The researchers’ estimate therefore combines two different realities: a real excess risk in many survivor groups and the simple fact that more people are reaching ages at which cancer becomes common. This makes the 15.2 percent figure important but not deterministic. It describes the cumulative experience of a large population, not a universal probability that applies equally to someone treated for a localized tumor at 70 and someone treated for lymphoma at 15.

The findings point toward a more personalized model of survivorship care. A follow-up plan could incorporate the survivor’s age at treatment, original cancer type, radiation fields, chemotherapy exposures, family history, genetic results, smoking and alcohol history, body weight, and other risk factors. For some people, enhanced screening may be warranted, such as earlier breast imaging after chest radiation during youth or careful skin examinations after melanoma. For others, the priority may be smoking cessation, protection from ultraviolet radiation, vaccination, physical activity, weight management, or ensuring that routine population screening is not lost amid the complexity of cancer care. The study supports surveillance that is targeted rather than indiscriminate: screening everyone more intensively could expose patients to unnecessary procedures, false positives, radiation, expense, and anxiety, while failing to reach survivors who face the highest risks.

The analysis also exposes the challenge of turning population statistics into equitable care. SEER provides powerful information, but registry data generally cannot capture every detail that determines second-cancer risk, including precise radiation doses, complete chemotherapy histories, genetic testing, lifestyle changes, or access to follow-up services. The registries also represent selected geographic areas rather than every US community, and the study’s estimates may be affected by differences in diagnosis, record linkage, and survival across eras of treatment. Survivors who lack insurance, live far from specialty centers, or face language and financial barriers may be less likely to receive recommended surveillance. The authors report no funding for the work and say that the specific SEER files used can be requested, supporting further investigation into which survivors carry the greatest risks.

For patients, the central message is neither alarm nor complacency. Most cancer survivors will not develop multiple malignancies, and an elevated population risk does not mean that a second cancer is inevitable. But a history of cancer should remain part of a person’s medical identity even after treatment ends. New symptoms, unusual changes, and overdue screening deserve attention, while routine care should be coordinated with clinicians familiar with the long-term effects of cancer therapy. The new estimates suggest that the next era of oncology must measure success not only by whether the first tumor is eliminated, but also by whether survivors receive the knowledge, monitoring, and preventive care needed to protect the decades of life that treatment has made possible.

Subject of Research: Subsequent malignant neoplasms among cancer survivors in the United States

Article Title: Subsequent malignant neoplasm among cancer survivors in the United States

Article References: Tonorezos, E. S., Devasia, T. P., Gallicchio, L., et al. “Subsequent malignant neoplasm among cancer survivors in the United States.” Journal of Cancer Survivorship (2026). Original research article

Image Credits: AI Generated

DOI: 10.1007/s11764-026-02102-5

Keywords: cancer survivorship, subsequent malignant neoplasms, second primary cancer, SEER Program, cancer surveillance, childhood cancer survivors, Hodgkin lymphoma, melanoma, bladder cancer