What does a survivorship care plan include?

A survivorship care plan is a written document covering everything that happened during cancer treatment and everything planned for monitoring and support going forward. It records the cancer diagnosis, stage, and treatment details — surgery, chemotherapy regimens and cumulative doses, radiation therapy fields and dose, and any biological or hormonal therapies. It then sets out the surveillance schedule for detecting recurrence or new cancers, a late-effect monitoring plan, lifestyle recommendations, mental health supports, and genetic testing recommendations for family members. Cancer Australia and the RACGP Red Book both endorse it as standard of care in Australian general practice.

How does my GP check for heart damage from chemotherapy?

Certain chemotherapy drugs — particularly anthracyclines such as doxorubicin and epirubicin, and the targeted drug trastuzumab — can affect heart muscle function. Monitoring involves regular echocardiograms (cardiac ultrasound) at baseline, six months, twelve months, and every two years thereafter. Blood tests (troponin, NT-proBNP) and cardiac MRI may be used for subclinical concerns. Aggressive management of blood pressure, cholesterol, blood glucose, and smoking status reduces the additional cardiac risk from these agents. Symptoms such as new breathlessness, ankle oedema, or reduced exercise tolerance in a chemotherapy survivor always warrant urgent cardiac review.

When does cancer follow-up shift from my specialist to my GP?

The transition depends on cancer type, risk category, and your oncology team's practice. For most common cancers — breast, colorectal, prostate, melanoma — at low to moderate risk, the shift toward GP-led care typically happens between two and five years after completing active treatment, when surveillance intensity can be safely reduced. High-risk situations — aggressive histology, prior recurrence, ongoing hormonal therapy complications, or cardiotoxicity — often keep annual specialist review in place. Research published in the Journal of Clinical Oncology found GP-led follow-up to be non-inferior to specialist care for early breast cancer survivorship.

What late effects appear years after cancer treatment?

Late effects are treatment-related consequences that emerge months to years after therapy ends. Cardiovascular effects include heart failure from anthracyclines and accelerated coronary artery disease from chest radiation therapy — sometimes emerging fifteen or more years later. Bone thinning is common in survivors on hormone-suppressing therapies (aromatase inhibitors for breast cancer, androgen deprivation for prostate cancer). Peripheral neuropathy from platinum or taxane chemotherapy can persist indefinitely. Thyroid problems are common after neck irradiation or immunotherapy. Cognitive difficulties and persistent fatigue each affect a substantial proportion of survivors. Regular structured reviews matter even when you feel well.

Should family members of cancer survivors be tested for inherited cancer risk?

If a known pathogenic genetic variant — such as BRCA1, BRCA2, Lynch syndrome genes, or Li-Fraumeni syndrome — has been identified in a cancer survivor, first-degree relatives have up to a 50% chance of carrying the same variant. Cascade genetic testing allows those who carry the variant to access surveillance, prevention, and risk-reduction options before cancer develops. The process is coordinated through a genetic counselling service; your GP can initiate a referral via the eviQ-AU pathway. Genetic information has implications for life insurance and employment, which a genetic counsellor will discuss beforehand.

Cancer survivorship

Cancer survivorship: what your GP manages after treatment ends

By Dr HB Lo, FACRRM Reviewed 24 June 2026 13 min read

Australia has approximately 1.4 million cancer survivors in 2024, growing around 6% per year as treatments improve. Cancer survivorship begins at diagnosis and extends through the rest of life — it is not simply the period after treatment ends.

General practice leads long-term survivorship care across five domains: surveillance for recurrence and new primary cancers, management of late treatment effects (heart, bone, nerves, hormones, cognition), lifestyle optimisation, psychosocial support, and cascade genetic testing for family members. A written survivorship care plan is the foundation of coordinated care.

Australia has approximately 1.4 million cancer survivors as of 2024, and that number grows by around 6% each year as incidence rises and treatment outcomes improve. The Australian Institute of Health and Welfare puts five-year relative survival across all cancers at roughly 70–71%, with several cancers — breast at stages I–II, prostate, testicular, melanoma, thyroid — exceeding 90%.

“Surviving cancer” no longer means cured and discharged. Cancer Council Australia and Cancer Australia both define survivorship as beginning at the time of diagnosis and extending through the rest of a person’s life — covering those on active treatment, those in remission, those living with chronic cancer, and those approaching end of life. The distinction matters because survivorship care is an active, ongoing discipline, not a gap between clinic appointments.

In Australian general practice, the GP is typically the lead long-term coordinator once the acute oncology workload has settled — usually around the two- to five-year mark depending on cancer type and risk. Research by Grunfeld and colleagues (J Clin Oncol 2006) found GP-led follow-up non-inferior to specialist-led care for early breast cancer — a finding that underpins the shared-care model now standard in RACGP Red Book guidance. Despite this, surveys conducted by Cancer Australia suggest fewer than half of Australian survivors receive a documented survivorship care plan — a significant gap that general practice is well-placed to address at the point of care transition.

A. Core clinical — the AU general-practice framework

The five domains of survivorship care

The NCCN Survivorship Guidelines (v.1.2024), ESMO survivorship guidelines 2024, and Cancer Australia Survivorship Framework 2023 organise survivorship care around five domains:

Surveillance for recurrence and new primary cancers — disease-specific and time-varying in intensity.
Late and long-term effects of treatment — cardiovascular, bone, endocrine, neurological, cognitive, fertility, bowel, bladder, sexual function.
Lifestyle — physical activity, diet quality, weight management, smoking cessation, and alcohol moderation.
Psychosocial wellbeing — mood, fear of recurrence, relationships, sexuality, work, and financial health.
Second cancer prevention and cascade genetic testing — BRCA1/2, Lynch syndrome, Li-Fraumeni, and other hereditary syndromes.

The survivorship care plan

A written survivorship care plan (SCP) is standard of care per the RACGP Red Book and Cancer Australia Survivorship Framework. It documents the cancer diagnosis, stage and biomarkers, all treatments received (surgery, chemotherapy regimens with cumulative doses, radiation therapy fields and total dose, biologic and immunotherapy agents, hormonal therapy), the surveillance schedule, a late-effect monitoring plan, lifestyle recommendations, psychosocial referrals, and cascade genetic testing recommendations. It is updated at every major care transition and at annual review.

History

A comprehensive survivorship history captures the full cancer story:

Cancer history — primary site, histology, stage, biomarkers, date of diagnosis, any recurrences.
Treatment history — specific regimens and cumulative doses, radiation therapy fields, biologic agents (trastuzumab, bevacizumab), immune checkpoint inhibitors, and hormonal therapy duration.
Treatment-specific late-effect screen — cardiovascular symptoms (breathlessness, ankle oedema, reduced exercise tolerance) in anthracycline/trastuzumab/chest radiation survivors; peripheral symptoms (numbness, tingling, balance problems) in platinum/taxane recipients; thyroid symptoms after neck irradiation or immunotherapy; and cognitive concerns broadly.
Lifestyle — current exercise volume, dietary pattern, BMI trajectory, alcohol intake, smoking status.
Psychosocial — mood (PHQ-9, GAD-7), fear of recurrence (a specific and prevalent survivorship concern), relationship and sexual function impact, return-to-work status, financial stress.
Family history — particularly first-degree cancer history relevant to genetic cascade testing.

Physical examination

Examination follows the treatment history. Key elements include:

Cancer-specific surveillance — breast and axillary and supraclavicular lymph nodes, head and neck mucosa and cervical lymph nodes, melanoma full-skin examination and lymph node palpation, as applicable to the cancer type.
Cardiovascular — blood pressure, resting heart rate, JVP, lower limb oedema, S3 gallop, displaced apex beat, and basal pulmonary crackles — particularly relevant in anthracycline, trastuzumab, or chest radiation survivors.
Bone and musculoskeletal — height measurement (loss suggests vertebral compression fracture), kyphosis, balance and gait (falls risk screen).
Thyroid — examination and palpation in patients with prior neck irradiation.
Neurological — peripheral neuropathy distribution (stocking-glove from platinum or taxane agents), deep tendon reflexes, Romberg test for balance.
Full skin examination — annually for all survivors, documented and photographed where appropriate; skin is the commonest site of second primary cancer across many tumour groups.
Mental state — observed affect and distress thermometer; suicidality screen when clinically indicated.

Investigations

Investigations are driven by the treatment history and presenting concerns:

Cardio-oncology — echocardiogram at baseline, 6 months, 12 months, and 2-yearly in survivors who received anthracyclines, trastuzumab, or chest radiation, per Plana et al. (J Am Soc Echocardiogr 2014) and Pluim et al. (Br J Cancer 2017). Cardiac MRI with global longitudinal strain (GLS) assessment for subclinical concerns.
Metabolic — annual lipids, HbA1c, and blood pressure; accelerated cardiometabolic risk in androgen deprivation therapy (ADT), aromatase inhibitor (AI), and post-radiation therapy survivors. Combined cardiovascular risk assessment per the Heart Foundation 2023 Australian CVD Risk Calculator.
Bone density (DEXA) — baseline and 2-yearly in patients receiving AI, ADT, those with treatment-induced premature menopause, or post-pelvic radiation. Per ANZBMS 2024 recommendations.
Thyroid function (TSH ± fT4) — annually in patients with prior neck irradiation or those who received immune checkpoint inhibitors.
Full blood count, iron studies, B12, folate, vitamin D — particularly when evaluating cancer-related fatigue; also for bone-health monitoring in those on antiresorptive therapy.
Tumour markers — as specified in the disease-specific surveillance plan (CEA for colorectal, PSA for prostate, CA-125 for ovarian).

B. Late effects of treatment — the evidence base

Late effects are treatment-related consequences that emerge months to years after therapy ends. They are distinct from recurrence — though both may present similarly and must be carefully distinguished.

Cardiovascular late effects

Anthracycline-associated cardiomyopathy — cumulative-dose-related oxidative damage to cardiomyocytes; risk rises significantly above 250–400 mg/m² doxorubicin-equivalent. Typically presents as heart failure with reduced ejection fraction months to years post-treatment. Echocardiographic surveillance per Plana ASE 2014 detects subclinical dysfunction before overt symptoms develop.

Trastuzumab-associated cardiac dysfunction — HER2-pathway-mediated; generally reversible on cessation and dose-modification; requires surveillance during active therapy and into early survivorship.

Radiation-associated cardiovascular disease — accelerated coronary artery disease, valvular disease, and pericardial disease in those who received mediastinal or left-chest radiation therapy; may emerge 10–20 years post-treatment. A high index of suspicion for cardiac symptoms is warranted in this group, even decades later.

Endocrine late effects

Hypothyroidism occurs in 30–50% of patients within 10 years of neck radiation therapy and is also a recognised late effect of immune checkpoint inhibitors. Annual TSH monitoring is recommended.

Adrenal insufficiency — secondary to checkpoint inhibitor-induced hypophysitis or prolonged glucocorticoid use during treatment; consider in survivors with unexplained postural hypotension, persistent fatigue, or hyponatraemia.

Treatment-induced premature menopause — premature ovarian insufficiency from cyclophosphamide, alkylating agents, or pelvic radiation in 30–80% of premenopausal women depending on regimen and age; carries additional cardiovascular and bone-density consequences requiring its own management framework.

Osteoporosis — driven by AI use in hormone-receptor-positive breast cancer, ADT in prostate cancer, treatment-induced premature menopause, and glucocorticoid exposure. Fracture risk is substantial without structured bone-health surveillance.

Neurological late effects

Chemotherapy-induced peripheral neuropathy — primarily from platinum agents and taxanes; stocking-glove sensory distribution; 30–50% of recipients develop persistent symptoms. Functional impact includes impaired fine motor skills, balance problems, and falls risk in older adults.

Cognitive change (“chemo-brain”) — subjective and objective difficulties with memory, processing speed, and executive function; underlying mechanisms include neuroinflammation, vascular injury, and hormonal changes. Management centres on cognitive rehabilitation, physical activity, sleep optimisation, and mood treatment.

Psychological late effects

Fear of recurrence is among the most prevalent survivorship concerns — present in 40–70% of survivors and often disproportionate to actual recurrence risk. Major depression and anxiety disorders each affect 20–30% of the survivorship population. Systematic screening with the distress thermometer, PHQ-9, and GAD-7 at survivorship reviews enables targeted referral via a Mental Health Care Plan.

C. Cardio-oncology, bone health, and lifestyle

Cardio-oncology in general practice

Any survivor who received anthracycline chemotherapy, trastuzumab, or radiation therapy to the mediastinum or left chest field needs a structured echocardiogram surveillance schedule. The GP role is to confirm this is in place, manage cardiovascular risk factors aggressively (blood pressure target below 130/80 mmHg, statin use per the Heart Foundation CVD Risk Calculator, HbA1c management, smoking cessation), and refer to a cardio-oncology service when LV dysfunction, new murmur, or exertional symptoms emerge.

Bone health

Bone loss from AI, ADT, treatment-induced premature menopause, or glucocorticoid use is preventable and treatable with structured general practice management:

DEXA at baseline when beginning long-term AI or ADT; repeat 2-yearly per ANZBMS 2024.
Vitamin D — maintain ≥75 nmol/L; supplementation per NPS MedicineWise guidance.
Calcium — 1,000–1,300 mg/day; prioritise dietary sources.
Weight-bearing and resistance exercise — supervised by an exercise physiologist where available.
Antiresorptive therapy — alendronate or risedronate (PBS general benefit); denosumab (Prolia 60 mg SC 6-monthly — PBS Authority Streamlined) or zoledronate for higher-risk patients.
Dental review before initiating bisphosphonate or denosumab — medication-related osteonecrosis of the jaw is a recognised complication.

Lifestyle — the survivorship foundation

Physical activity is among the most robustly supported survivorship interventions. The Bower et al. ASCO guideline (J Clin Oncol 2014/2022) and Demark-Wahnefried et al. (J Clin Oncol 2008) support 150 minutes of moderate aerobic activity plus two resistance sessions per week — improving fatigue, cardiovascular fitness, bone density, mood, and quality of life across survivorship cohorts. Referral to an exercise physiologist via the GP Chronic Condition Management Plan (GPCCMP) provides Medicare-subsidised, structured support.

A Mediterranean or plant-rich dietary pattern, weight optimisation (avoiding sarcopenic weight loss while addressing excess adiposity), smoking cessation (associated with improved all-cause and cancer-specific survival), and alcohol moderation per NHMRC guidelines complete the lifestyle foundation that supports every other survivorship domain.

D. Australian operations

MBS items

Long-term cancer survivorship care in general practice sits primarily within standard consultation items (23, 36, 44 — Level B/C/D as clinically appropriate). Additional key items:

GPCCMP — cancer survivorship with ongoing late effects qualifies as a chronic condition; preparation (item 965) and 3-monthly reviews (item 967); enables direct referral to up to 5 allied health sessions per year (10 for Aboriginal and Torres Strait Islander patients) — exercise physiology, dietetics, psychology, physiotherapy, occupational therapy.
Mental Health Care Plan — items 2715/2717; 10 subsidised psychology sessions per year for documented fear of recurrence, depression, anxiety, or post-traumatic stress linked to cancer.
Cardiac echocardiogram — item 55113 under GP or specialist referral with documented indication.
DEXA bone density — items 12306/12312/12315 for eligible clinical indications.
Case conferencing — items 132/133 for multidisciplinary care coordination with oncology or allied health.
ATSI Health Assessment — item 715 annually.
Telehealth — items 91790/91891; 12-month existing-relationship requirement applies.

PBS items

Hormonal therapy — tamoxifen, anastrozole, letrozole, exemestane (breast cancer); LHRH agonists/antagonists (prostate cancer) — require PBS Authority.
Bone-modifying agents — alendronate and risedronate (PBS general benefit); denosumab Prolia (PBS Authority Streamlined 60 mg SC 6-monthly); zoledronate (PBS Authority).
Antidepressants (SSRI/SNRI) — PBS general benefit for documented mood disorder.
Pregabalin or gabapentin for chemotherapy-induced peripheral neuropathy — PBS Authority Required; SafeScript/RTPM monitored.

Vaccinations in cancer survivors

The ATAGI Australian Immunisation Handbook — Immunocompromised patients 2024 recommends annual influenza, age-appropriate pneumococcal, COVID-19 boosters, recombinant herpes zoster vaccine (Shingrix — preferred over live zoster vaccine in this population), HPV where eligible, and hepatitis B if non-immune. Live attenuated vaccines are contraindicated during active chemotherapy or biologic therapy and for 3–6 months after cessation.

Multidisciplinary integration

GP survivorship coordination typically draws on: treating oncologist (annual specialist review for moderate-to-high risk patients), cardio-oncology, exercise physiology, dietetics, psychology, pelvic-floor physiotherapy, occupational therapy, social work, genetic counsellor (via eviQ-AU pathway for BRCA1/2 or Lynch syndrome families), Cancer Council financial counselling (13 11 20), and speech pathology for head and neck cancer survivors. Beyond Five provides 24/7 support specifically for head and neck cancer survivors.

E. Special populations

Aboriginal and Torres Strait Islander survivors. Five-year cancer survival is significantly lower for First Nations Australians than for non-Indigenous Australians — driven by later-stage diagnosis, geographic access barriers, and systemic inequities. Aboriginal Liaison Officer involvement, ACCHO co-care pathways, Closing the Gap PBS co-payment access, and the 715 ATSI Health Assessment annually are essential components of culturally safe survivorship care for this population.

Older adults (≥65 years). Polypharmacy, functional decline, frailty, cognitive impairment, and competing comorbidities complicate survivorship care. Comprehensive geriatric assessment principles apply. My Aged Care supports older survivors with care needs. Medication review is particularly important given the interaction burden of ongoing hormonal therapy, antiresorptive agents, and cardiovascular medications.

Young adults and fertility. Treatment-related premature ovarian insufficiency or azoospermia raises fertility concerns that require early and direct discussion — ideally before any gonadotoxic therapy. Post-treatment fertility counselling and referral to a reproductive endocrinologist or andrologist is appropriate when fertility matters to the patient, supported by Anderson et al. (Lancet Diabetes Endocrinol 2019) and the ASCO fertility preservation guideline 2018.

Hereditary cancer syndrome families. Where a germline pathogenic variant — BRCA1, BRCA2, Lynch syndrome gene, TP53 — has been identified in the cancer survivor, cascade genetic testing for first-degree relatives is standard of care per Domchek et al. (J Clin Oncol 2014). GP referral via the eviQ-AU pathway connects families to funded genetic counselling and provides clarity on surveillance and risk-reduction options before cancer develops. Genetic information has implications for life insurance and employment, which trained genetic counsellors discuss before testing.

Paediatric cancer survivors transitioning to adult care. Late-effect profiles from childhood cancer treatment differ substantially from adult-onset cancers — growth hormone deficiency, neurocognitive late effects, and second malignancy risk from childhood radiation are particular concerns. Careful handover documentation from the paediatric oncology team is essential for continuity of survivorship care in general practice.

When to escalate

Contact the oncology team or arrange urgent review when a survivor presents with:

Unexplained weight loss, new persistent bone pain, new neurological symptoms, new lymphadenopathy, or haemoptysis — possible recurrence or second primary requiring imaging and tumour marker workup.
New breathlessness, peripheral oedema, or reduced exercise tolerance in an anthracycline or chest radiation survivor — possible cardiotoxicity requiring urgent echocardiogram and cardiology review.
New postural hypotension, persistent fatigue, and hyponatraemia in a prior immune checkpoint inhibitor recipient — possible adrenal insufficiency; check 8 am serum cortisol.
Abnormal full blood count (unexplained cytopenias, circulating blasts) in prior alkylator or topoisomerase II recipients — possible therapy-related AML or myelodysplastic syndrome.
Acute limb swelling, warmth, and erythema in a post-lymph-node-dissection survivor — DVT, lymphoedema, and cellulitis each require different management.
Suicidal ideation or severe acute distress — same-day referral to a mental health service or Lifeline 13 11 14.

What this article is and is not

This is general health information drawn from current Australian general practice and specialist guidelines — the RACGP Red Book, Therapeutic Guidelines (eTG), Cancer Australia Survivorship Framework, Cancer Council Australia, and AIHW Cancer Data — alongside major survivorship trials and NCCN/ESMO international guidance. It is not personal medical advice and does not create a doctor–patient relationship. Individual survivorship plans depend on cancer type, treatment history, ongoing therapies, and personal circumstances and are developed with your treating GP, oncologist, and specialist team.

For Australian consumer-friendly survivorship resources: Cancer Council Australia 13 11 20, HealthDirect, Better Health Channel, Beyond Five — head and neck survivorship.

For mental health support: Lifeline 13 11 14, Beyond Blue 1300 22 4636.

Sources cited

Frequently asked questions

What does a survivorship care plan include?

A survivorship care plan is a written document covering everything that happened during cancer treatment and everything planned for monitoring and support going forward. It records the cancer diagnosis, stage, and treatment details — surgery, chemotherapy regimens and cumulative doses, radiation therapy fields and dose, and any biological or hormonal therapies. It then sets out the surveillance schedule for detecting recurrence or new cancers, a late-effect monitoring plan, lifestyle recommendations, mental health supports, and genetic testing recommendations for family members. Cancer Australia and the RACGP Red Book both endorse it as standard of care in Australian general practice.
How does my GP check for heart damage from chemotherapy?

Certain chemotherapy drugs — particularly anthracyclines such as doxorubicin and epirubicin, and the targeted drug trastuzumab — can affect heart muscle function. Monitoring involves regular echocardiograms (cardiac ultrasound) at baseline, six months, twelve months, and every two years thereafter. Blood tests (troponin, NT-proBNP) and cardiac MRI may be used for subclinical concerns. Aggressive management of blood pressure, cholesterol, blood glucose, and smoking status reduces the additional cardiac risk from these agents. Symptoms such as new breathlessness, ankle oedema, or reduced exercise tolerance in a chemotherapy survivor always warrant urgent cardiac review.
When does cancer follow-up shift from my specialist to my GP?

The transition depends on cancer type, risk category, and your oncology team's practice. For most common cancers — breast, colorectal, prostate, melanoma — at low to moderate risk, the shift toward GP-led care typically happens between two and five years after completing active treatment, when surveillance intensity can be safely reduced. High-risk situations — aggressive histology, prior recurrence, ongoing hormonal therapy complications, or cardiotoxicity — often keep annual specialist review in place. Research published in the Journal of Clinical Oncology found GP-led follow-up to be non-inferior to specialist care for early breast cancer survivorship.
What late effects appear years after cancer treatment?

Late effects are treatment-related consequences that emerge months to years after therapy ends. Cardiovascular effects include heart failure from anthracyclines and accelerated coronary artery disease from chest radiation therapy — sometimes emerging fifteen or more years later. Bone thinning is common in survivors on hormone-suppressing therapies (aromatase inhibitors for breast cancer, androgen deprivation for prostate cancer). Peripheral neuropathy from platinum or taxane chemotherapy can persist indefinitely. Thyroid problems are common after neck irradiation or immunotherapy. Cognitive difficulties and persistent fatigue each affect a substantial proportion of survivors. Regular structured reviews matter even when you feel well.
Should family members of cancer survivors be tested for inherited cancer risk?

If a known pathogenic genetic variant — such as BRCA1, BRCA2, Lynch syndrome genes, or Li-Fraumeni syndrome — has been identified in a cancer survivor, first-degree relatives have up to a 50% chance of carrying the same variant. Cascade genetic testing allows those who carry the variant to access surveillance, prevention, and risk-reduction options before cancer develops. The process is coordinated through a genetic counselling service; your GP can initiate a referral via the eviQ-AU pathway. Genetic information has implications for life insurance and employment, which a genetic counsellor will discuss beforehand.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.