Models of Care in Providing Comprehensive Healthcare on Cancer Survivors: A Scoping Review with a TIDieR Checklist Analysis

Abstract

Background: The study’s aim is to identify the models of care used to provide survivorship care plans (SCPs) to cancer survivors in healthcare services, describing what kind of professionals are involved, in which settings and timings, and their feasibility. Methods: The Joanna Briggs Institute methodology for scoping reviews is followed. Studies that considered the SCPs applying different models of care, in any healthcare setting on any adult cancer survivors who completed oncological treatments, have been included. Pubmed, Embase, Cochrane Library, Scopus, and Cinahal were searched from 2013 to 2023 with these keywords: “Survivorship Care Plan”, “Oncology”, and “Program”. The study selection process was reported with the PRISMA-ScR. A total of 325 records were identified, 42 were screened, and, ultimately, 23 articles were included. Results: The models of care include: SCP standardization in hospitals; self-support oriented; consultation-based; primary or specialist direct referral; shared care; a multimodal approach. Multidisciplinary teams were involved in the SCP models of care. The settings were private clinics or cancer centers. One-hour SCP interventions were most frequently delivered through in-person visits, by telephone, or online. Conclusions: Implementing SCPs is feasible in healthcare contexts, but with challenges, like time and resource management. Patient-centered programs promoting coordinated care are promising models of care.

1. Introduction

Globally, cancer is the second leading cause of death, with 9.6 million deaths in 2018 [1]. In countries where health systems are strong, the survival rates of many types of cancers are improving thanks to accessible early detection, treatments, and survivorship care [1]. Furthermore, recent oncological clinical research is integrating long-term follow-up and health-related quality of life [2]. The National Cancer Institute’s Office of Cancer Survivorship (NCCS) defines cancer survivorship as the life experience of a person with cancer after treatment until the end of life. It stresses how discussing survival problems with carers can give hope to newly diagnosed patients and support them in being an active part of their treatment path [3]. However, the health needs associated with cancer survivorship are often complex and require specific and personalized approaches [4]. Moreover, these needs evolve along with scientific progress, as well as in survivorship policies and programs, that must also face context-related issues to guarantee equal access to quality care [5]. Survivorship care plans (SCPs) empower care coordination, optimizing follow-up care with various providers [6]. SCPs provide guidelines and support cancer survivors (CSs) in promoting healthy behaviors and tailored lifestyle recommendations, increasing their knowledge on diagnosis, the late effects of cancer treatments, and recurrence [6]. SCPs appear feasible, but additional research is needed to clarify their effectiveness and implementation issues [7]. Still, no absolutely replicable reference exists for any well-being environment to reproduce an SCP. All models should provide personalized and comprehensive patient care that meets the long-term individual needs to improve these patients’ overall health and outcomes [8]. In the Italian epidemiological and demographic context, SCP implementation is still sporadic [9]. This scoping review aims to analyze the organizational models of survivorship care in healthcare contexts.

2. Materials and Methods

The proposed scoping review was conducted according to the methodology of the Joanna Briggs Institute (JBI) for scoping reviews [10]. The review question was built following the population–concept–context (PCC) framework [10] to ensure clarity. The primary outcome was to identify and describe the models of care used to provide SCPs (concept) to CSs (population) in healthcare services (context). The secondary outcome was to evaluate (1) what kind of professionals are involved in providing SCPs; (2) which settings and timings are planned in the SCPs offered to the patients; (3) the feasibility of the implementation of the SCPs’ models of care. The protocol of this scoping review is registered on Open Science Framework (osf.io/5wm6g; accessed on 22 January 2024).

2.1. Eligibility Criteria

The inclusion criteria are as follows: (1) studies that considered the SCP intervention applying different models of care in any healthcare setting; (2) studies that evaluated any outcome on adult CSs that completed the active chemo/radiotherapy treatment or healthcare personnel perceptions; (3) experimental, quasiexperimental, observational study designs, qualitative and mixed-method studies, and also systematic reviews that met the inclusion criteria; (4) studies published from 2013 to 2023. Thus, the exclusion criteria are listed as follows: (I) studies that do not refer to the oncological field; (II) the nonadult population; (III) incomplete or unpublished literature; ineligible evidence types (conference papers, clinical cases, and theoretical/position papers).

2.2. Search Strategy

We initially searched for articles in MEDLINE. We evaluated the available evidence in the last ten years to include relevant international experiences of SCP implementation, as their relevance is not only influenced by the time-related scientific progress, but also by the healthcare-context-related issues and by its population. The databases (Pubmed, Embase, Cochrane Library, Scopus, and Cinahl) were searched in May 2023, with no language limitations, with these keywords: “Survivorship Care Plan”, “Oncology”, and “Program”. The search strategy, including all keywords and index terms, was reconciled in each database until content-related saturation. The reference list of all included sources of evidence was screened for additional studies.

2.3. Study Selection

The study selection process, represented in Figure 1, is conferred in a Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for a scoping review (PRISMA-ScR) flow diagram [10]. Mendeley software (2.92.0.55 version), currently used in the literature [11], was chosen to import the results and remove duplicates. Records were screened for eligibility by two independent reviewers in each phase: firstly, by evaluating the title and the abstract; secondly, after the full-text reading. Any disagreements were discussed at each stage of the selection process by the reviewers. Reasons for the exclusion of studies were recorded and reported.

2.4. Data Extraction

The selected articles were extracted into Excel by one reviewer and independently cross-checked. If the full texts were unavailable, the abstracts were considered in the analysis, reported, and discussed separately. Extracted data included the author, year, country, study design, professionals, setting, timing, endpoints, and main results. These elements were sought according to the specific outcomes stated before. A narrative and thematic synthesis was conducted by one reviewer to summarize the results, evaluating the SCP interventions.

2.5. TIDieR Checklist

The Template for Intervention Description and Replication (TIDieR) [12], a tool to improve the quality of the reporting and the reproducibility of healthcare interventions, has been used to analyze the SCPs in detail. This checklist is currently used in similar research [13,14]. It consists of a checklist of 12 items and the relative guide, explaining and elaborating each item and examples of appropriate reporting. For complex interventions, as in this case, this level of detail is necessary for each intervention component. However, this information needs to be included or reported.

2.6. Critical Appraisal of the Evidence

Although this step is not considered mandatory in the methodology followed, we decided to critically appraise the literature included because it provides more certainty when referring to this intervention, specifically on how it should be methodologically evaluated and implemented in different healthcare contexts. The quality assessment was conducted with the Effective Public Health Practice Project (EPHPP) [15]. It is a widely used instrument with an excellent degree of inter-rating reliability for experimental and observational studies [15]. The score’s sum of the six domains (selection bias, study design, confounders, blinding, data collection methods, withdrawals, and drop-outs) constituted the overall quality rating that could be “strong”, “moderate”, or “weak”. Qualitative studies have been evaluated with the Critical Appraisal Skills Programme (CASP) checklist [16], a commonly used tool in similar research [17,18]. As reported in the recent literature [19], guidelines were assessed with the Appraisal of Guidelines, Research, and Evaluation (AGREE) II checklist [20]. Two independent reviewers conducted the quality assessment and discussed and solved any discrepancies.

3. Results

3.1. Literature Search Results

As represented in Figure 1, the literature search identified 325 records: 38 from Pubmed, 136 from Embase, 26 from the Cochrane Library, 67 from Scopus, and 58 from Cinahl. The results obtained were relevant and satisfactory. As many duplicates were retrieved, other databases (e.g., Web of Science and Google Scholar) were not consulted further. After deleting 18 duplicates, 307 articles were screened by title and abstract reading. A total of 42 papers were assessed for eligibility: 19 studies were of the excluded: not pertinent (N = 16) and not eligible publication types (N = 3). Finally, 23 articles were included in the review. As almost half of the evidence included was older than five years, we agreed to present them separately into two subgroups (before and after 2019): this permitted a more specific analysis considering the most recent technoscientific progress. The main findings are summarized in Appendix A and Appendix B. The SCP interventions of the studies included are analyzed with the TIDieR checklist in Appendix C and Appendix D.

3.2. Characteristics of the Included Literature

The articles involved participants from America (n = 17), Asia (n = 2), and Oceania (n = 4). The study designs were observational (n = 7), experimental (N = 12), mixed-methods (N = 2), qualitative (n = 1), and guideline (n = 1). Specifically, the experimental studies were: randomized controlled trials (RCTs) (N = 4), pilot studies (N = 4), implementation projects (N = 2), and quality-improvement projects (N = 2). Thirteen studies evaluated an SCP intervention in clinical contexts [21,22,23,24,25,26,27,28,29,30,31,32]; six studies described the tool-development or integration processes [33,34,35,36,37,38]. The SCPs were confronted with usual care in four RCTs [39,40,41,42]. One guideline on breast cancer survivors (BCSs) was found [43]. BCSs were involved in twelve studies [24,27,29,31,32,33,34,36,37,40,41,43]; six with various types of cancer [21,22,23,28,30,38]; one with the bladder cancer type [26]; two with colorectal cancer (CRC) types [23,24]; one with the lung cancer type [35]; one with the melanoma type [25]; one with the head–neck cancer type [39]; one with the gynecological cancer type [32].

3.3. Critical Appraisal with the Sources of Evidence

As chronologically reported in

Table 1. Quality assessment of the included quantitative studies with the Effective Public Health Practice Project (EPHPP).

Quantitative Study	EPHPP
Lee et al. (2023) [39]	Strong
Lai-Kwon et al. (2022) [25]	Moderate
Williamson-Butler et al. (2022) [40]	Strong
Lee et al. (2020) [26]	Moderate
Corsini et al. (2020) [30]	Moderate
Glaser et al. (2019) [32]	Moderate
McGrath et al. (2019) [38]	Weak
Su et al. (2019) [41]	Strong
Nàpoles et al. (2019) [29]	Moderate
Ivanics et al. (2019) [27]	Moderate
Tevaarwerk (2017) [36]	Moderate
Rosenberg et al. (2016) [21]	Moderate
Jefford et al. (2016) [42]	Strong
O’Hea et al. (2016) [37]	Moderate
Berman et al. (2016) [35]	Weak
Grant et al. (2015) [34]	Weak
Jefford et al. (2015) [23]	Moderate
Rosales et al. (2014) [22]	Weak
Downs-Holmes et al. (2014) [33]	Weak
Patt et al. (2013) [28]	Weak
Dulko et al. (2013) [24]	Moderate

, the quality of the evidence was variable: strong (N = 4), moderate (N = 11), and weak (N = 6). The study design, the robustness of the methodology, and the sample size were the main elements influencing the rates. The overall quality of the guideline [43] was 6/7 on the AGREE II scale. The qualitative study [31] was considered of good quality from the CASP checklist.

3.4. Results of the Individual Sources of Evidence

We present the findings of studies published before 2019. The objectives of risk-adapted visits (RAVs) in the Living in the Future (LIFE) program described in Rosenberg et al. [21] are focused on patient reintegration into primary care and community resources, and educating CSs on diagnosis, treatments, and recommendations for preventive healthcare. The education addresses lifestyle nutrition/fitness, genetics, sexuality, employment, cognition, and lymphedema. Rosales et al. [22] implemented a successful survivorship model in a tumor institute: they reviewed 118 medical records to evaluate survivorship needs and satisfaction. Weight management (35%), fatigue (30%), and sexuality (27%) resulted in some of the most frequent worries. This SCP improved patient engagement, satisfaction, and care coordination. Jefford et al. [23] developed an analysis framework of reports to synthesize the key themes, enablers, and challenges of six 2-year Victorian Cancer Survivorship Program (VCSP) projects. The interventions were considered appropriate by CSs. Strong leadership, workforce education, risk-stratified pathways, and shared personalized care models were the primary enablers. The lack of tool validity, the limited evidence, the workforce redesign, and issues around survivorship terminology were challenging factors. Then, Jefford et al. [42] conducted a multicenter RCT aiming to improve the quality of life (QOL), psychological concerns, and CRC survivors’ care needs (SCNs). The intervention, including the educational materials, needs assessment, end-of-treatment session, and three follow-up telephone calls, was compared to the usual care (UC) (N = 110). Between-group differences in distress, SCNs, and QOL at 2 and 6 months were small and nonsignificant. The SCP group was more satisfied with the SCP than the UC group. O’Hea et al. [37] presented the development results of a web-based breast cancer SCP: the Polaris Oncology Survivorship Transition (POST) matched data from the electronic health records (EHRs) and oncology care providers (OCPs). Twenty-five women ending treatment in the past year were selected from outpatient clinics and chemotherapy units. They received the POST computerized assessment and a tailored SCP. A total of 70% of the responders rated the SCP highly satisfactory. Berman et al. [35] used the OncoLife and the LIVESTRONG care plans to identify demographic, treatment, and toxicity data of primary lung cancer survivors: of 689 patients, neurocognitive adverse effects were the most frequent (48.8%). Dulko et al. [24] aimed to evaluate the process of an SCP completion (patient response rate: 73%), and to survey oncology staff (OF) (response rate: 94%) and primary care physicians (PCPs) (response rate: 71%) regarding the challenges of SCPs in two facilities. Despite its usefulness, the creation time and insufficient knowledge of CS issues were perceived barriers. Grant et al. [34] described the implementation of follow-up models for BC survivors across 14 Canadian Regional Cancer Centers: all regions used SCPs and patient education materials, direct-to-primary care, transition clinics, and shared respect. A total of 85% of patients reported feeling adequately prepared for the transition to primary care. Downs-Holmes et al. [33] described the necessary steps for developing and implementing an institution-specific survivorship program to fulfill the new standards for survivorship care. Patt et al. [28] implemented an SCP in a cancer center, creating a toolkit, interorganizational collaboration, and assembling a working team. In Runowicz et al. [43], the purpose of the guideline was to provide recommendations for breast cancer survivors’ care: recommendations concerned surveillance for breast cancer recurrence, long-term effects, health promotion, and care coordination. Tevaarwerk et al. [36] described a clinical trial assessing the survivors’ knowledge after the receipt of treatment summaries. The exploratory analysis showed that a significant proportion of treatment summaries contained at least one error (25%) or omission (22%).

The findings of the studies published after 2019 are presented below. Williamson-Butler et al. [40] aimed to compare an RCT design with an SCP program (POST) to UC: the outcome was set on the quality of discussion (QOD) between providers and patients. At their last treatment visit, two hundred patients were randomized. The POST women reported a better QOD. Su et al. [41] employed an RCT to search if breast CSs receiving a web-based SCP were more likely to improve on at least one of the four targeted issues than the attention controls. A total of 70.9% of women improved in fertility-related concerns, hot flashes, vaginal symptoms, and contraception compared to 57.3% of the control group. Lee C.T. et al. [26] described, with a mixed-methods approach, the feasibility of SCPs among breast cancer survivors. Patients found high acceptability and engagement; 59 SCPs were completed by providers without any difficulty, confirming the clearness, relevance, and feasibility. Lai-Kwon et al. [25] assessed the feasibility and acceptability of a nurse-led, telehealth-delivered SCP for metastatic melanoma survivors. The participation rate was 57%; 97% completed the program, demonstrating its utility and acceptability (3/4 AIM items). Ivanics et al. [27] conducted a project evaluating two SCP programs implemented in a cancer institute with a quality-improvement Plan–Do–Study–Act model. System II (treatment summaries by multidisciplinary breast specialists) had fewer inaccuracies than System I (treatment summaries by nonspecialist breast clinic staff). Lee L-Y. et al. [39] employed an RCT design to evaluate the effects of a nurse-led SCP compared to usual care on emotional distress, physical and mental health, social support, and resilience among 100 dyads (caregivers and patients with advanced head and neck cancer). In the nurse-led SCP, the outcomes slightly improved in six months, with statistical significance. Napoles et al. [29] evaluated the feasibility and acceptability of a linguistically suitable Spanish-speaking breast cancer survivor SCP. A total of 83% of women completed all five coaching calls. A total of 81% rated the app’s overall quality as “very good” or “excellent.” McGrath et al. [38] standardized and integrated an SCP into the EHR: this increased the participation of other specialists and the rate of completion from 10% to 34%. Glaser et al. [32] described an SCP in a survivorship clinic with a network of support services. A total of 908 CSs received the SCP and personalized complementary care. Corsini et al. [30] reported a multicentric pilot study that tested SCP tools with a quality-improvement approach: based on the 43 consultations made, barriers included perceived knowledge, the time to complete the documentation, referral pathways, and the lack of administrative support. Fok et al. [31] explored the perspectives of PCPs towards managing BCSs in shared-care with oncologists. Most PCPs referred to limitations in managing acute and nononcological issues. PCPs’ role may grow, including cancer surveillance and unmet needs.

3.5. Synthesis of the Results

3.5.1. Professionals Involved in Providing the SCP

Generally, the SCP approach is multidisciplinary. Although the professionals most frequently involved in the SCPs are medical oncologists (MOs), PCPs, and nurses, in six studies, the MOs/PCPs and the nurses worked together [21,26,29,30,35,37]; in two studies, only MOs/PCPs were involved [31,41]. A sizeable multidisciplinary approach was described in four studies [23,28,33,34]. In seven studies, the SCP was provided by a nurse [22,24,25,36,39,40,42], and in two studies [30,38], they worked in teams. Two studies referred to the OS [27,32]. There were no substantial differences between the professionals involved in the SCPs before or after 2019. This suggests that the results were not distinctly susceptible to scientific progress over this period.

3.5.2. Setting and Duration of the SCP Interventions

Eleven studies were multicentric [21,22,23,24,28,30,34,36,37,39,42]. Eleven studies involved one center [25,26,27,31,32,33,35,38,40,41]. Four studies enrolled patients from outpatient private clinics [22,26,27,37]. Cancer centers/survivorship clinics were involved in nine studies [28,30,31,32,33,34,36,38,39]. Tevaarwerk et al. [36] provided intervention with an in-person visit or by telephone, while, in seven studies, intervention was provided only by an in-person visit [22,24,26,28,30,37,38]; in three studies, intervention was provided only by telephone [25] or was web-based [35,41]. Five studies planned remote follow-up after the first visit [21,27,39,40,42]. One study organized home visits [29]. Jefford et al. [23] analyzed various models:

• shared care with discharge to a general practitioner (GP), with one or two appointments supporting health promotion;
• specialist care with GP support through multidisciplinary visits;
• self-support or community services referral.

According to Glaser et al. [32], the survivorship clinic offers a one-time visit with referrals, transition to long-term care, or self-referral. Most studies that reported this information provided a one-hour intervention (N = 6) [21,22,25,28,39,42]; two studies [27,40] provided an intervention that lasted less than one hour; the other two studies provided an intervention that lasted more than one hour [22,30]. Studies conducted before 2019 were mainly multicentric. Meanwhile, the most recent studies were developed in a single health center. Specialized cancer centers and private clinics had the same commitment over several years in the proposals of the survivorship care plan.

3.5.3. Models of Care

As describing complex interventions can be challenging, the TIDieR checklist helped us to summarize the core elements of the different experiences of providing survivorship care and how they are provided in the healthcare contexts:

• SCP standardization in hospital care: the SCP was used to collect information about specific survivorship issues [35] or for quality-improvement projects aiming to (1) improve the efficacy with the EHR integration of the SCP document [38,40]; (2) improve the accuracy of the SCP document [36]; (3) improve the knowledge and consciousness about specific survivorship issues [41]; (4) improve the complete comprehension of the SCP document [29].
• Self-support oriented [23,41].
• Consultation-based: several studies reported similar experiences. The SCP intervention was created and completed with the patient during a hospital visit. The SCP document was recorded within the patient chart, and a summary of the indications were given to the patient and sent to the PCP. Clinicians managed the follow-up remotely [22,24,26,28,30,39,42]. Two studies reported a project where a specific computer program was built [37] and used [40]: this integrated information between the EHR, MO, and patients, and was used to create the SCP. One study organized telehealth consultations [25]. In two studies, the ON managed the intervention [21,36].

Most of the experiences reviewed involved multiple stakeholders but varied in the focus of the care provider referral:

• PCP direct referral [34].
• Specialist direct referral [23].
• Integration between specialist and primary care: the key elements of the integration were multimodal resources, dedicated clinics, and a shared-care model. One study used different resources (visits, summaries, and a phoneline) to catalyze the passage from active treatment to follow-up care [21]. Glaser et al. [32] reported the experience of a survivorship clinic linked with external services concerning wellness and nutrition. A transition clinic within one of the cancer centers involved in the study of Grant et al. helped transition survivors back to their PCPs [34]. A shared-care model was applied in coresponsibility between the MO and PCP [34], as in Fok et al. [31], where the approach was risk-stratified. In Jefford et al. [23], the patient was discharged to the PCP, with one or two survivorship appointments supporting health promotion.
• Multimodal approach: the studies [23,30,34] reported different experiences in testing the models of care that varied according to the service available in the territory.

Studies showed similarities in adapting the models of care to each context over time, specifically on accessibility and follow-up. However, digital and innovative strategies have grown in the last five years.

4. Discussion

A scoping review methodology was selected [10], as it provides literature mapping on a specific topic, showing concepts, evidence gaps, and the types of available studies [44]. The overall body of evidence concerning the topic was variable and of moderate quality. Breast cancer was the most frequent when a specific type of cancer was analyzed. The SCPs were confronted with usual care in the RCT designs: one found statistically significant differences in the SCP group on social support, emotional distress, physical and mental health, and resilience improvement after six months [39]. Nevertheless, a similar study [42] conducted in 2015 with a bigger sample size found no significant differences other than a higher satisfaction rate. A significantly higher quality of discussion with the providers was found in the SCP group of another study [40].

The SCPs involved are primarily provided in multidisciplinary, patient-centered contexts, integrated with primary care at different levels. The results were valid in promoting individualized healthcare, self-management, and well-being. Implementing and adapting an SCP in different healthcare contexts appears to be a feasible intervention. Many human and technological resources provide the intervention presented in the reviewed studies, negatively impacting costs [21,34]. Most emerging challenges, like the lack of time, administrative support, and specific training, worsen as the medical facility has less volume of patients and a greater distance to the central hub [30]. Nevertheless, innovative models of care that consider community characteristics and needs (self-support and service-oriented, web-based interventions, and periodic home visits) [25,36,41] are promising in optimal timing, resourcing, and cost-effectiveness, and can be studied with robust design studies. Technological integration in usual care and the balance between specialty and primary care remain challenging in many contexts. The main enablers in implementing SCPs were focused on preparing survivors for post-treatment care. Some survivors face new models of survival assistance immediately after treatment. In contrast, others need time to process and recognize the end of treatment before contemplating survival challenges. Stratified pathways of early preparation for survival are based on individual needs and self-management with shared-care models [21]. Nursing survival models have successfully provided comprehensive care, addressed the unique needs of CSs, and improved patient self-management [23,25,26,33]. The introduction of survival programs increases the awareness among health professionals of the need to enhance post-treatment care. The limited capacity of outpatient services has led to the development of new approaches to survival care, such as the passage to primary care settings [31,41]. Clinical solid leadership, community organizations, stakeholders, and primary care providers are crucial to successful implementation [23,28,33,34]. In this regard, training and education are also determinants to support professionals in involving patients and family members appropriately. A barrier to the successful implementation of SCPs is the lack of valuable assessment tools to predict the needs of survivors [21,33,37]: the documentation and follow-up of survival care, including goal setting, symptom reassessment, and follow-up, are often inadequate, which may hinder the provision of comprehensive care [24]. The literature needs more evidence to support new care models. Another relevant aspect is redesigning the health workforce, as providing survival care requires specific education and training for operators in different care settings [29,31]. In addition, the care teams needed help identifying patients who had finished the therapy and were suitable for the SCP due to the incomplete treatment plans or the unclear responsibility of the SCP among different specialties [24]. Moreover, one of the main obstacles to evolving the SCP is linked to time: the study of medical records, especially for patients who have received treatment in different settings, where obtaining prior or external data, including chemotherapy data, has been reported as challenging. The difficulty in updating SCPs appears familiar to many care plans, and there have been mixed responses as to when the SCPs should be updated for disease progression or new primary diagnoses. Another impact is the limited access to survivors and insufficient knowledge, where PCPs have reported limited access to survivors and inadequate understanding of cancer survivors’ problems, indicated as obstacles to the follow-up organization. The barriers highlighted the need for institutional support, better communication between healthcare providers, and potential improvements in EHR systems to facilitate the implementation of the SCPs [25,29,35,38,41]. Being able to take advantage of technological advancements to meet the needs of survival could provide the assurance of equal access to care plans, ensuring their traceability and redirection to potential health benefits, and, consequently, with medical management for the long-term results of cancer survival.

4.1. Limitations

The present study has some limitations. A small number (N = 23) of studies were eligible for this review; almost half of the studies were dated beyond 5 years. The small sample sizes of several of the non-RCT studies analyzed could not permit the generalization of the results. Moreover, European experiences needed to be included in the literature examined, making it difficult to compare, and eventually adapt, the results in universal healthcare systems.

4.2. Implication for Practice

Different SCP models are potentially replicable in different healthcare contexts, like multidisciplinary nurse-led transition education programs. The studies demonstrate that nurses are well-positioned to provide patient education and support regarding SCPs, helping patients understand their health conditions, treatments, and preventive healthcare [25]. Many studies have shown that nurse-managed survival care is safe, comprehensive, and successful when placed in the healthcare coordination of cancer patients [25,30,32,38,39,40], even with digital health [29]. The nursing profession is indispensable in health education to achieve the physical and psychosocial results of the patient. The other fundamental aspect is related to the economic benefits derived by the time savings and the reduced use of health resources compared to the care led by specialists. They can also empower cancer survivors to take an active role in their wellness and connect them to community resources for emotional and physical recovery [26] as facilitators of the transition from oncology care to primary care. Further research may focus on innovative and cost-effective models of care combined with solid competence and training, decisive in assuring sustainable and high-quality SCPs.

5. Conclusions

This scoping review aimed to identify the models of care used to provide survivorship care plans (SCPs) to cancer survivors in healthcare services, describing what kind of professionals are involved, in which settings and timings, and their feasibility. The main models of care implemented to provide SCPs are standardization in hospitals, self-support oriented, and consultation-based, with primary or specialist direct referral, with a shared-care or a multimodal approach. Multidisciplinary teams are mostly involved in private clinics or cancer centers. One-hour SCP interventions were most frequently delivered through in-person visits or digital health. Implementing SCPs is feasible in healthcare contexts, but with challenges, like time and resource management. Patient-centered programs promoting coordinated care are promising models of care. Promoting dynamic care between the hospital and territory may ensure a more graded assistance: nurses are promising in this vision, favoring continuity, quality, and the appropriateness of survivorship care.