Treatment ends. Recovery doesn’t.

Following treatment, patients do not necessarily transition into a state of full recovery. While specific diseases may be clinically controlled, patients frequently continue to experience persistent symptoms alongside the emergence or co-existence of additional chronic conditions, creating a sustained need for ongoing adaptation. In cancer contexts, survivorship care extends beyond treatment to include ongoing surveillance, management of long-term adverse effects, and comorbidity care, and is often delivered within complex and fragmented pathways characterized by communication gaps, unclear responsibilities, and patients acting as intermediaries between providers (Love et al., 2022). More broadly, this reflects a structural feature of chronic disease management, in which patients are required to navigate across multiple levels of care, including primary care, specialist services, and hospital settings.

At the patient level, this post-treatment phase is frequently marked by persistent and interacting symptom burdens. Cancer-related fatigue, for example, is among the most prevalent and debilitating long-term symptoms, driven by interacting inflammatory, neuroendocrine, and psychosocial mechanisms, and can persist long after treatment completion (Kafetzopoulos et al., 2025). In addition, psychological conditions such as anxiety, depression, and fear of recurrence commonly co-occur. The study of Deng et al. (2024) indicates that these symptoms do not occur in isolation but form distinct clusters of burden, which are associated with significantly poorer physical and mental health-related quality of life. Survivorship is therefore more accurately characterized not as the resolution of illness, but as the persistence and interaction of multiple symptom burdens.

The complexity extends beyond symptom-level burden to the level of coexisting chronic diseases. Many patients live with or develop multiple chronic conditions, resulting in multimorbidity. A nationwide Danish study demonstrates that patients with multimorbidity experience highly fragmented care across primary and hospital sectors, and that such fragmentation is associated with increased risks of potentially inappropriate medication and mortality, suggesting suboptimal treatment outcomes (Prior et al., 2023). At the population level, this reflects a broader shift in healthcare: according to OECD (2025), 82% of primary care users aged 45 and above live with at least one chronic condition, while over half experience multimorbidity, indicating that multimorbidity has become the norm rather than the exception in primary care.

Within this context, fragmented healthcare systems further intensify the burden of post-treatment care. Systems organised around single diseases are poorly aligned with patients living with multiple, interacting conditions, requiring patients to coordinate care across providers and settings (Montori, 2021). As a result, managing persistent symptoms and multimorbidity becomes increasingly complex.

Reference:

Ecancer. (2025, February 7). Fear of breast cancer recurrence: Impact and coping with being in a dark place. Ecancer. https://ecancer.org/en/news/25984-fear-ofbreast-cancer-recurrence-impact-andcoping-with-being-in-a-dark-place

Love, M., Debay, M., Hudley, A. C., Sorsby, T., Lucero, L., Miller, S., Sampath, S., Amini, A., Raz, D., Kim, J., Pathak, R., Chen, Y., Kaiser, A., Melstrom, K., Fakih, M., & Sun, V. (2022). Cancer Survivors, Oncology, and Primary Care Perspectives On Survivorship Care: An Integrative review. Journal of Primary Care & Community Health, 13, 21501319221105248. https://doi.org/10.1177/21501319221105248

Montori, V. M. (2021). Removing the blindfold: The centrality of care in caring for patients with multiple chronic conditions. Health Services Research, 56(S1), 969–972. https://doi.org/10.1111/1475-6773.13865

OECD (2025), Does Healthcare Deliver?: Results from the Patient-Reported Indicator Surveys (PaRIS), OECD Publishing, Paris, https://doi.org/10.1787/c8af05a5-en.

Deng, W. H., Lie, H. C., Ruud, E., Loge, J. H., Kiserud, C. E., & Rueegg, C. S. (2024). Profiles of Fatigue and Psychological Symptoms in Long‐Term Childhood, Adolescent, and Young Adult Cancer Survivors—The NOR‐CAYACS Study. Cancer Medicine, 13(22), e70425. https://doi.org/10.1002/cam4.70425

Kafetzopoulos, V., Pittaka, M., Ioannidis, G., & Moniem, I. (2025). Chronic Fatigue in Cancer Survivorship: Psychiatry Versus Oncology or Psychiatry with Oncology? Current Oncology Reports, 27(7), 883–905. https://doi.org/10.1007/s11912-025-01697-9

Piombo, S. E., Barrington-Trimis, J., & Valente, T. W. (2023b). Impact of social networks and norms on e-cigarette use among adolescents in Southern California: a prospective cohort study. BMJ Public Health, 1(1), e000163. https://doi.org/10.1136/bmjph-2023-000163