Thryve & Survivorship Clinic: Reimagining Cancer Aftercare

While traditional oncological follow‑up often ends after five to ten years, many survivors of gynecological cancers continue to struggle with late effects of treatment. The Survivorship Clinic, led by Charité Universitätsmedizin Berlin, is proving that long‑term survivors can benefit from holistic, interdisciplinary support well beyond conventional follow‑up. Yet scaling this new care model brings key challenges: how to systematically detect and address complex late effects, integrate lifestyle and psychosocial support, and generate evidence to justify reimbursement. To overcome these hurdles, Charité partnered with cross‑sector clinical and research collaborators to implement the Survivorship Sprechstunde as a model of care.

The Partnership

Charité’s Frauenklinik (Clinic for Gynecology, Department of Oncologic Surgery) launched the Survivorship Clinic to specifically care for women whose initial diagnosis of a gynecologic tumor dates back at least five years. The Clinic is evaluated as a new care model, supported by funding from the Innovationsfonds of the Gemeinsamen Bundesausschuss. It partners with multiple university women’s clinics (e.g. TU Dresden, UKE Hamburg, Tübingen, Klinikum Fürth) to form an interventional vs. control structure across sites. 

Charité’s role is as an anchor institution: hosting the specialized visits, coordinating interdisciplinary support (neurology, cardiology, psycho‑oncology, sport medicine, endocrinology, etc.), and designing individualized Survivorship Care Plans. 

Other partners contribute data collection, health economics evaluation, and networked delivery in control sites to compare outcomes. 

The Challenge

Before launching this model, Charité and its collaborators had to overcome several obstacles:

• Lack of structured follow-up beyond 5–10 years: Although many survivors are considered “cured,” more than half continue to experience treatment-related late effects that impair quality of life.
• Heterogeneity of late effects: These include fatigue, peripheral neuropathy, “chemobrain” (cognitive impairment), cardiotoxicity, osteoporosis, sexual dysfunction, depression, and more, each requiring different expertise.
• Fragmented care across specialties: Patients often see isolated specialists (neurology, cardiology, psycho-oncology) without coordinated oversight or a central point of continuity.
• Demonstrating cost-effectiveness: To make this new model fundable and scalable, it needed a rigorous evaluation framework with health economic and patient‑reported outcomes.
• Patient identification and engagement: Recruiting long-term survivors (≥ 5 years from diagnosis) across multiple centers and motivating them to participate in a novel program was a logistical and behavioral hurdle.
• Interoperability in data and care delivery: Collecting consistent clinical, questionnaire, imaging, and wearable/training data across sites and disciplines required robust protocols and infrastructure.

The Solution: Integrated Survivorship Care Model

To address these challenges, Charité and its project partners built a comprehensive, interdisciplinary provision model centered around the Survivorship Sprechstunde. Thryve provided the digital health infrastructure to support this care model, enabling secure data integration, real-world activity tracking, and scalable interoperability across sites.

• Interdisciplinary One‑stop Visits: Women in the intervention arm attend structured in-person visits at Charité. These include detailed anamnesis, review of past therapies, assessment of complaints, screening for late effects, and psychological and lifestyle counseling.
• Survivorship Care Plans (SCPs): Each participant receives a personalized plan covering prevention, monitoring, management of late effects, and follow-up recommendations across specialties.
• Lifestyle & Exercise Module: A sport medicine arm offers diagnostics (e.g. spiroergometry, stress ECG) and prescribes individualized strength and endurance training over 12 months. Telemedical supervision of training is integrated, with periodic adjustments based on wearable / activity tracker data.
• Monitoring & Questionnaires: Participants fill out validated quality-of-life and symptom questionnaires (e.g. SF-36, QLQ-C30) at baseline, 3, 6, 9, and 12 months to track subjective outcomes.
• Referral & Specialist Integration: When a late effect is identified, patients are referred to associated specialty services (neurology, cardiology, fatigue center, sexual medicine, psycho-oncology) within the Charité network.
• Health Economics & Evaluation: The trial uses a two-arm design (intervention vs control), with endpoints including health-related quality of life after 12 months (primary: SF-36), as well as frequency/severity of late effects, resource use, and cost-effectiveness.
• Scalability & Control Sites: Control clinics in Dresden, Hamburg, Tübingen, Fürth, and Wolfsburg serve as comparison arms. If results are favorable, the model can be rolled out to these sites.

‍

The Results

Since the Survivorship Clinic began seeing patients, key milestones and early outcomes underscore its potential:

• Patient reach & uptake: By 2024, the Survivorship Sprechstunde had served over 370 women whose cancer diagnosis was more than five years ago.
• Care model innovation: The study establishes a new care pathway in Germany for long‑term survivors of gynecological cancer, a gap that until now had no structured solution.
• Evaluation pending: The rigorous evaluation is still in progress, with full analysis expected by 2025.
• Early qualitative impact: In public announcements, the clinic emphasizes how longer consultations allow attention to prevention, lifestyle, cardiovascular risks, and patient empowerment, dimensions often neglected in conventional follow-up.
• Future potential: If the evaluation confirms benefits and cost-effectiveness, the Survivorship model may be adopted as a routine service under statutory health insurance (Kassenleistung) across Germany.

This collaboration exemplifies how oncology follow-up can evolve from episodic surveillance into enduring, patient-centered care, combining medical, psychological, and lifestyle support to restore quality of life and validate value to payors and the health system.