As Korea's cancer survivor population grows, long-term care is increasingly needed for second cancers, late effects, comorbidities, and psychosocial concerns. Tertiary hospital-centered follow-up and existing chronic disease programs cannot fully address survivors' treatment histories and risk profiles.
This study reviewed domestic policies and international models, identifying four gaps: information sharing, risk-based follow-up, reimbursement, and education and consultation pathways. It proposes a staged system connecting cancer treatment hospitals, coordination institutions, and primary care. In a dual-physician model, treating and primary care physicians jointly manage care plans with coordinator support, while combined cancer-specific and general health risk stratification guides care intensity.
Recommendations include cancer-type-differentiated care, appropriate reimbursement, a shared care-plan platform, and flexible coordination arrangements for