Advancing survivorship care for metastatic cancer: insights from MASCC-ASCO Standards and Recommendations

Due to advances in targeted treatments, there is a growing population of individuals living with incurable cancer, encompassing both solid and hematologic malignancies, who are undergoing continuous, recurrent, or intermittent treatments (1). This population may live for years or decades with managed disease, requiring ongoing medical appointments, maintenance treatments and management of ongoing toxicities, which are often unpredictable and can impair function and quality of life (1). Advanced and metastatic cancers have varied disease trajectories, which include periods of stability, progression, and the possibility of transitioning to end-of-life care (2,3) and have unique care goals and challenges compared to those with early-stage or localized disease, or those at the end of life (2). These include functional impairments and related debility, along with depression and anxiety (4). Despite these challenges, this group continues to have unmet needs in domains such as financial, health system, information, psychological, physical, and daily living (4). This highlights the increasing need for comprehensive supportive care for individuals with advanced or metastatic cancer.

The “Survivorship Care for People Affected by Advanced or Metastatic Cancer: MASCC-ASCO Standards and Practice Recommendations” was published in April 2024 to establish consistent and high-quality survivorship care for individuals with incurable cancers. It was developed following a systematic review of 81 studies and a scoping review of 17 guidelines and frameworks. A group of 77 experts across 33 countries participated in the Delphi study and agreed on seven standards: Person-Centered Care, Coordinated and Integrated Care, Evidence-Based and Comprehensive Care, Evaluated and Communicated Care, Accessible and Equitable Care, Sustainable and Resourced Care, and Research and Data-Driven Care (5). However, despite providing a comprehensive overview of the supportive needs of individuals living with advanced or metastatic cancer, the MASCC-ASCO Standards and Practice Recommendations presents some challenges.

Strengths of the MASCC-ASCO Standards and Practice Recommendations

The MASCC-ASCO Standards and Practice Recommendations offers a comprehensive, compassionate, and evidence-based approach to survivorship. The MASCC-ASCO Standards and Practice Recommendations represents a significant shift in the oncology community’s approach to survivorship care for individuals with advanced and metastatic cancer. Current national survivorship guidelines fail to adequately address the specific needs of this population. In contrast, Hart et al. have developed the first research-driven framework for standards and practice recommendations that are tailored to the unique challenges faced by cancer survivors living with advanced or metastatic disease.

Furthermore, one of the strengths of the MASCC-ASCO Standards and Practice Recommendations is its holistic strategy, which addresses the physical, emotional and social dimensions of survivorship (5). For this group, the continuous uncertainty and stress of living with a chronic, life-threatening illness can be psychologically challenging (6). The MASCC-ASCO Standards and Practice Recommendations acknowledges that surviving cancer extends beyond medical treatment by encompassing the entire spectrum of patients’ experiences.

A vital component of the MASCC-ASCO Standards and Practice Recommendations is its emphasis on a multidisciplinary approach. It promotes a strong support network by involving oncologists, primary care providers, mental health professionals, and other specialists (5). This collaboration ensures that all aspects of a patient’s well-being are addressed, from managing side effects to providing psychological and social support (1). Effective documentation of treatment goals, survivorship issues, and the specific roles of each healthcare provider facilitates high-quality care (1).

Additionally, the MASCC-ASCO Standards and Practice Recommendations strongly focus on patient-centred and individualized care. For those with metastatic cancer, clear and consistent communication throughout their course is critical (7). For instance, the Patient-Centered Survivorship Care Index (PC-SCI) includes seven multi-item factors reflecting survivors’ priorities: information and support in survivorship, medical home, patient engagement, care coordination, help navigating insurance, care transitions, and prevention and wellness services (7). These factors are well-established in the literature as essential to high-quality patient-centred care and should be leveraged to enhance survivorship care and long-term outcomes (7).

Further, a notable strength is the inclusion of patient advocates and experts from high-income countries and low—to middle-income countries in its development. This diverse representation ensures inclusivity, addressing the needs and perspectives of various populations and healthcare settings (5).

The MASCC-ASCO Standards and Practice Recommendations also excels in its commitment to evidence-based recommendations that are regularly updated to incorporate the latest research (5), ensuring patients receive the current best practices and comprehensive supportive care. As such, healthcare professionals, both cancer specialists and non-specialists, are encouraged to integrate new evidence into their practice. The MASCC-ASCO Standards and Practice Recommendations emphasizes the inclusion of the patient’s voice in the design and conduct of clinical trials, enhancing the relevance and applicability of research findings to real-world care (5).

Weaknesses and challenges

While the MASCC-ASCO Standards and Practice Recommendations provides a framework for managing patients with advanced or metastatic cancer, it has some weaknesses and challenges.

Firstly, implementing the MASCC-ASCO standards in diverse healthcare settings, particularly in resource-limited environments, presents several challenges (5). These standards often require substantial infrastructural, financial, and human resources, which may not be available in all settings. For example, establishing person-centred or coordinated and integrated care necessitates a robust healthcare infrastructure, including access to multidisciplinary teams and advanced health information systems, which is not applicable to all (8). Additionally, the training and continuous professional development required to maintain such standards can be financially challenging for under-resourced health systems (8).

Further, in low- and middle-income countries (LMICs), financial constraints and limited infrastructural capabilities significantly limit the implementation of MASCC-ASCO standards. The high cost of advanced medical technologies and a shortage of trained healthcare professionals make it challenging to provide the recommended comprehensive and evidence-based care (9). Financial toxicity may prevent patients from accessing essential survivorship services, widening the gap in equitable care (10). It also remains unclear whether a resource-stratified approach has been considered in the creation of the MASCC-ASCO Standards and Practice Recommendations. Ultimately, the lack of sustainable and adequately resourced care systems exacerbates the difficulty in delivering continuous, high-quality survivorship care.

The MASCC-ASCO Strengths and Recommendations, while comprehensive, do not fully address the needs of diverse patient populations, particularly in terms of racial, ethnic, and socioeconomic disparities. The one-size-fits-all approach overlooks different populations’ unique cultural, linguistic, and socioeconomic contexts (5). For instance, the MASCC-ASCO Standards and Recommendations emphasize the importance of culturally sensitive care but may need more specific strategies to ensure equitable access and tailored interventions for marginalized groups (5). This is mainly due to the underrepresentation of diverse populations in research studies used to inform these standards and practice recommendations, leading to gaps in evidence and effectiveness for these groups. To address these gaps, the MASCC-ASCO Standards and Practice Recommendations can encourage increasing the representation of diverse populations in research studies (11) and developing specific guidelines that consider the unique needs of various racial, ethnic, and socioeconomic groups. For example, the Americans with Disabilities Act (ADA) mandates reasonable accommodations to support individuals with disabilities. In oncology, this can include providing accessible facilities, offering assistive devices, and ensuring that communication is appropriate for patients with visual, hearing and/or cognitive impairments (12). Furthermore, a next step includes implementing culturally sensitive training for healthcare providers (13). However, while culturally sensitive training provides healthcare providers (HCPs) with the skills necessary to address the needs of cancer survivors, the presence of systemic barriers, including the emphasis on efficiency and standardized outcomes, and time constraints which limit patient-provider interactions, impedes the application of such training (14). To effectively implement culturally sensitive practices, it is necessary to address these systemic challenges, including restructuring healthcare delivery models to allow HCPs more time with patients, reducing administrative burdens, and valuing patient-centred care over rigid adherence to metrics (15). By doing so, the MASCC-ASCO Standards and Practice Recommendations can promote inclusivity and equity in survivorship care more effectively.

Although the MASCC-ASCO Standards and Practice Recommendations are broad domains, disease- and population-specific survivorship care guidelines need to be developed by clinicians, policymakers and researchers. However, designing survivorship care to this unique population will need to be adapted locally, for optimal outcomes.

Adapting the MASCC-ASCO Standards and Practice Recommendations for LMICs

It is essential to critically examine the feasibility of implementing the MASCC-ASCO Standards and Practice Recommendations within LMICs, where diverse local constraints pose significant challenges. Implementing such standards in full within LMICs demands consideration of these regions’ specific infrastructural, financial, and cultural barriers.

A practical approach involves identifying critical elements of the MASCC-ASCO Standards and Practice Recommendations that are most feasible for immediate implementation, focusing on low-cost, high-impact interventions that address the most pressing needs of cancer survivors. For instance, prioritizing the management of long-term toxicities and essential psychosocial support can provide tangible benefits without the immediate necessity for extensive resources (16).

Overcoming cultural, financial, and infrastructural barriers requires innovative, locally tailored strategies. Community engagement and education are vital in this context. For example, training community health workers to deliver survivorship care and using mobile health technologies can improve access and adherence to care protocols without substantial investments in healthcare infrastructure (17). Right-siting of survivorship care involving primary care providers is another successful strategy that has led to significant cost reduction and healthcare utilization (18). Additionally, leveraging existing community structures and local non-governmental organizations (NGOs) can facilitate more culturally congruent healthcare interventions, which are crucial for the acceptance and effectiveness of the MASCC-ASCO Standards and Practice Recommendations within different cultural contexts (19).

Moreover, it is critical to develop funding strategies to ensure implemented programs’ sustainability. Collaborations with international donors, local governments, and private sectors can provide financial support to scale these interventions effectively. Furthermore, policy advocacy is needed to integrate survivorship care into national health plans, ensuring long-term commitment and resource allocation (20).

Developing local guidelines

In developing local guidelines for survivorship care, it is essential to tailor them to local populations’ specific contexts and needs. By addressing specific resource constraints, healthcare architecture, and significant health challenges, survivorship care is made practical, sustainable, and accessible within the community it serves (21). For example, the MASCC-ASCO Standards and Practice Recommendations suggests integrating local healthcare providers alongside patient advocacy groups and policymakers to ensure the practical feasibility and effectiveness of care plans (5). Furthermore, rural areas might face different healthcare accessibility issues compared to urban centers. Understanding these local nuances allows for the creation of more effective and practical care plans that resonate with the community’s realities.

Additionally, the involvement of local stakeholders is crucial. As noted in the MASCC-ASCO Standards and Practice Recommendations, their firsthand experience with the community’s needs and local healthcare system makes them valuable in adapting the standards practically (22). Examples of successful local adaptations, such as using community health workers in low-resource settings or telemedicine to bridge gaps between rural patients and urban centers, illustrate the potential of local innovations in transforming survivorship care (23). However, while the MASCC-ASCO Standards and Practice Recommendations is a step forward, it does not provide a detailed framework for implementation that accounts for varied local realities, nor does it delve into the mechanics of stakeholder involvement in the adaptation process. This oversight can limit its practical application across diverse global contexts (24).

Selective implementation

The MASCC-ASCO Standards and Practice Recommendations provides a robust framework for supporting individuals with incurable cancer. However, its practical implementation can be challenging due to resource constraints and varying institutional capabilities. Therefore, a selective implementation strategy is essential for prioritizing and deploying the most impactful components of the MASCC-ASCO Standards and Practice Recommendations, particularly in resource-constrained settings.

A strategic approach to implementation involves prioritizing aspects that significantly benefit patients’ quality of life. Emphasizing elements such as follow-up care, comprehensive management of long-term side effects, and robust psychosocial support is essential. For instance, structured follow-up care can significantly reduce the recurrence of disease and manage the side effects of cancer treatment, which are pivotal in improving patient outcomes (25). Furthermore, rehabilitation should be prioritized, which can help preserve patients’ function and prevent disability. These components address survivors’ immediate needs, helping mitigate the ongoing challenges they face and improving their overall well-being.

Phased implementation is a practical strategy that gradually incorporates elements of the MASCC-ASCO Strengths and Practice Recommendations based on current resources and capabilities. Starting with the most feasible components, such as establishing basic follow-up care protocols or integrating essential psychosocial support services, can provide immediate improvements in patient care. This strategy allows healthcare providers to build on small successes, gradually enhancing their capabilities to support more complex aspects of the MASCC-ASCO Standards and Practice Recommendations. For example, initiating telehealth services can be a starting point to expand access to care and manage follow-up appointments effectively before fully integrating comprehensive psychosocial support services. As resources allow, more complex interventions, such as comprehensive long-term side effect management programs, can be integrated, ensuring a sustainable expansion of services (23).

Telehealth and digital health tools are particularly pertinent in the post-pandemic era, where such technologies have proven essential in transcending geographical barriers. Implementing digital tools can facilitate remote monitoring and consultation, thereby enhancing the reach and efficiency of survivorship care (24). These tools are beneficial not only in resource-rich settings but also in other settings. However, they can be particularly transformative in regions where direct access to specialized healthcare providers is limited, ensuring that care is more inclusive and accessible to all survivors, regardless of geographical location (25).

Conclusions

With the growing number of patients with advanced and metastatic cancer worldwide, it is instrumental to produce clear, evidence-based standards and recommendations focused on advanced and metastatic cancer survivorship. The MASCC-ASCO Standards and Practice Recommendations is one such example, which provides holistic and multidisciplinary recommendations for advanced and metastatic survivorship. It strongly focuses on patient-centred care and incorporates evidence-based recommendations that are regularly updated to align with the latest research. Nonetheless, we anticipate challenges when implementing its standards in diverse healthcare settings and with diverse patient populations. As such, the MASCC-ASCO Standards and Practice Recommendations needs to be carefully implemented in LMICs. Local guidelines should be produced based on the MASCC-ASCO Standards and Practice Recommendations, which are better tailored to specific populations. By examining and implementing the strategies utilized by other guidelines, the MASCC-ASCO Standards and Practice Recommendations can better adapt to various countries and populations while still providing updated and relevant survivorship information.

Healthcare providers, policymakers, and researchers must continue prioritizing survivorship care by improving and implementing the MASCC-ASCO Standards and Practice Recommendations and tailoring it to specific populations. With the evolving survivorship care landscape, further evaluation, research, and adaptation of survivorship care is instrumental in meeting the needs of cancer survivors. This will only happen through continued collaboration between healthcare providers, researchers, policymakers, and cancer survivors, locally and internationally, allowing for the prioritization of cancer survivorship research and implementation worldwide.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article has undergone external peer review.

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-24-144/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-24-144/coif). C.B.S. II serves as the Editor-in-Chief of Annals of Palliative Medicine from April 2014 to April 2027. S.F.L. serves as an unpaid co-chair for the Palliative Radiotherapy Subcommittee of Annals of Palliative Medicine from October 2023 to September 2025. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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