Shared care

Who watches what, after treatment ends

Survivorship rarely fails because a guideline was unknown. It fails because no one was named. This is the responsibility split, domain by domain, with the re-referral triggers that make a hand-off letter worth sending.

Cardiac late effects

Oncology supplies: Supplies cumulative anthracycline dose, HER2 exposure, and radiation fields with doses.
Specialist manages: Cardio-oncology reads surveillance imaging and manages confirmed dysfunction.
Primary care owns: Orders the scheduled echo, manages blood pressure and lipids, and asks the symptom questions at every visit.
Re-referral trigger: New LVEF decline, strain change, unexplained dyspnea, or reduced exercise tolerance.

Endocrine and fertility

Oncology supplies: Documents alkylator exposure and any gonadal or cranial radiation.
Specialist manages: Endocrinology and reproductive endocrinology manage replacement and fertility planning.
Primary care owns: Runs annual thyroid function and screens for pubertal, menstrual, or libido changes.
Re-referral trigger: Abnormal thyroid studies, delayed or arrested puberty, or any fertility question.

Second primary cancers

Oncology supplies: Defines the radiation field and the resulting screening obligation.
Specialist manages: Breast imaging, GI, and dermatology run the modality-specific screens.
Primary care owns: Owns the screening calendar and the recall when a study is missed.
Re-referral trigger: Any missed screening interval, or a new palpable or visible finding.

Neurocognitive and psychosocial

Oncology supplies: Notes CNS-directed therapy and intrathecal exposure.
Specialist manages: Neuropsychology tests; psychology and social work carry distress and accommodation work.
Primary care owns: Screens at each educational or occupational transition and refers.
Re-referral trigger: New academic or workplace difficulty, or a positive distress screen.

Medication burden

Oncology supplies: Confirms which supportive-care medicines were time-limited by design.
Specialist manages: Pharmacy leads structured deprescribing review.
Primary care owns: Runs the annual medication review and executes tapers.
Re-referral trigger: Any medicine continued past its intended course, or a new fall, sedation, or renal change.

Financial and coverage

Oncology supplies: Flags the treatment cost exposure at discharge.
Specialist manages: Financial navigation and social work handle appeals and assistance programs.
Primary care owns: Asks the cost question directly and refers rather than assuming it is handled.
Re-referral trigger: Skipped medication, deferred imaging, or a coverage change.

Domain	Oncology supplies	Specialist manages	Primary care owns	Re-referral trigger
Cardiac late effects	Supplies cumulative anthracycline dose, HER2 exposure, and radiation fields with doses.	Cardio-oncology reads surveillance imaging and manages confirmed dysfunction.	Orders the scheduled echo, manages blood pressure and lipids, and asks the symptom questions at every visit.	New LVEF decline, strain change, unexplained dyspnea, or reduced exercise tolerance.
Endocrine and fertility	Documents alkylator exposure and any gonadal or cranial radiation.	Endocrinology and reproductive endocrinology manage replacement and fertility planning.	Runs annual thyroid function and screens for pubertal, menstrual, or libido changes.	Abnormal thyroid studies, delayed or arrested puberty, or any fertility question.
Second primary cancers	Defines the radiation field and the resulting screening obligation.	Breast imaging, GI, and dermatology run the modality-specific screens.	Owns the screening calendar and the recall when a study is missed.	Any missed screening interval, or a new palpable or visible finding.
Neurocognitive and psychosocial	Notes CNS-directed therapy and intrathecal exposure.	Neuropsychology tests; psychology and social work carry distress and accommodation work.	Screens at each educational or occupational transition and refers.	New academic or workplace difficulty, or a positive distress screen.
Medication burden	Confirms which supportive-care medicines were time-limited by design.	Pharmacy leads structured deprescribing review.	Runs the annual medication review and executes tapers.	Any medicine continued past its intended course, or a new fall, sedation, or renal change.
Financial and coverage	Flags the treatment cost exposure at discharge.	Financial navigation and social work handle appeals and assistance programs.	Asks the cost question directly and refers rather than assuming it is handled.	Skipped medication, deferred imaging, or a coverage change.

Four ways shared care quietly breaks

Everyone assumes the other clinic is watching

The most common survivorship failure is not a missed guideline; it is an unassigned one. Name an owner for every late effect in the hand-off letter.

The hand-off letter has no re-referral trigger

A letter that says 'please continue routine follow-up' returns nothing. State the specific finding that should send the survivor back.

The exposure summary never leaves the treating system

If primary care cannot see the cumulative dose, it cannot apply any schedule. The survivor carrying a portable, printable summary solves this without an interface project.

Transition happens on a birthday rather than on readiness

Age-based transfer out of pediatric follow-up drops survivors precisely when surveillance obligations lengthen. Use a readiness checklist and a named receiving clinician.

Common shared-care questions

Who is responsible for ordering surveillance echocardiograms after oncology discharge?

Whoever is named in the hand-off letter. In most shared-care models primary care orders the scheduled study and cardio-oncology interprets and manages abnormal results, but that split has to be written down rather than assumed.

What should a survivorship hand-off letter contain?

The exposure summary with cumulative doses and radiation fields, the surveillance schedule with intervals, a named owner for each late-effect domain, and the specific findings that should trigger re-referral.

When should a survivor be referred back to oncology?

For suspected recurrence, a second primary cancer, or any question about the original treatment record. Routine late-effect surveillance is generally not a reason to send the survivor back.

How do we handle survivors who move or change clinicians frequently?

Portability is the answer: the survivor holds a printable summary and surveillance calendar they can hand to any clinician, so the plan travels with the person rather than the practice.

Put the split in writing

Hand-off letter templates Surveillance schedules Content gap map Privacy and data ownership