The improvement in continuity and integrity of survivorship care for breast cancer survivors in Chinese healthcare system

Breast cancer is a major threat to human health. For a long term, breast cancer and the side effects of cancer treatments affect health and life quality of cancer survivors. With the development of medical technology for breast cancer in recent decades, the long‐term survival rate of breast cancer patients has been dramatically improved. There is an urgent need to identify and establish a health care model that could provide more customized, long‐term, and comprehensive medical services for breast cancer patients, especially for those in China. Multiple cancer survivorship care plans that have been widely used in Western countries, such as chronic care, shared care, and disease‐specific model, were summarized from original researches, systemic reviews, and health guidelines published by national and international health organizations. In currently available cancer survivorship care plans, oncology nurses played an indispensable significant role. But current existing cancer survivorship care plans could not be directly implemented in China due to different cultural backgrounds between Eastern and Western countries. Some adjustments and modifications need to be done on the basis of existing survivorship care plan to make it more suitable to Chinese patients' needs and with Chinese characteristics. For providing continuous and integrated high‐quality cancer survivorship care suitable for Chinese health care system, innovative technologies (telehealth, internet‐based symptom monitoring, mobile applications, etc.) could be rationally used as supplementary tools for current cancer survivorship care plans.

70.7%, which means that the therapeutic strategies that are currently used for breast cancer are effective and patients with breast cancer generally have a favorable prognosis. 3  to 85%-90%. 5 According to the data collected between 2003 and 2005, 5-year survival rate of breast cancer patients in China was 73%. 6 However, advanced breast cancer (ABC) is treatable but incurable. Currently, there are few available standard treatments for ABC.
According to the fourth ESO-ESMO international consensus guidelines for ABC, ABC patients require a long-term, complex, and multidisciplinary maintenance treatment, which can help with postponing disease progression, improving patients' quality of life, and prolonging patient survival. During the course of illness and treatments, physicians should keep patients informed of their conditions, available treatment options, and supportive and palliative care. Besides, patients should be encouraged to voluntarily participate in the decision-making process about their treatments where they can share their preferences and personal medical experiences with their health care providers. Innovatively, the involvement of oncology nurse practitioners, the application of TELEMEDICINE (provides cancer patients who live in remote regions with medical advises under certain circumstances), fertility preservation, and so on are also of great significance.
The combination of advanced anticancer therapies, diverse forms of supportive systems, and high-quality social care can jointly contribute to prolonging the survival of ABC patients. 7  The complete case management that is used in China currently has shown great advantages in improving patients' quality of life and promoting patients' satisfaction with oncological care within months or even years after discharge. However, the treatments of breast cancer have been prominently improved and the survivals of breast cancer patients have been greatly prolonged in the past decades. Cancer itself and its treatments may exert multiple potential effects on patients, which may last for years or even decades. Herein, how to provide cancer survivors with proper long-term medical care is a novel problem that needs to be solved. The National Academy of Medicine of the United States released a report in 2005 entitled from cancer patient to cancer survivor: lost in transition, which concluded the problems generated during cancer survivorship care, such as longterm challenges, unmet needs, gaps, and so on. 11 Such phenomenon also happened in China. Most of follow-ups may be suspended due to the failed transfer of cancer survivors from oncologists to primary care physicians, even though primary care physicians are willing to provide medical care for cancer survivors. Besides, profiles of patients after receiving different cancer therapies and specific guidelines for survivor care are still unavailable. Therefore, it is of great importance to explore and evaluate potential care models for providing breast cancer survivors with the most efficient and high-quality long-term health care. Current survivorship care guidelines are consensus-based but not evidence-based. According to a report released by the National Academy of Medicine of the United States in 2005, the key components of survivorship care included prevention of new cancers, surveillance for cancer spread, assessment, and intervention for late and long-term effects caused by cancer treatments, and coordination between specialists and primary care providers (PCPs). To meet these requirements, various models of cancer survivorship care have been developed or being developed or evaluated. This study reviews several cancer survivorship care models that have been established.

| Search strategy
The following search terms were used: models of survivorship care, cancer follow-up care, shared care, disease-specific care, comprehensive survivorship care or program, and follow-up of cancer survivors.
The initial search was conducted using online database Pubmed, MEDLINE, and Embase.

| Study selection
Two researchers independently reviewed titles and abstracts and selected potentially relevant articles. Then, we reviewed the full texts to confirm the eligibility and summarized descriptions, characteristics, cons, pros, participants, effectiveness, and efficiency of each care model from original studies. jointly offer health care to one patient. 12 It is a systematic riskstratified approach characterized by involvement, communication, and coordination between health care providers with different professional backgrounds. Several studies indicated that this model could be applied in cancer care for survivors. [13][14][15] In this model, a PCP is mainly responsible for non-cancer care. Once a patient is diagnosed with cancer, the patient will be referred to an oncology specialist. The oncology specialist will provide expert care for the patient during the entire treatment as well as after treatment when the patient is at highrecurrence risk. After oncological treatment, the oncologist needs to write a summary of the treatment and develop an individualized survivorship care plan, which will be handed over to both the survivor and his/her PCP for exchanging the physiological condition of the survivor and ensuring his/her post-treatment survivorship care. 16    The third type of survivorship care program is a specialized multidisciplinary survivor program that involves physicians, nurse practitioners, social workers, psychologists, administrators, and a network of consulting physicians. In this program, survivorship care is provided in a risk-based manner. 17 This model originated from pediatric cancer clinics and has functioned well so far. In this model, a minority of survivors are provided with resource-intensive services by multidisciplinary specialized medical teams, which means that a single cancer survivor may face multiple health care providers simultaneously. Hence, the model is featured by a waste of medical resources and not worth being promoted as a universal adult cancer survivorship (Table 1).

| DISCUSSION
All these survivorship care plans originated from Western countries. The improvement and innovation of care models are crucial to achieve optimal clinical outcomes, reduce costs, and improve patients' quality of life and satisfaction with care outcomes.
Currently, multidisciplinary-team management model is widely used in breast cancer survivorship care in China. 18 However, this model can only provide care after patients' discharge from hospital in a certain period of time instead of the whole lifecycle. The continuity of care is hardly to achieve without enormous human resource in this model. Rehabilitation clinic lead by case managers is also established in China and some promising results was reported but some free service (health consulting, guidance of rehabilitation exercises, etc) are surprisingly time consuming and could affecting work enthusiasm of case managers. 19 It was clearly pointed out that it is necessary to work on the follow-ups after the discharge of patients from hospital and provide transitional care in Outline of Nursing Development Plan in China (2011-2015). And it will be gradually established and improved the long-term nursing care system which is "supported by institutions, based on home care, and relied on community" said in the 12th Five-Year Plan. In the system, people will be provided with long-term care, rehabilitation, health education, and palliative care when is needed. 20 According to national conditions, it is suggested to train professionals working on the survivorship care in the future, develop professional theoretic guidelines, build multidisciplinary-team, and emphasize the role of family caregivers to help patients to achieve better quality of life. 21 Thus, it can be seen that we are still far from developing a cancer survivorship care plan that is efficient and suitable for the Chinese

CONFLICT OF INTEREST
The authors declare no conflicts of interest.

AUTHOR CONTRIBUTIONS
Dejing Xu contributed to the conception of the study and helped perform the analysis with constructive discussions. Shuchang Lou performed the experiment and performed the data analyses and wrote the manuscript. Jun Li contributed significantly to analysis and manuscript preparation.

ETHICS STATEMENT
The study was approved by the insititutional review board (CWO) of Jiangsu Cancer Hospital, China. All patients provided written informed consent.