A snapshot of the cancer survivorship landscape in Singapore

ABSTRACT

Cancer survivorship has emerged as a critical healthcare priority as global survival rates continue to improve. With the increase in cancer incidence and declining mortality in Singapore, healthcare systems face increasing demands to provide comprehensive care across the cancer continuum, from diagnosis and active treatment to end of life, while also addressing the long-term survivorship challenges, including psychosocial distress, fear of recurrence, and the absence of personalised survivorship plans. Current survivorship care remains oncologist-centric with limited stratification between hospital-based oncology services and community health providers. This underscores the urgent need for a national cancer survivorship framework and guidelines to meet the growing demands of cancer survivors while ensuring quality healthcare delivery. This review examines the current state and ongoing work of cancer survivorship care in Singapore, identifies existing challenges, and explores future directions towards developing a comprehensive framework within the local healthcare ecosystem.

CLINICAL IMPACT

What is New

• This review serves to update the latest status, policy, and needs for cancer survivorship in Singapore.
• Findings underscore the potential identification of facilitators of and barriers to cancer survivorship programmes, paving the way for subsequent survivorship work including artificial intelligence and cancer survivorship, cancer rehabilitation, and economic impact to sustain the programme.

Clinical Implications

• The review supports the need to increase the awareness of and knowledge of cancer survivorship frameworks and cancer rehabilitation, which is emerging in Asia.
• This work serves as a starting point to meet the growing cancer survivor population needs prior to conducting implementation science.

Cancer remains the leading cause of morbidity in Singapore, and new cases have increased from 61,522 (2010–2014) to 91,574 (2019–2023), while the cancer death rate has fallen by 21% since 2012.^1,2 The most common cancers affecting Singaporean men are prostate (18.0%), colorectal (15.8%), and lung (13.2%), while those affecting women are breast (29.9%), colorectal (12.6%), and lung (8.1%), with survival rates having greatly improved because of advances in screening and timely treatment.³ Although cancer affects 1 in 4 Singaporeans over their lifetime, 5-year survival rates have tripled in the past 5 decades. In the US alone, the cancer survivor population is estimated to grow from 18 to 26 million by 2040, with similar trends observed in middle- and high-income countries worldwide.⁴

Despite advancements in anti-cancer treatment and therapy, improvements in care and disease control do not guarantee a restoration of health. Therefore, cancer survivorship care plans and national guidelines play an integral role in the healthcare system. In recognition of the urgency of cancer survivorship care, the Ministry of Health (MOH), Singapore, released a seminal report “Singapore’s Approach to Cancer” in January 2026, outlining survivorship quality as 1 of the 5 main thrusts, and emphasises the importance of community support and access to quality care services as key domains to support long-term recovery and return to normalcy.⁵

In 2005, the Institute of Medicine (IoM) released a report detailing how cancer patients were “lost in transition” as they transitioned to cancer survivorship following primary treatment.⁶ The IoM recommended a survivorship care plan for every survivor, yet the complex nature of the survivorship care team, healthcare resource allocation, and programme sustainability remain challenging issues to be addressed. According to the US National Cancer Institute, a person with a cancer diagnosis is considered a survivor from diagnosis through the end of life. After primary treatment, a survivor transitions into an extended phase consisting of close surveillance for recurrence or secondary cancers, commonly referred to as the survivorship phase.⁷ Four distinct phases of survivorship have been proposed: acute, chronic, long-term, and cured, reflecting the illness trajectory and the differing care needs at each stage.⁸ Re-establishing normalcy poses a significant challenge for survivors, as long-term adverse effects including cognitive decline and fatigue continue to plague quality of life. Additionally, psychosocial anxiety and a constant fear of recurrence persist throughout the survivorship continuum.⁹ It is increasingly important to improve not only cancer mortality, outcomes, and quality of life but also the psychological well-being of cancer patients after treatment. In this regard, community-based cancer rehabilitation services play a pivotal role in supporting the transition from hospital-based care to community living or primary care settings, facilitating return to pre-illness functional levels.^10,11

Although tremendous progress has been made, the implementation of survivorship care remains fragmented and insufficiently personalised to the needs of individual survivors.¹² A major limitation in survivorship care is the paucity of evidence for cancer survivorship programmes and appropriate methods to evaluate the programme’s effectiveness.^13-15 Research on cancer survivorship is an emerging field in Asia, and it has been shown that cancer survivors in Southeast Asia (SEA) are often unprepared for cancer complications and the sequelae of treatment, culminating in physical disability, distress, and reduced quality of life (QOL).¹⁶ Socioeconomic status, including employment and housing type, has also been shown to impact QOL.¹⁷ While cancer rehabilitation is beneficial, practical barriers exist and impede the implementation of cancer survivorship efforts in Singapore.^11,18-20 In this review, the authors discuss the current landscape and challenges of Singapore’s cancer survivorship programme and future directions for advancing survivorship care from a healthcare system perspective.

An overview of SEA cancer survivorship efforts

Although several reports have investigated the unmet needs of cancer survivors in Asia, 2 landmark studies have provided insight into the variations in symptom burden and supportive care needs across multiple countries, namely, the Association of Southeast Asian Nations Costs in Oncology²¹ and Survivorship Transitions and Care in the Asia Pacific²² studies, which examined 5249 and 1748 survivors across 8 and 9 countries, respectively, as summarised by Koczwara et al.²³ Despite these findings, efforts to implement a formal cancer survivorship plan across the region have been gaining ground with the effort of the Asia-Pacific Primary Care Cancer Research Group with representatives from Singapore, Malaysia, Hong Kong, and Australia.²⁴ Additionally, the passage of the National Cancer Control Act in the Philippines and Alola Foundation in Timor-Leste alongside certain patient organisations have contributed to cancer policy development in Malaysia and Singapore. High-income countries, such as the US and the UK, tend to have greater engagement with policymakers and in research, as evidenced by the establishment of dedicated cancer survivorship departments, accreditation bodies, and the publication of national white papers.²³

Landscape of cancer survivorship in Singapore

Cancer rehabilitation programme

Apart from cancer survivorship, which encompasses the entire cancer journey from the time of diagnosis through the end of life, cancer rehabilitation is a goal-specific process aimed at helping cancer survivors achieve optimal physical, social, and psychological health within the limits of disease and treatment for functional improvement. Cancer rehabilitation is divided into 3 main paradigms—(1) preventive, (2) restorative, and (3) supportive rehabilitation—and may commence before (prehabilitation) or after cancer treatment.¹⁰

The primary focus of prehabilitation is to optimise physiological procedures prior to treatment, to allow for faster recovery and to mitigate the severity of post-treatment sequelae using targeted physical, nutritional, and psychological interventions. It has been shown to improve gait, QOL, and cardiopulmonary function. An early initiative in 2007 at Khoo Teck Puat Hospital in Singapore involved frail patients requiring colorectal surgery with a multidisciplinary team comprising nurse clinicians, physiotherapists, and clinicians delivering personalised care, including patient assessment, nursing care, and prehabilitation programme outline.²⁵ Although the programme led to shorter hospital stays and faster recovery with apparent benefits, it has yet to be extended to other cancer types in Singapore. However, such prehabilitation efforts provide a valuable basis for the integration of a similar workplan into a personalised cancer survivorship care plan.

Building on this pilot programme, the National University Cancer Institute, Singapore (NCIS) merged 2 programmes in 2019 for surgical prehabilitation before cancer surgery and geriatric oncology support for older adults to form the Geriatric Oncology LongituDinal End to eNd programme to support patients from cancer diagnosis to cancer survivorship. Many of the participants reported improved outcomes in global health status from the programme, though further evaluation for sustainability is still required.²⁶

While numerous efforts have been invested in hospital-based outpatient cancer rehabilitation in western countries, comparatively little focus has been directed towards community-based cancer rehabilitation programmes. In Singapore, community rehabilitation centres provide general rehabilitation services, including joint mobility, balance retraining, and fatigue management that cancer patients can benefit from. For cancer-specific rehabilitation services, the Singapore Cancer Society (SCS) is the primary provider, offering holistic survivorship care alongside specialised functions such as lymphoedema management delivered by trained therapists.²⁷ To assess the impact of community-based cancer rehabilitation programmes, an earlier study involving a multiethnic cohort of 304 cancer patients found impaired health-related QOL (HRQOL) and high distress levels in a community rehabilitation setting.²⁸ However, a subsequent retrospective study conducted 2 years later involving 197 cancer patients in Singapore demonstrated significant reductions in mean distress thermometer scores and improved HRQOL at 3- and 6-month assessments.²⁹

First cancer survivorship care forum

Singapore’s first cancer supportive and survivorship care forum was held on 3 December 2016, involving 74 oncology practitioners, including oncologists, nurses, pharmacists, and allied health professionals, with the aim of raising awareness of survivorship and provide a platform to address the challenges associated with delivering cancer supportive care in Singapore.¹¹ The forum highlighted the current challenges in Singapore’s survivorship care landscape, including the current oncologist-centric model and the challenges of meeting increasing demand for cancer care services in a sustainable manner. This approach is in contrast with survivorship care models developed in the US and Europe, where survivorship care is delivered through a shared care model, which has been demonstrated to improve QOL, reduce costs, increase care continuity, and reduce oncologists’ burden. The forum proposed that survivorship care should encompass the following principles: survivor-centred care, integrated and coordinated care, promotion of wellness, research-driven and evidence-based practices, and accessible and equitable care. 

Community-based survivorship trial and implementation

Several culturally adapted community-based survivorship intervention programmes have been trialled in Singapore. For example, a psychoeducation group programme tested in 72 Asian early-stage breast cancer survivors showed reduced physical distress and fatigue, yielding overall positive feedback.³⁰ This highlights the value of identifying survivors with unmet supportive care needs. The growing cohorts of cancer survivors prompt the need to navigate follow-up care models. A decision aid (DA) was developed and evaluated for acceptability and usability with 73% of participants finding it useful for decision-making.³¹ Remarkably, the Breast Cancer Survivorship Inter-Professional Community, a pilot trial on breast cancer survivorship, found that a shared care model with family physician visits and community pharmacists through survivorship care plan was feasible in Singapore.³²

Community-based shared care survivorship model and cancer rehabilitation paradigms

The core values of shared care in primary care focus on 4 key areas as defined by Starfield’s “4C” framework: maintaining close contact with survivors (Contact), providing holistic care (Comprehensiveness), fostering patient–physician relationships (Continuity), and coordinating specialties (Coordination).^33,34 The implementation of the shared care survivorship model is a relatively nascent concept in Asian settings. Current recommendations for shared care implementation, including care processes, healthcare professional training, patient education, and policies, have been predominantly developed and discussed within western healthcare systems. For a multicultural country like Singapore, the shared care model has been focused on chronic disease management and mental health issues while the cross-system application of these recommendations in cancer survivorship remains unclear and challenging to adopt because of several systemic factors. These include the division of the 3 healthcare clusters as regional managers covering central-north, west, and east Singapore, financial structural differences between public and private healthcare entities, and the fact that primary care providers (PCPs) in Singapore have historically rated primary care delivery less favourably than their counterparts in western countries, such as Australia and the UK.^20,35 Despite these challenges, a Singapore study suggests that a well-designed multicultural model succeeded. For example, a randomised controlled trial of the Accessible Cancer Care to Enable Support for Cancer Survivors (ACCESS) programme, built on routine distress screening, found improved physical functioning, increased activity levels, and lowered psychosocial distress relative to usual care.³⁶ Another focus group study on community practitioners stressed that the success of community survivorship relied on the participation of survivors and should incorporate non-cancer-related medical histories, with multicultural differences taken into consideration.²⁰

Before discussing the ongoing work of the shared care model in Singapore, the authors seek to gain an understanding of health concerns and familiarity with cancer survivorship. An early qualitative study among multiethnic breast cancer survivors in Singapore revealed an unfamiliarity with the term “survivorship” and identified cognitive impairment and peripheral neuropathy as key symptoms. Participants frequently highlighted limited consultation time and unplanned hospitalisation as significant barriers, often perceiving these as indicators of suboptimal care.³⁷ Two independent qualitative reviews have assessed the perspectives of PCPs in breast cancer survivorship within a community-based shared care model in Singapore.^38,39 Although the majority of PCPs’ current role involves managing non-cancer issues and preventive care, many aspire to expand their involvement in cancer surveillance and psychosocial support. However, they emphasised that specialised training in care protocols and timely access to oncologists are necessary prerequisites. A qualitative study by Ke et al. involving 70 PCPs in Singapore indicated that low-risk breast cancer survivors exhibited acceptability of PCPs’ involvement in follow-up treatment throughout the survivorship course.³⁹ PCPs perceived the shared care model positively for its ability to provide holistic care while adapting global recommendations to an Asian context. While the willingness of PCPs to share care with oncologists is encouraging, optimising such programmes requires distinct role definitions, clinical standard operating procedures, data sharing, financial processes, effectiveness evaluation, and improved resource allocation.

Cancer survivorship progress, guideline, and roadblocks in Singapore

Numerous guidelines and programmes have been published by Singapore national agencies, professional societies, and hospitals to address the survivorship issues in Singapore (Table 1). Notably, MOH has specifically stressed the importance of quality survivorship care as 1 of the 5 strategic thrusts in the latest report. Another important milestone is the MOH Community Collaborative Care that brought all 3 healthcare clusters together with private general practitioners (GPs) to promote cancer survivorship, with a handbook outlining the needs of breast and colorectal cancer survivors and recommended surveillance modalities and toxicities to monitor. Further plans include harmonising cancer survivorship care plans within an electronic medical record (EMR) along with survivorship registry. A major change is that cancer survivors are eligible for subsidies for cancer surveillance under the Breast Screen Singapore programme. In 2019, 2 steering groups were established in parallel to drive primary cancer care, research, and education. The first steering group comprised Singapore Primary Care Cancer Network (SPRiNT) members from NCIS and NCCS, SCS, 3 polyclinic clusters, and primary care network GPs. The second steering group comprised members from SPRiNT and cancer research institutions from Malaysia, Hong Kong, and Australia.

However, a nationally endorsed and unified guideline is still lacking for several reasons. First, effective provision requires a multidisciplinary approach comprising oncology nursing, rehabilitation, and allied health professionals. Currently, this involvement is largely provisional and not systematically integrated into routine oncologic care, particularly for patients with complex survivorship needs, such as greater treatment toxicity, comorbidities, financial, or psychosocial issues. Second, while prior work has described the roles of the professionals involved in the shared care model,³² these descriptions have yet to be implemented as a standard of care, such as specifying responsibilities between community and specialist clinics, referral pathways, training and competency requirements, data sharing, and oncologist’s role. Third, the financial subsidy framework for cancer survivors, whether via the review of MediSave, MediShield Life, and MediFund (3M) along with third-party insurance, will need to be finalised at a national level.

Table 1. List of latest cancer survivorship work and key focus areas in Singapore.

Globally, there is little information available on the cost-effectiveness of cancer survivorship programmes because of their complex nature, making the programme effectiveness measurement challenging. In Singapore, comparing outcomes across survivorship care models is difficult, as reported by Ke et al., who showed that the evaluation of guideline adherence was constrained by the EMR within each healthcare cluster that is inaccessible to private providers, which likely underestimates new diagnoses in the community.³¹ This study also highlights the need to reverse the overutilisation of oncologist services by leveraging primary care strengths. At the system level, artificial intelligence (AI) could improve guideline adherence by integrating data across healthcare clusters, stratifying risks, and triaging. AI-driven decision tools can prompt PCPs with guideline actions and aid survivors to self-manage symptoms post-diagnosis.^40-42 An assessment study from the same author on a 5-year post-treatment cancer survivorship care on the compliance with international guidelines showed adherence rates to surveillance and osteoporosis care were high, yet extensive utilisation of oncologist services could be reversed by coordinating survivorship care with PCPs.¹⁹

An important goal of cancer survivorship is cancer rehabilitation. It varies according to patients’ needs, but it aims to restore and optimise physical, social, psychological, and vocational functioning within the limits imposed by the cancer and its treatment. Consequently, healthcare clusters may struggle to justify the value of these initiatives. Restoring physical and social function, establishing a holistic return-to-work framework, and defining the employer’s role in facilitating workforce reintegration are essential metrics for measuring the true effectiveness of any cancer survivorship plan.

Evaluation of cancer survivorship effectiveness in Singapore: A proposed method

Singapore is experiencing a rapid demographic transition, with projections indicating that 23.8% of residents will be aged 65 years and above by 2030.⁴³ Simultaneously, there has been a sharp rise in cancer incidence among those under 50 years of age over the last decade, specifically, a 15.5% increase in men in their 30s and 25.3% increase in women in their 40s.⁵ Although scientific rigour is a primary metric for measuring survivorship programme success, a survivor-centred approach should be employed to capture the specific health outcomes of both younger (<40 years old) and older (>65 years old) survivors across Singapore’s multicultural landscape. To achieve this evaluation objective, national data exchange platforms, such as the Trusted Research and Real world-data Utilisation and Sharing Tech dataset, comprising health-related research and anonymised data, could be a useful resource for clinical, population, and costing data. As a preliminary step towards a formal evaluation framework, Halpern’s 14 measurements categorised by Kissick’s iron triangle, Porter’s outcome measure, and Donabedian’s framework can be adapted.¹³ To leverage Singapore’s unique strength in regional healthcare clusters, comprehensive national EMR data, multicultural population, and the national 3M financing model, a hybrid model can be used to comprehensively assess the quality and value of a survivorship programme as outlined in Fig. 1.

Fig. 1. Hybrid framework integrating the Donabedian model and Porter’s equation for assessing value-based cancer survivorship care in Singapore.

Potential of AI in cancer survivorship planning in Singapore

A scoping review of AI-powered digital health technologies in cancer survivorship care concluded that the majority of studies are currently designed for breast cancer survivors. These studies primarily focused on cancer recurrence, prediction, clinical decision support, symptom monitoring, and survivability modelling, all of which have been demonstrated to improve QOL and physical function.⁴⁴ For instance, AI serves as a decision support tool that makes delineation and implementation feasible.⁴⁵ It has potential in risk stratification, as demonstrated by machine learning-based prediction of adverse survivorship outcomes so that higher-risk survivors may benefit from more intensive care.^46,47 Model integration with large data on 25,592 cancer survivors predicted unplanned healthcare use and symptom burden, providing a framework for risk stratification and prediction to facilitate proactive survivorship care.⁴⁸

The DA study by Ke et al. concluded that future work should focus on adapting AI to optimise information delivery to attributes such as age and familiarity with primary care.³¹ Similar AI-based clinical decision tools can facilitate shared decision-making in survivorship by flagging patients at risk, stratifying the risk, and mapping guideline-based options during the decision process between patients and clinicians.⁴⁹ The shared decision model has its trade-off—although survivors vigilantly self-monitor for symptoms, which increases the chance of early detection, it could also increase anxiety and decrease QOL.⁵⁰ Consequently, recent consensus calls for AI-enabled supportive care across the survivorship journey.⁵¹ Importantly, these tools should support clinicians as real-world use remains limited by data quality, model accuracy, and trial validation.

Harnessing a robust digital infrastructure and deep AI talent pool, Singapore has pursued a comprehensive approach to implementing AI across the healthcare system, as exemplified by the government-supported development and adoption of AI-enabled tools (Table S1).  Singapore’s healthcare landscape offers a “test-bed” for AI owing to the centralised data architecture, databases, and well-documented patient journeys. These features support the development of robust AI training models applicable to specific cancer survivorship care functions, including symptom monitoring, clinical decision-making, and follow-up care. For example, AI tools, such as the Community Acquired Pneumonia and COVID-19 AI Predictive Engine, can be repurposed to help GPs determine whether a survivor’s new symptom is manageable or requires escalation back to a national cancer centre. Moreover, a key strength of Singapore lies in the structured AI-innovation ecosystem, which enables real-world testing via a sandbox approach. Platforms such as the AI-enabled medical imaging platform for Singapore public healthcare accelerate AI adoption in radiology and support the deployment of imaging algorithms, while Health Empowerment thru Advanced Learning & Intelligent eXchange consolidates de-identified data for testing AI models for predictive care.

Fig. 2. AI-supported shared decision-making and risk stratification transition stable survivors from hospital oncology to GP and polyclinic, with case-by-case referral for complex needs.

CONCLUSION

Singapore possesses all the required components to launch a successful national cancer survivorship programme supported by highly skilled healthcare professionals and world-class hospital systems. The proposed shared care model aims to alleviate oncologists’ burden by redirecting routine follow-up care from tertiary centres to primary and community healthcare settings (Fig. 2). In this transition, oncology nurses and allied health professionals are integral, not only to navigate the transition from hospital to community but also to educate patients on cancer survivorship plans, disease awareness, and the long-term benefits of this care-stratified model. With increasing cancer survival rates, an ageing population, and significant unmet needs in survivorship support, an efficient cancer support system and a survivorship plan have never been more urgent. This service should be designed to complement the needs of Singapore’s diverse cultural background and align with existing healthcare infrastructure. By involving working groups across hospitals, primary and community health providers, as well as social and community partners (e.g. volunteer welfare organisations), Singapore can create a framework that benefits not only cancer survivors but also their primary caregivers.

Supplementary material

Table S1. Compilation of AI-centred healthcare innovation in Singapore applicable to cancer survivorship care.  

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