Supportive Care in Cancer (2023) 31:14

https://doi.org/10.1007/s00520-022-07501-9

RESEARCH

Refocusing cancer supportive care: a framework for integrated cancer

care
Meinir Krishnasamy1,2,3,4 · Amelia Hyatt2,3 · Holly Chung1,2 · Karla Gough2,5 · Margaret Fitch6

Received: 11 May 2022 / Accepted: 25 November 2022 / Published online: 14 December 2022
© The Author(s) 2022

Abstract
Objective Cancer supportive care comprises an integrative field of multidisciplinary services necessary for people affected by
cancer to manage the impact of their disease and treatment and achieve optimal health outcomes. The concept of supportive
care, largely driven by Margaret Fitch’s seminal supportive care framework, was developed with the intent to provide health
service planners with a conceptual platform to plan and deliver services. However, over time, this concept has been eroded,
impacting implementation and practice of supportive care. This study therefore aimed to examine expert contemporary views
of supportive care with the view to refocusing the definition and conceptual framework of cancer supportive care to enhance
relevance to present-day cancer care.
Methods A two-round online modified reactive Delphi survey was employed to achieve consensus regarding terminology
to develop a contemporary conceptual framework. A listing of relevant cancer supportive care terms identified through a
scoping review were presented for assessment by experts. Terms that achieved ≥ 75% expert agreement as ‘necessary’ were
then assessed using Theory of Change (ToC) to develop consensus statements and a conceptual framework.
Results A total of 55 experts in cancer control with experience in developing, advising on, delivering, or receiving sup-
portive care in cancer took part in the Delphi surveys. Expert consensus assessed current terminology via Delphi round 1,
with 124 terms deemed relevant and ‘necessary’ per pre-specified criteria. ToC was applied to consensus terms to develop
three key statements of definition, and a comprehensive conceptual framework, which were presented for expert consensus
review in Delphi round 2.
Conclusion Finalised definitions and conceptual framework are strongly aligned with relevant international policy and
advocacy documents, and strengthen focus on early identification, timely intervention, multidisciplinary collaboration, and
end-to-end, cross-sector, cancer supportive care.

Keywords Cancer · Supportive care · Conceptual framework · Definitions · Health system

Introduction
* Meinir Krishnasamy
[email protected]
Due to the rapid evolution of modern anti-cancer treatment,
1
Academic Nursing Unit, Peter MacCallum Cancer Centre, cancer is now considered a chronic disease [1, 2]. Novel
305 Grattan Street Parkville, Melbourne, Australia treatments deliver longer survival, but often with a range of
2
Health Services Research Group, Peter MacCallum Cancer acute toxicities and long-term side effects which negatively
Centre, Melbourne, Australia impact quality of life and necessitate ongoing health ser-
3
Sir Peter MacCallum Department of Oncology, The vice use [2, 3]. Furthermore, appreciation of the far ranging
University of Melbourne, Victoria 3010, Australia psychosocial consequences of a cancer diagnosis, such as
4
Victorian Comprehensive Cancer Centre Alliance, financial toxicity or fear of cancer recurrence, has become
Victoria 3010, Australia much more apparent [4].
5
Department of Nursing, Faculty of Medicine, Dentistry, As an integrated field of multidisciplinary interventions,
and Health Sciences, The University of Melbourne, cancer supportive care comprises services necessary for
Melbourne 3052, Australia
people affected by cancer to manage the demands of dis-
6
Bloomberg Faculty of Nursing, University of Toronto, ease and treatment [1]. The concept of supportive care and
Toronto, Canada

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recognition of its contribution to comprehensive cancer ser- and ability to have their healthcare needs fulfilled [11]. To
vices has been largely driven by Margaret Fitch’s seminal that end, quality cancer supportive care must be conceptu-
supportive care framework, published almost 20 years ago alised and measured by its impact on patient experiences
[5]. This person-centred framework highlights seven key and outcomes, rather than as discrete clinical services and
domains which need to be routinely and iteratively assessed interventions [12, 16]. Influenced by a focus on value-based
and supported across the entire cancer pathway to deliver healthcare, where value is defined as outcomes that matter
optimal patient experience and outcomes of care: informa- to patients [17], this study set out to examine contemporary
tional, emotional, practical, physical, psychological, social, views of supportive care. The objective was to establish
and spiritual [5]. consensus definition statements for cancer supportive care
The original intent of the framework was to provide using a modified Delphi process [18] and, using these state-
health service planners with a conceptual platform to plan ments, inform the development of a conceptual framework
and deliver services. Importantly, the framework aimed to to refresh the concept of cancer supportive care, relevant to
direct attention to the potential for supportive care to be present-day cancer care [19].
required at all facets of the cancer journey: during screening,
diagnosis, treatment, and follow-up cancer care [5]. Over
time, numerous definitions of supportive care have arisen Methods
[6–8] resulting in a lack of consensus regarding the concept,
which has impacted its application and availability across A two-round online modified reactive Delphi was employed
different care settings [1, 9, 10]. Initially, intended to be to identify consensus terms for supportive care definitions
conceptualised as an approach to care delivery impacting and deliver a contemporary conceptual framework for sup-
the totality of a patient’s experience and outcomes, support- portive care, using Theory of Change (ToC) [19]. This study
ive care has become synonymous with separate or disparate was reviewed and approved by the University of Melbourne
clinical services and interventions targeting disaggregated HREC (approval no: 1955021.1).
needs [11, 12]. As a consequence, component elements of
cancer supportive care have received differing levels of Advisory group
attention, prioritisation, and funding resulting in services
which are highly fragmented, sporadically implemented, and An advisory group comprising key national stakeholders in
poorly evaluated [13–15]. supportive care was established to provide overarching guid-
Erosion of the underlying principle of totality of experi- ance and input into the Delphi process. Members comprised:
ence and care as articulated in Fitch’s conceptual frame- policy makers, clinicians, senior academics, cancer non-
work for supportive care appears to have arisen as a conse- government organisation leaders, and consumer advocates.
quence of efforts to research and/or implement supportive
care as a series of discreet interventions, delivered at static Design
time-points, in an attempt to demonstrate impact on health
outcomes [10]. Much of the research undertaken since the This study utilised the Delphi technique: a structured, itera-
publication of the framework has presented descriptive tive process designed to facilitate expert contributions via
reports of unmet needs across heterogeneous cohorts of sequential survey rounds to establish consensus on a par-
cancer patients at all stages of their illness pathway, or has ticular topic or issue [20]. Specifically, a reactive modified
attempted to demonstrate efficacy of discrete interventions Delphi approach was employed, by which the initial Delphi
targeted at specific domains of need. This disaggregated survey was developed through a comprehensive literature
approach to Fitch’s original conceptualisation has resulted in review of seminal supportive care definitions rather than
a body of evidence that has largely failed to generate robust open-text panel responses, followed by two, rather than
data of its benefit at patient or system levels. In turn, this has three rounds of expert review and consensus-building. This
damaged clinicians and health service administrators’ per- approach was selected to acknowledge the importance and
ceptions of the value of investing in comprehensive support- continuing relevance of published literature regarding sup-
ive care as a fundamental component of quality cancer care. portive care, while maximising expert consensus in refresh-
Given the remarkable changes in cancer treatments and ing these statements.
care since the publication of Fitch’s original Supportive Care
Framework, it seemed opportune to re-visit and, if appro- Delphi round 1 development: scoping review
priate, refocus the definition and framework of cancer sup-
portive care. A key characteristic of quality, person-centred A scoping review was conducted to identify seminal pub-
care, is that regardless of diagnosis, or the severity or nature lished definitions of supportive care for adults affected
of need, all individuals experience the same level of access by cancer. Identified definitions were analysed using

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qualitative content analysis to identify all unique terms Data collection

used within definitions; similar terms were categorised
[21]. All unique terms were then presented for consensus The Delphi round 1 survey included six demographic items
review in the Delphi round 1 survey. and presented identified cancer supportive care terms organ-
ised by category. Each category included multiple terms;
participants were requested to rate their agreement for
Delphi round 2 development: Theory of Change inclusion for all terms they agreed were relevant, univer-
sal, and appropriate using a 7-point Likert scale (strongly
Using consensus terms and categories identified in Delphi agree, agree, somewhat agree, neither agree nor disagree,
round 1, refreshed supportive care statements of definition somewhat disagree, disagree, strongly disagree). Respond-
and a conceptual framework were developed and presented ents were also invited to contribute their own terms to each
for expert review and consensus in the Delphi round 2 category as they felt relevant.
survey. ToC modelling was used to determine the person-, In the Delphi round 2 survey, participants were asked to
organisation- and system-level inputs and outputs neces- review the refreshed statements and conceptual framework
sary to deliver a contemporary supportive care framework and rate their agreement on a 7-point Likert scale against
true to the refreshed supportive care statements of defini- 11 statements regarding their design, proposed usage, and
tion [19]. ability to support improved research and quality cancer sup-
portive care. Respondents were invited to suggest changes
to the wording for the refreshed statements or design of the
Delphi participants conceptual framework and also provide additional comments
regarding their agreement for or against the 11 statements.
Criteria used to select potential participants comprised expe-
rience of developing, advising on, delivering, or receiving Data analysis
supportive care in cancer. Potential participants working in
clinical, research, policy, and quality roles in Australia, the Participant agreement with terms presented in the Delphi
UK, and Canada (countries recognised as leaders in cancer round 1 survey was assessed against the following pre-speci-
supportive care), and in consumer advocacy roles (which fied consensus criteria: Necessary, ≥ 75% of experts felt that
included patient and informal carers) were invited to par- they agreed or strongly agreed with the inclusion of the term
ticipate. Special attention was made to extend invitations (consensus met); Supplementary, ≥ 60% experts felt that they
to those working in specialised areas of cancer supportive agreed or strongly agreed with the inclusion of the term
care, such as Aboriginal and Torres Strait Islander health (considered meeting consensus only if ‘Necessary’ criteria is
and culturally and linguistically diverse (CALD) oncology not met); Unnecessary, < 60% experts felt that they agreed or
care. Snowball recruitment techniques were applied at round strongly agreed with the inclusion of the term (consensus not
1, where participants were encouraged to send on the study met). Additional terms suggested by respondents were ana-
invitation to colleagues whom they felt would also be appro- lysed using content analysis, compared with existing terms
priate to participate. to determine originality, and were retained or discarded as
agreed by members of the project team.
Responses to Likert scale items presented in the Delphi
Procedures round 2 survey were analysed descriptively using frequen-
cies, range, means, and standard deviations. Interpretive
Invitations to participate were sent via email (either directly description was used to analyse open-text items [23].
by the research team, or via snowball sampling). Those who
were interested in taking part were directed to provide online
informed consent. All participants who provided consent Results
were emailed Delphi surveys for both rounds.
Delphi rounds 1 and 2 were designed and distributed to Cancer supportive care definition refresh: terms
experts via REDCap online data collection and management and categories
software [22]. Surveys were sent approximately 3 months
apart, with respondents allocated a 2-week window for A total of 12 papers were identified which contained seminal
completion (round 1: 20/08/2020–03/09/2020; round 2: definitions of cancer supportive care (see Table 1 for list of
30/11/2020/08/12/2020). Two reminder emails were sent for papers).
each round. Each survey included clear description regard- Prior to the commencement of analysis, four definitions
ing Delphi development, aims, and purpose. were excluded as terms used were not unique; that is, they

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Table 1  Review of literature containing seminal definitions of cancer supportive care

Author, year Title

Boucher NA et al. 2017 [24] Feasibility and acceptability of a best supportive care checklist among clinicians
Carrieri D et al., 2018 [9] Supporting supportive care in cancer: the ethical importance of promoting a holistic conception of quality of
life
Fitch M, 2008 [5] Supportive care framework
Hui D, 2014 [10] Definition of supportive care: does the semantic matter?
Klastersky J et al., 2016 [1] Supportive/palliative care in cancer patients: quo vadis?
Koll T et al., 2016 [25] Supportive care in older adults with cancer: across the continuum
Loeffen EA et al., 2017 [26] The importance of evidence-based supportive care practice guidelines in childhood cancer—a plea for their
development and implementation
Olver I, 2016 [3] The importance of supportive care for patients with cancer
Olver I, 2022 [8] Supportive care in cancer—a MASCC perspective
Rittenberg CN et al., 2010 [27] An oral history of MASCC, its origin and development from MASCC’s beginnings to 2009
Victorian Government Depart- Providing optimal cancer care: supportive care policy for Victoria
ment of Human Services, 2009
[28]
Ward S et al., 2004 [29] Improving supportive and palliative care for adults with cancer

were already covered in the remaining eight definitions. 9.Achievement of cancer supportive care services (exam-
A total of 204 terms were identified; content analysis of ple terms: dignity, improved treatment outcomes, func-
these terms resulted in the development of the following 11 tional autonomy, empowerment, fewer post hospital
categories: complications)
10. Domains of cancer supportive care (example terms:
1. Individual health contexts related to cancer supportive social, physical, informational, psychological, practi-
care service delivery (example terms: cancer, cancer cal, spiritual)
treatment) 11. Specific clinical and psychosocial issues resolved by
2. Guiding actions for provision of cancer supportive care cancer supportive care services (example terms: can-
(example terms: assessment, screening, management, cer-related fatigue, hepatoxicity cachexia, mucositis,
intervention, treatment) ascites, extravasation, alopecia, polypharmacy)
3. Issues addressed by cancer supportive care services
(example terms: side-effects, unmet needs, toxicity, All terms and categories were presented to the Advisory
adverse effects) Committee for review. A total of 23 items were deemed
4. Who benefits from cancer supportive care services duplicates and were removed; however, all categories
(example terms: patients, carers, family) remained. Approved categories and terms were presented
5. Cancer care continuum stages where cancer support- to experts in the Delphi round 1 survey.
ive care services should be available (example terms:
diagnosis, treatment planning, survivorship, during Delphi round 1 survey
palliative treatment, at relapse, at bereavement)
6. Overarching imperatives of cancer supportive care ser- A total of 61 people were invited to participate via direct and
vice delivery (example terms: evidence-based, com- snowball email invitation. All those who provided consent
prehensive, integral, core component of care, timely, (n = 55) completed the Delphi round 1 survey. Respondents
multi-specialty) were predominantly female (n = 47, 85% and were from a
7. Who delivers cancer supportive care services (example range of different healthcare sectors (see Table 2). A small
terms: multi-disciplinary teams, nurses, general practi- proportion of overseas experts took part (7%, n = 4).
tioners, psychologists, social workers, chaplains, spe-
cialist nurses) Building consensus
8. Locations where cancer supportive care services are
delivered (example terms: primary care, tertiary care, One hundred twenty-four of the 181 terms included in
non-government organisations, palliative care unit, round 1 were identified as ‘necessary’ by participants and,
advocacy groups, community healthcare) therefore, met inclusion for consensus agreement. All items

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Supportive Care in Cancer (2023) 31:14 Page 5 of 10 14

Table 2  Rounds 1 and 2 Delphi participants which met the ‘supplementary’ and ‘unnecessary’ criteria
Round 1 Round 2 were discarded.
Terms identified as ‘necessary’ in category 10, domains
Years worked in supportive care n = 55 n = 37
of cancer supportive care, very closely aligned with those
Mean, standard deviation 14 11 16 12 articulated by Margaret Fitch in her seminal work defining
Range 2 45 2 45 cancer supportive care [5]. Therefore, this category was
Role category n % n % removed from the ongoing process of consensus-building,
Clinician 21 38 14 38 because it was recognised as having continuing relevance.
Researcher 6 11 6 16 Category 11 comprised the listing of specific clinical and
Policymaker 4 7 3 8 psychosocial issues resolved by cancer supportive care ser-
Quality representative 12 22 4 11 vices. Category 11 was likewise removed due to systematic
Consumer advocate 9 16 6 16 bias identified in the selection of terms rated ‘necessary’ by
Carer 2 4 2 5 respondents. Specifically, medical terms were more likely
Other 1 2 1 3 to be excluded (e.g., ascites or extravasation) as opposed to
Missing 0 0 1 3 terms more commonly understood by lay audiences (e.g.,
Gender financial, sleep).
Male 7 13 5 14
Female 47 85 31 84 Cancer supportive care definition refresh: ToC
Missing 1 2 1 3 statements and conceptual framework
Postcode
Major city 39 71 22 59 Terms and categories which met consensus were assessed
Inner regional 10 18 8 22 using ToC to map provision of cancer supportive care as
Outer regional 2 4 1 3 a complex intervention [19]. Consensus terms and catego-
International 4 7 4 11 ries listed above were analysed to determine the inputs and
Missing 0 0 2 5 outputs necessary for provision of supportive care, and to
make explicit the multiple causal pathways and feedback
loops between service provision and the intended outcomes
of having supportive care integrated as a platform underpin-
ning delivery of cancer services (Fig. 1). The statements of

Fig. 1  Integrated cancer care framework

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14 Page 6 of 10

Table 3  Respondent’s agreement with the with the meaningfulness and usefulness of the refreshed concept statements
ITEMS Strongly Agree Some- Neither Somewhat Disagree Strongly
agree what agree nor disagree disagree
agree disagree
n % n % n % n % n % n % n %

1. The concept statements reflect the nuances, complexities, and information required to effectively 14 38 20 54 2 5 0 0 0 0 1 3 0 0
convey
what cancer supportive care entails or aspires to achieve (n = 37)
2. The concept statements are meaningful and useful to guide best practice 14 39 19 53 1 3 0 0 1 3 1 3 0 0
models of cancer supportive care (n = 36)
3. The concept statements are meaningful and useful to help inform health services of 6 16 17 46 10 27 2 5 1 3 0 0 1 3
what implementation of comprehensive supportive care requires (n = 37)
4. The concept statements are meaningful and useful to help health services 6 16 18 49 9 24 2 5 1 3 1 3 0 0
assess quality of their supportive care provision (n = 37)
5. The concept statements are meaningful and useful to guide future 11 31 13 36 8 22 3 8 1 3 0 0 0 0
research endeavours (n = 36)
6. The concept statements are meaningful and useful to convey/explain supportive 9 24 17 46 6 16 0 0 2 5 3 8 0 0
care to patients, carers and family members (n = 37)
7. The concept statements are meaningful and useful to convey/explain supportive care 15 42 12 33 5 14 2 6 1 3 1 3 0 0
to multidisciplinary clinicians (n = 36)
Supportive Care in Cancer (2023) 31:14
Supportive Care in Cancer (2023) 31:14 Page 7 of 10 14

definition and the conceptual framework were presented to

Strongly
disagree
participants in the Delphi round 2 survey.

0 0
0 0

0 0

0 0
Statements of definition: Cancer Supportive Care
What
Disa-

1 3
1 3

1 3

1 3
gree
Supportive care is a core, evidence-based component of comprehen-
sive patient-centred cancer care
Who and When and Where
disagree
Some-

The delivery of supportive care requires a multi-disciplinary

what

2 5
2 5

0 0

2 5
approach, in the screening, assessment, management, intervention
and treatment of the side-effects, symptoms and needs of cancer
patients, carers and family. Supportive care is delivered in all
agree nor
disagree
Neither

healthcare settings, at all steps of the cancer pathway from diagno-

0 0
2 5

0 0

1 3 sis to survivorship and end of life

Why
Importantly, the provision of supportive care is designed to: empower
Some-

and enhance decision-making; maximise tolerance and benefit from

Table 4  Respondent’s agreement with the usefulness of the proposed framework to strengthen research, health system planning, and integration

21 57 5 14
18 49 5 14

22 59 6 16
agree
what

21 57 3 8

therapy; alleviate symptoms of cancer and side-effects of treatment;

optimise functional autonomy, wellness and health outcomes; and
improve coping, self-care and dignity
Strongly Agree

Delphi round 2 survey

8 22
9 24

8 22

9 24
agree

A total of 37 respondents took part in the second round

4. The framework clearly demonstrates how and where supportive care integrates within the health system to facili-
3. The framework can help inform health service or system planning for integration of supportive care into cancer

of the Delphi, with response rate of 67% from consent

2. The framework can guide or inform future research direction to strengthen the evidence base for integration of

(Table 2). Most participants strongly agreed/agreed/some-

what agreed with all 11 statements presented about the state-
ments of definition and framework. Importantly, respondents
felt that the definition statements are effective in convey-
ing what cancer supportive care entails (n = 36, 97%), are
meaningful and useful to guide best practice models (n = 34,
94%), and will inform health services of what implemen-
tation of comprehensive cancer supportive care requires
1. The framework contains all essential/core components of cancer supportive care

(n = 34, 94%) (Table 3). Similarly, most participants agreed

that the framework contained all components of supportive
care (n = 34, 92%), would be useful in strengthening the evi-
dence-base for integration of cancer supportive care (n = 32,
86%), and could help inform health system planning (n = 36,
97%) (Table 4).

Open text comments

The small proportion of participants who selected ‘some-

what disagree/disagree/strongly disagree’ with the 11 state-
ments about the statements of definition and framework were
invited to provide additional comments regarding their selec-
tate comprehensive cancer care

tion. Predominantly, disagreement was due to perceived gaps

in detail. For example, ‘more detail with regard to who deliv-
cancer supportive care

ers supportive care’ was reported by one participant as the

reason why they disagreed with statement 3, describing use-
treatment/care

fulness to inform health services regarding implementation

of comprehensive cancer supportive care. Statement 6 had
the most disagreement, with five participants stating they
felt that the statements may be too complex for patients and

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14 Page 8 of 10 Supportive Care in Cancer (2023) 31:14

their family. A separate patient or ‘lay’ version of the defini- As such, identifying, intervening, preventing, or miti-
tions of supportive care was suggested. One participant who gating the myriad consequences of cancer has become a
disagreed with statement 3 did not give a reason for this, and value-based proposition for cancer care providers look-
for statement 4, comments were provided that referred to ing to effectively and efficiently, use increasingly scarce
disparities in healthcare access rather than responding about resources. Our work asserts that there is pressing need
the framework itself. to refocus cancer supportive care. Our refreshed inte-
grated cancer care framework, developed and endorsed
through consensus by international experts, re-orients the
Discussion conversation about cancer supportive care from a discus-
sion about service delivery and discrete interventions to a
Our study set out to explore the need for a refreshed sup- value-based health system frame of reference concerned
portive care definition and framework to refocus the dia- with reducing fragmentation and achieving outcomes that
logue about cancer supportive care. Refreshed statements matter to patients. This assertion refocuses supportive care
of definition were generated and endorsed by international to Fitch’s original framework and intent.
experts in cancer supportive care. These contributions were Our refreshed statements and framework support a shift
provided by predominantly female participants—reflective in thinking away from the current understanding of sup-
of the workforce and those mainly involved in provision of portive care to an appreciation of its importance as the
supportive care. The statements align strongly with interna- basis for delivery of integrated cancer care [14, 29, 30].
tional policy and advocacy documents that focus on early Unlike existing international models of supportive care,
identification, timely intervention, multidisciplinary collab- where supportive care is articulated as one component of
oration, and end-to-end, cross-sector care—characteristics cancer care [6, 7, 26], our framework offers a new para-
that cannot equitably or effectively be achieved through an digm for integrated cancer care, where each component
individual-level or fragmented approach to care provision of cancer care and treatment occur within a supportive
[7, 8, 26]. care framework. Delivery of treatments is no longer con-
While cancer supportive care has long been recognised ceptualised as the primary activity of cancer care, where
as an important component of cancer service delivery [6–8], all other aspects of care are additive or recommended, but
published evidence suggests an ongoing, high burden of rather, delivery of cancer therapies or excellent symptom
unaddressed need across all supportive care domains for management is understood to optimally occur within a
many patient groups, at all stages of their cancer experi- framework of supportive care. It offers a way of clarify-
ence. In part, these data have been explained by inadequacy ing the blurred lines between supportive, palliative, end of
of or inability to resource integration of supportive care, life, and survivorship care, demonstrating that the delivery
into routine cancer services. Our study findings suggest that of acute cancer care, the disciplines of survivorship, pal-
a focus on investment, although important, may overlook liative, and end of life care interconnect with each other
a critical issue. That is, that supportive care is much more within a supportive care frame of reference. Importantly,
than a series of discreet services that co-occur within cancer this conceptualisation is much more aligned with how peo-
services, but rather is a conceptual framework guiding the ple experience their lives, where there is integration of the
planning, resourcing, and delivery of cancer care. Adoption various domains (separated largely for our convenience
of a supply or service-driven approach to cancer supportive as health care professionals and researchers, for descrip-
care has consistently failed to demonstrate value to patients tion and measurement), but which can be very challenging
or health systems and has resulted in disinvestment in deliv- for individuals to articulate as discrete events or issues.
ery of comprehensive supportive care [17]. Persisting with outdated models, where supportive care
Since the publication of Fitch’s original supportive care sits alongside other aspects of cancer care, will further
framework in 2008, there has been a revolution in cancer the misconception that the provision of supportive care is
treatments. People are living longer with the consequences additive to cancer care delivery, rather than the premise
of cancer and cancer therapy, and health service use has upon which all cancer care is delivered [6–8].
grown exponentially. As people live longer with the con- At an individual patient level, the refreshed statements
sequences of cancer and cancer treatments, the impact of and framework facilitate identification of patient needs at a
insufficient or inaccessible supportive care and the chal- population and individual level. At the health service level,
lenges this presents for recovery is increasingly apparent. they provide opportunity to explore improved healthcare
Subsequently, insights provided by those affected by can- system performance, cost effectiveness of integrated can-
cer contribute important understanding of where and why cer care, and demonstration of improvement through use
improvement is needed. of contemporary quality indicators. At a clinical level, the

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Supportive Care in Cancer (2023) 31:14 Page 9 of 10 14

framework and quality indicators provide opportunity to bet- Open Access This article is licensed under a Creative Commons Attri-
ter understand workforce training needs and skills require- bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
ments, and better enable individual clinicians to understand as you give appropriate credit to the original author(s) and the source,
their role within the multi-disciplinary application of inte- provide a link to the Creative Commons licence, and indicate if changes
grated cancer care. were made. The images or other third party material in this article are
Supportive care has frequently been misunderstood included in the article's Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
as an optional or non-essential aspect of cancer care [7]. the article's Creative Commons licence and your intended use is not
Our framework offers a refocused and refreshed proposi- permitted by statutory regulation or exceeds the permitted use, you will
tion—radical in its conceptualisation—–which proposes need to obtain permission directly from the copyright holder. To view a
an understanding of cancer supportive care as the tem- copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/.
plate for integrated cancer service planning and delivery.
It shifts an understanding of supportive care as a sub-
speciality, discipline, or series of interventions to a way References
of understanding, planning, delivering, and evaluating
1. Klastersky J, Libert I, Michel B, Obiols M, Lossignol D (2016)
integrated cancer care. Supportive/palliative care in cancer patients: quo vadis? Sup-
Underpinned by a series of supportive care assump- port Care Cancer 24(4):1883–1888. https://​doi.​org/​10.​1007/​
tions developed through the use of Theory of Change, s00520-​015-​2961-9
the framework offers insight to meaningful outcomes for 2. Jordan K, Aapro M, Kaasa S, Ripamonti C, Scotté F, Strasser F
et al (2018) European Society for Medical Oncology (ESMO)
supportive cancer care research that focus on maximising position paper on supportive and palliative care. Ann Oncol
health outcomes that matter to people affected by cancer 29(1):36–43. https://​doi.​org/​10.​1093/​annonc/​mdx757
and the system within which care is delivered. Our work 3. Olver IN (2016) The importance of supportive care for patients
contributes new perspectives to the literature on support- with cancer. Med J Aust 204(11):401–402. https://​doi.​org/​10.​
5694/​mja16.​00279
ive care. It offers health service administrators, policy 4. Yousuf ZS (2016) Financial toxicity of cancer care: it’s time to
makers, health services researchers, and multidisciplinary intervene. J Natl Cancer Inst 108(5):djv370. https://​doi.​org/​10.​
clinicians an opportunity to re-envision supportive care 1093/​jnci/​djv370
as a conceptual framework to plan, deliver, and evaluate 5. Fitch M (2008) Supportive care framework. Can Oncol Nurs J/
Revue canadienne de soins infirmiers en oncologie 18(1):6–14.
quality cancer care. Importantly, our work orients sup- https://​doi.​org/​10.​5737/​11819​12x18​1614
portive care as the fundamental context through which all 6. Berman R, Davies A, Cooksley T, Gralla R, Carter L, Darlington
other aspects of cancer care are delivered. E et al (2020) Supportive care: an indispensable component of
modern oncology. Clin Oncol 32(11):781–788. https://d​ oi.o​ rg/1​ 0.​
Acknowledgements We would like to wholeheartedly thank the partic- 1016/j.​clon.​2020.​07.​020
ipants whose involvement made this study possible. We also thank the 7. Balboni TA, Hui K-K P, Kamal AH (2018) Supportive care in
members of our advisory committee for their expertise and guidance. lung cancer: improving value in the era of modern therapies. Am
Soc Clin Oncol Educ Book 38:716–25. https://​doi.​org/​10.​1200/​
Author contribution All authors have made substantial contributions to EDBK_​201369
some or all of the following: (1) the conception and design of the study, 8. Olver I, Keefe D, Herrstedt J, Warr D, Roila F, Ripamonti CI
or acquisition of data, or analysis and interpretation of data, (2) drafting (2020) Supportive care in cancer—a MASCC perspective. Sup-
the article or revising it critically for important intellectual content, and port Care Cancer 28(8):3467–3475. https://​doi.​org/​10.​1007/​
(3) final approval of the version to be submitted. s00520-​020-​05447-4
9. Carrieri D, Peccatori F, Boniolo G (2018) Supporting support-
Funding This study is funded by the Cancer Support, Treatment and ive care in cancer: the ethical importance of promoting a holistic
Research Unit, Department of Health, Victoria, Australia. conception of quality of life. Crit Rev Oncol Hematol 131:90–95.
https://​doi.​org/​10.​1016/j.​critr​evonc.​2018.​09.​002
Data availability Available upon request. 10. Hui D (2014) Definition of supportive care: does the semantic
matter? Curr Opin Oncol 26(4):372–379. https://d​ oi.o​ rg/​10.1​ 097/​
Code availability Not applicable. CCO.​00000​00000​000086
11. Levesque J-F, Harris MF, Russell G (2013) Patient-centred access
Declarations to health care: conceptualising access at the interface of health
systems and populations. Int J Equity Health 12(1):1–9. https://​
Ethics approval This study was approved by the University of Mel- doi.​org/​10.​1186/​1475-​9276-​12-​18
bourne Human Research Ethics Committee (approval no: 1955021.1). 12. Loiselle CG, Howell D, Nicoll I, Fitch M (2019) Toward the
development of a comprehensive cancer experience measurement
Consent to participate Informed consent was obtained from all par- framework. Support Care Cancer 27(7):2579–2589. https://​doi.​
ticipants included in the study. org/​10.​1007/​s00520-​018-​4529-y
13. Hui D, Hoge G, Bruera E (2021) Models of supportive care in
Consent for publication Not applicable. oncology. Curr Opin Oncol 33(4):259–66. https://d​ oi.o​ rg/1​ 0.1​ 097/​
CCO.​00000​00000​000733
14. Sanson-Fisher R, Hobden B, Watson R, Turon H, Carey
Conflict of interest The authors declare no competing interests. M, Bryant J et al (2019) The new challenge for improving

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14 Page 10 of 10 Supportive Care in Cancer (2023) 31:14

psychosocial cancer care: shifting to a system-based approach. 25. Koll T, Pergolotti M, Holmes HM, Pieters HC, van Londen G,
Support Care Cancer 27(3):763–769. https://​doi.​org/​10.​1007/​ Marcum ZA et al (2016) Supportive care in older adults with
s00520-​018-​4568-4 cancer: across the continuum. Curr Oncol Rep 18(8):1–10. https://​
15. Pinkham EP, Teleni L, Nixon JL, McKinnel E, Brown B, Joseph doi.​org/​10.​1007/​s11912-​016-​0535-8
R et al (2021) Conventional supportive cancer care services in 26. Loeffen E, Kremer L, Mulder R, Font-Gonzalez A, Dupuis L,
Australia: a national service mapping study (The CIA study). Sung L et al (2017) The importance of evidence-based sup-
Asia‐Pacific J Clin Oncol https://​doi.​org/​10.​1111/​ajco.​13575 portive care practice guidelines in childhood cancer—a plea for
16. Hanefeld J, Powell-Jackson T, Balabanova D (2017) Understand- their development and implementation. Support Care Cancer
ing and measuring quality of care: dealing with complexity. Bull 25(4):1121–1125. https://​doi.​org/​10.​1007/​s00520-​016-​3501-y
World Health Organ 95(5):368. https://​doi.​org/​10.​2471/​BLT.​16.​ 27. Rittenberg CN, Johnson JL, Kuncio GM (2010) An oral history of
179309 MASCC, its origin and development from MASCC’s beginnings
17. Lee T, Porter M (2013) The strategy that will fix healthcare: Har- to 2009. Support Care Cancer 18(6):775–784. https://​doi.​org/​10.​
vard Business Review Boston 1007/​s00520-​010-​0830-0
18. Boulkedid R, Abdoul H, Loustau M, Sibony O, Alberti C (2011) 28. Victorian Government Department of Human Services (2009)
Using and reporting the Delphi method for selecting healthcare Providing optimal cancer care. Supportive care polivy for Vic-
quality indicators: a systematic review. PLoS One 6(6):e20476. toria. https://​conte​nt.​health.​vic.​gov.​au/​sites/​defau​lt/​files/​migra​
https://​doi.​org/​10.​1371/​journ​al.​pone.​00204​76 ted/​files/​colle​ctions/​polic​ies-​and-​guide​lines/p/​provi​ding-​optim​
19. De Silva MJ, Breuer E, Lee L, Asher L, Chowdhary N, Lund al-​cancer-​care-​suppo​rtive-​care-​policy.​pdf (accessed July 2022)
C et al (2014) Theory of change: a theory-driven approach to 29. Ward S, Salazano S, Sampson F, Cowan J (2004) Improving sup-
enhance the Medical Research Council’s framework for com- portive and palliative care for adults with cancer. Econ Rev
plex interventions. Trials 15(1):1–13. https://​doi.​org/​10.​1186/​ 30. Sturmberg JP, O’Halloran DM, Martin CM (2010) People at the
1745-​6215-​15-​267 centre of complex adaptive health systems reform. Med J Aust
20. Jünger S, Payne SA, Brine J, Radbruch L, Brearley SG (2017) 193(8):474–8. https://​doi.​org/​10.​5694/j.​1326-​5377.​2010.​tb040​
Guidance on Conducting and REporting DElphi Studies (CRE- 04.x
DES) in palliative care: recommendations based on a methodo- 31. Chambers DA, Glasgow RE, Stange KC (2013) The dynamic
logical systematic review. Palliat Med 31(8):684–706. https://​doi.​ sustainability framework: addressing the paradox of sustainment
org/​10.​1177/​02692​16317​690685 amid ongoing change. Implement Sci 8(1):1–11
21. Morgan DL (1993) Qualitative content analysis: a guide to paths
not taken. Qual Health Res 3(1):112–121. https://d​ oi.o​ rg/1​ 0.1​ 177/​ Publisher's note Springer Nature remains neutral with regard to
10497​32393​00300​107 jurisdictional claims in published maps and institutional affiliations.
22. Harris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O’Neal
L et al (2019) The REDCap consortium: building an interna-
Practice implications The refreshed cancer supportive care
tional community of software platform partners. J Biomed Inform
statements of definition and conceptual framework offer health
95:103208. https://​doi.​org/​10.​1016/j.​jbi.​2019.​103208
service administrators, policy makers, researchers, and clinicians
23. Thorne S (2016) Interpretive description: qualitative research for
the opportunity to re-envision supportive care theoretical framework
applied practice: Routledge.
to guide the planning, delivery, and evaluation of quality cancer
24. Boucher NA, Nicolla J, Ogunseitan A, Kessler ER, Ritchie CS,
care. Importantly, this work further orients supportive care as the
Zafar YY (2018) Feasibility and acceptability of a best supportive
fundamental context through which all other aspects of cancer care
care checklist among clinicians. J Palliat Med 21(8):1074–1077.
should be delivered.
https://​doi.​org/​10.​1089/​jpm.​2017.​0605

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