Designing for Delivery: A Delphi Study of Feasibility-Informed Implementation Strategies for a Fear of Cancer Recurrence Clinical Pathway

Designing for Delivery: A Delphi Study of Feasibility-Informed Implementation Strategies for a Fear of Cancer Recurrence Clinical Pathway | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Designing for Delivery: A Delphi Study of Feasibility-Informed Implementation Strategies for a Fear of Cancer Recurrence Clinical Pathway Ben Smith, Verena Shuwen Wu, Alison Pearce, Jia Liu, Heather L Shepherd, and 12 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8889572/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Purpose Fear of cancer recurrence (FCR) is pervasive among cancer survivors, yet evidence-based care is rarely implemented. Clinical pathways offer a structured approach to translating evidence into practice. This study identified key implementation barriers, enablers, and strategies for feasibly integrating an FCR clinical pathway comprising screening, assessment, and triage to stepped care into practice. Methods A three-round Delphi study was conducted with Australian health professionals and FCR researchers. Participants rated and provided qualitative feedback on the feasibility of FCR clinical pathway elements. Qualitative responses were content analysed using the updated Consolidated Framework for Implementation Research. Recommended strategies were mapped using the Expert Recommendations for Implementing Change taxonomy. Results Eighty-nine participants completed Round 1, 69 Round 2, and 73 Round 3. Feasibility ratings varied across pathway elements (49–90%). Stepped care elements were widely endorsed as feasible (71–83% agreement), while resource-intensive recommendations (e.g., training all staff for screening) were perceived as least feasible. Key implementation enablers included Adaptability , Access to Knowledge and Information , and strong Innovation Recipient Need . Major barriers were Available Resources , Work Infrastructure and limited Innovation Deliverer Opportunity . Recommended strategies included tailoring delivery to local contexts and patient needs supported by modular training and local champions. Conclusion Implementing the FCR clinical pathway requires pragmatic adaptation and system-level support. Prioritising high-impact elements, providing training, integration into existing workflows, and shared decision-making to meet patient needs are critical. Future research should evaluate these strategies using hybrid effectiveness–implementation designs to ensure sustainable implementation and improved patient outcomes. fear of cancer recurrence cancer survivorship clinical pathway supportive care implementation Delphi study Figures Figure 1 Introduction The number of people living with and beyond cancer is growing rapidly, currently estimated to be over 53 million people globally [ 1 ]. Most people affected by cancer experience some degree of fear, worry, or concern about their cancer coming back or getting worse, which is referred to as fear of cancer recurrence (FCR) [ 2 ]. An international individual participant data meta-analysis (n = 9311) found 39% of people affected by cancer experience moderate FCR, while 19% experience severe/clinical FCR [ 3 ] equating to more than 30 million people affected by FCR globally. People with clinically severe FCR experience high and persistent levels of preoccupation and worry, hypervigilance to physical symptoms, and functional impairment [ 4 ]. Moreover, people with more severe FCR experience poorer mental health and quality of life [ 5 ], and use more healthcare services [ 6 ]. Receiving help with FCR has been identified as the greatest unmet supportive care need in people with cancer [ 7 ]. In response, a wide range of measures (e.g., the Fear of Cancer Recurrence Inventory [ 8 ], FCR-4/7 [ 9 ], Ottawa Clinical Fear of Recurrence instruments [ 10 ]) and treatments (e.g., ConquerFear [ 11 ], FORT [ 12 ], SWORD [ 13 ]) have been developed and shown to effectively identify, assess, and treat FCR [ 14 , 15 ]. However, translating these resources into routine clinical practice has proven challenging. Documented implementation barriers include limited awareness of FCR, inadequate referral pathways, concerns about equitable access, health professional capacity constraints, and challenges applying manualised FCR interventions in diverse clinical contexts [ 16 , 17 ]. Until recently, there was limited formal guidance on how to systematically address FCR in clinical settings. In 2024, this gap was addressed through the publication of Canadian FCR guidelines [ 18 ] and a complementary Australian FCR clinical pathway developed by our team [ 19 ]. Both advocate for routine FCR screening, followed by further assessment and triage to stepped care. Pilot studies have demonstrated the acceptability, feasibility, and preliminary efficacy of this approach [ 20 ], but there is limited evidence of successful implementation in routine care. Enhancing the translation of FCR research into clinical care and improving access to FCR treatment have been identified as international [ 21 ] research priorities. Clinical pathways are a well-established strategy for translating evidence into practice. By offering standardised, context-specific recommendations for multidisciplinary care, they help bridge the gap between research and routine clinical delivery [ 22 ]. To support implementation of FCR research, we developed a clinical pathway incorporating contemporary evidence and consensus-based guidance on optimal FCR screening, assessment, and triage to stepped care [ 19 ]. The pathway was developed through a three-stage Delphi process, whereby n = 94 participants – primarily health professionals working across varied disciplines and settings – reached consensus on 35/38 (92%) of proposed pathway elements based on alignment with best-practice and potential to improve patient outcomes (optimality). With consensus achieved regarding the optimal clinical pathway, the next critical step is to ensure feasibility of pathway elements. Feasibility was also assessed in the Delphi study and has been identified as a key antecedent of successful implementation. Analysis of qualitative feedback regarding feasibility can identify strategies to overcome perceived implementation barriers and enablers. This secondary analysis of data from the Delphi study conducted to establish the optimal FCR clinical pathway aimed to facilitate the successful future implementation of the pathway by: Reporting the perceived feasibility of optimal pathway elements; Identifying pathway implementation barriers and enablers; and Developing pathway implementation strategies. Methods Study Design and Context This study is a secondary analysis of data collected during a previously published three-round Delphi study that established consensus on optimal elements of a clinical pathway for identifying and managing FCR in routine care of early-stage cancer survivors [ 19 ]. The study was approved by the University of New South Wales Human Research Ethics Committee (HC230052), conducted in accordance with the Conducting and Reporting Delphi Studies (CREDES) guidelines [ 23 ], and reported following the Standards for Reporting Implementation Studies (StaRI) Statement [ 24 ]. Participants and Recruitment Eligible participants included Australian health professionals involved in the care of adult cancer survivors (≥ 18 years) and researchers who had co-authored a peer-reviewed paper on FCR within the past five years. Participants working primarily with paediatric populations were excluded due to contextual differences in FCR presentation and management. Participants were recruited via professional oncology organisations, conference presentations, and social media. All participants gave informed consent. Participants who completed Round 1 were invited to subsequent rounds; no new participants were recruited after Round 1. Outcomes and Analysis Feasibility assessment (Aim 1) Participants rated the feasibility (i.e., likelihood of implementation in routine care) of each pathway element using a 5-point Likert scale from “strongly disagree” to “strongly agree,” with a “Not my expertise” option for items outside a participant’s scope. The proportion of participants agreeing/strongly agreeing that an item was feasible was analysed descriptively. Identifying pathway implementation barriers and enablers (Aim 2) Open-ended comments were collected alongside the Delphi item for each pathway element and at the end of each pathway component to capture perceived implementation barriers and enablers. Directed content analysis was conducted on open-ended qualitative responses using the updated Consolidated Framework for Implementation Research (CFIR) [ 25 ]. Only responses related to pathway elements included in the final clinical pathway were analysed. The updated CFIR is one of the most widely used and validated frameworks for categorising implementation barriers and enablers (i.e., determinants). It comprises five domains: Innovation (intervention attributes), Outer Setting (external context), Inner Setting (organisational context), Individuals (characteristics of those involved in implementation), and Implementation Process (implementation activities) [ 25 ]. Each domain includes multiple constructs representing potential barriers and enablers to implementation. As the clinical pathway is currently in the pre-implementation phase, the Implementation Process domain was not coded. A codebook was developed by the research team based on the updated CFIR template (available at cfirguide.org) and adapted to the study context to aid consistent interpretation of constructs and support inter-rater reliability (see Appendix 1). Each qualitative response was independently coded by two researchers (AKV and JG) to the single most relevant CFIR domain and construct. Coders also classified whether the response reflected an implementation barrier, enabler, or neutral factor. The number of barriers and enablers relating to each construct was counted. Coding followed an iterative process. AKV and JG met regularly with the broader research team to discuss and refine coding decisions. Discrepancies were resolved through team consensus involving experienced qualitative/implementation researchers (ABS, AS, and VW). To enhance reliability, ABS and VW subsequently each coded half of the dataset, so every response was reviewed by three researchers. All coding was conducted using Microsoft Excel. Developing implementation strategies (Aim 3) Once key implementation determinants were identified, the CFIR-ERIC matching tool [ 26 ] was used to identify implementation strategies addressing the most common barriers and enablers. The CFIR-ERIC matching tool is a theory-informed resource that links specific implementation barriers and enablers identified using the CFIR, to evidence-based implementation strategies from the Expert Recommendations for Implementing Change (ERIC) taxonomy [ 27 ]. It enables systematic selection of strategies most likely to address identified contextual challenges, thereby enhancing the feasibility and likely success of implementation. Results Participants Of the 94 individuals who consented to participate in the Delphi study, 89 completed Round 1 (April–June 2023), 69 completed Round 2 (July–August 2023), and 73 completed Round 3 (November–December 2023). Participants (see Table 1 ) were primarily health professionals (86%), spanning disciplines including mental and allied health (n = 31, 33%), nursing (n = 30, 32%), and medical/radiation/surgical oncology (n = 18, 19%) working in metropolitan (84%) tertiary referral centres (47%) in public settings (54%). Table 1 Participant characteristics Characteristic N (%) of respondents Age 21–30 3 (3.2) 31–40 25 (26.6) 41–50 28 (29.8) 51–60 24 (25.5) 61–70 13 (13.8) Prefer not to say 1 (1.1) Gender Man/male 10 (10.6) Woman/female 84 (89.4) Country of birth Australia 71 (75.5) Other 23 (24.5) Language spoken at home English 82 (87.2) Other 12 (12.8) Aboriginal/Torres Strait Islander status Non-Indigenous 94 (100.0) Geographic area Metropolitan 79 (84.0) Regional 5 (5.3) Rural 10 (10.6) Primary role Clinician 81 (86.2) Researcher 10 (10.6) Educator 3 (3.2) Primary focus Psychology 18 (19.1) Social work 13 (13.8) Nursing 30 (31.9) Medical oncology 12 (12.8) Radiation oncology 5 (5.3) Surgical oncology 1 (1.1) Palliative care 1 (1.1) Other 14 (14.9) Work setting (clinician/educator; n = 84) a Tertiary referral cancer centre 44 (46.8) District/local hospital 22 (23.4) Non inpatient cancer treatment centre 18 (19.1) Non-hospital based 10 (10.6) Primary care 2 (2.1) Community centre 6 (6.4) Other 6 (6.4) Public/private (clinician/educator; n = 84) a Public 51 (54.3) Private 7 (7.4) Public and private 17 (18.1) Public charitable organisation 3 (3.2) Private charitable organisation 5 (5.3) Other 2 (2.1) Years worked with cancer survivors (clinician/educator; n = 84) 0–2 3 (3.2) 3–5 11 (11.7) 6–10 22 (23.4) 10+ 48 (51.1) Role caring for cancer survivors with FCR (clinician/educator; n = 84) a Screening and/or assessment 49 (52.1) Referral to psychosocial support 55 (58.5) Provision of psychosocial support 47 (50.0) Years conducting research (researcher; n = 10) 6–10 3 (3.2) 10+ 7 (7.4) a Respondents could select multiple responses Feasibility of pathway elements (Aim 1) Feasibility ratings for clinical pathway elements ranged from 49.4% (“All clinical staff should be trained to implement FCR screening and respond appropriately”) to 90.1% (“It is important that all health care professionals validate and normalise FCR”) (see Table 2 ). Average feasibility ratings were highest for the post-screening/triage stepped-care treatment pathway component (75.9%) and lowest for the supported self-management for moderate FCR pathway component (61.0%). Table 2 Optimal and feasible ratings for elements included in the FCR clinical pathway Pathway Component Optimal % a Feasible % a Screening 66.8% b Screening for FCR should commence at the completion of hospital-based treatment (e.g. surgery, chemotherapy, or radiotherapy) 52/72 (72.2%) 68/89 (76.4%) Screening for FCR should be conducted prior to a cancer survivor’s follow-up appointment to aid discussion during the appointment if needed 74/89 (83.1%) 61/89 (68.5%) Screening for FCR should be repeated after a cancer survivor’s follow-up appointment, to characterise the persistence of FCR 74/89 (83.1%) 57/89 (64.0%) A brief validated tool, administered either in written or verbal form, should be used to identify cancer survivors experiencing FCR needing further assessment 88/89 (98.9%) 75/89 (84.3%) Two-step screening should be used: (1) A brief (e.g. single-item) screening tool to identify individuals with potential FCR; (2) A longer (approx. 10-item) screening tool to assess FCR severity in those above cut-off on the initial measure 77/87 (88.5%) 60/89 (67.4%) Specific clinical staff should be designated to review the results of FCR screening 76/89 (85.4%) 51/89 (57.3%) All clinical staff should be trained to implement FCR screening and respond appropriately 75/89 (84.3%) 44/89 (49.4%) Triage, assessment, referral 71.4% a A triage conversation including discussion of results of FCR screening should take place with all cancer survivors (and their family caregiver if desired) 57/68 (83.8%) 37/69 (53.6%) Non-mental health specialists (e.g. cancer care nurses/coordinators) are well-placed to have triage conversations with cancer survivors 71/86 (82.6%) 63/86 (73.3%) Training is needed to support health care professionals to have triage conversations with cancer survivors about FCR 84/86 (97.7%) 72/86 (83.7%) When the results of screening and the triage conversation suggest a cancer survivor has severe FCR they should be assessed by a mental health specialist (e.g. psychologist/psychiatrist) to confirm the recommendation of specialist FCR care 75/86 (87.2%) 53/86 (61.6%) Patient education is needed to encourage uptake of recommended FCR interventions 77/86 (89.5%) 73/86 (84.9%) Post-screening/triage stepped-care treatment 75.9% a A stepped-care model is appropriate for managing FCR in cancer survivors 76/84 (90.5%) 64/85 (75.3%) All cancer survivors should firstly be allocated to Step 1 (Universal care) regardless of initial FCR levels, then be stepped up to higher levels based on results of subsequent screening 72/84 (85.7%) 60/85 (70.6%) Intervention recommendations for cancer survivors with moderate-severe FCR should consider their FCR level and their preference and capacity for engaging with self-management versus clinician-delivered interventions 59/66 (89.4%) 48/66 (72.7%) The specific FCR treatment recommended to a cancer survivor should be guided by the stepped-care algorithm, but should be discussed and agreed on by patients and clinicians 63/66 (95.5%) 55/66 (83.3%) If a cancer survivor does not engage with the initially agreed on FCR intervention alternative interventions within the same step should be discussed. If none appeal, less intensive interventions from the step below could be considered. 55/66 (83.3%) 50/66 (75.8%) Rescreening cancer survivors for FCR at routine follow-up appointments is an appropriate way of monitoring progress and guiding referral for further treatment if needed 78/85 (91.8%) 64/85 (75.3%) Key team members need to tailor the FCR clinical pathway for their service 73/85 (85.9%) 63/85 (74.1%) Tailoring should take into consideration the local cancer survivor population (e.g., cultural background and health literacy) and resources available 81/84 (96.4%) 68/85 (80.0%) Step 1: Universal care for Minimal to Mild FCR 64.4% a Cancer survivors should initially be provided with information about risk of recurrence, possible symptoms of recurrence and how they relate to FCR from their oncologist 70/81 (86.4%) 54/81 (66.7%) Oncology specialists and nursing staff are the ideal people to address mild FCR as part of routine care 69/81 (85.2%) 49/81 (60.5%) Primary healthcare professionals (e.g., general practitioners/GPs or GP nurses) could play an important role in addressing mild FCR in routine care, if trained appropriately 58/66 (87.9%) 38/66 (57.6%) It is important that all health care professionals validate and normalise FCR 78/81 (96.3%) 73/81 (90.1%) All cancer survivors with mild FCR should receive FCR psychoeducational materials provided by cancer support organisations (e.g., Cancer Council or Australian Cancer Survivorship Centre) 75/80 (93.8%) 66/81 (81.5%) If cancer survivors report minimal/mild FCR in rescreening, then they should continue to be screened for FCR and provided with information about FCR self-management and support options in case FCR worsens 58/66 (87.9%) 48/66 (72.7%) Step 2: Supported self-management for Moderate FCR 61.0% a Moderate FCR could primarily be addressed using online or group interventions, but other options should be offered to people who prefer/need other forms of support (e.g., elderly or culturally and linguistically diverse survivors) 57/65 (87.7%) 47/65 (72.3%) Survivors with moderate FCR should be presented with FCR treatment options either within or outside the hospital setting to accommodate their preferences and circumstances 53/65 (81.5%) 45/65 (69.2%) With further training, oncology health professionals without specialist psychology training (e.g., oncology nurses), could play an important role in delivering interventions recommended for moderate FCR 58/72 (80.6%) 33/65 (50.8%) Allied health (e.g. social workers) or psychologists are the best people to deliver the interventions recommended 65/78 (83.3%) 48/80 (60.0%) Healthcare professional-delivered booster sessions should be offered to patients whose FCR is improved but not remitted at rescreening 59/72 (81.9%) 42/80 (52.5%) Patients should be rescreened for FCR 6 months post-intervention to determine long-term progress 74/80 (92.5%) 49/80 (61.3%) Step 3: Specialist care for severe FCR 69.0% a A mental health specialist (i.e. a psychologist or psychiatrist) should deliver interventions for severe FCR 72/78 (92.3%) 50/78 (64.1%) A progress review should be conducted at completion or discontinuation of psychological treatment for FCR 75/78 (96.2%) 60/78 (76.9%) Rescreening is appropriate for monitoring progress at FCR treatment completion/discontinuation and in the longer-term (e.g., 6 months post-FCR treatment) 72/78 (92.3%) 51/78 (65.4%) Ultimately the treating psychologist or psychiatrist should decide whether a patient requires further treatment (e.g. booster sessions) 65/78 (83.3%) 56/78 (71.8%) Rescreening is appropriate for monitoring progress at treatment completion/discontinuation 66/76 (86.8%) 52/78 (66.7%) a Reported percentages represent the number of participants who agreed or strongly agreed with the item divided by the number of people who responded to that item, excluding those who indicated “Not my expertise”. The highest optimal rating was taken from across rounds, and items were rated for feasibility once across all rounds, which is why denominators differ for the optimality and feasibility ratings within items and feasibility ratings across items b Average feasibility for each pathway component was calculated by summing the percentage for each individual element included in the pathway and dividing by the total number of included elements in that component *Shading denotes strength of feasibility ratings. Blue indicates 90–100% agreement; purple indicates 80–90% agreement; pink indicates 70–80% agreement; orange indicates 60–70% agreement; dark yellow indicates 50–60% agreement; and light yellow indicates < 50% agreement. Determinants of pathway feasibility (Aim 2) Of the 639 qualitative responses collected, 410 related to elements ultimately included in the FCR clinical pathway, which were coded to the Innovation (n = 99), Individuals (n = 125), Inner Setting (n = 144), and Outer Setting (n = 9) updated CFIR domains. Thirty-three responses were coded as ‘not applicable’ due to brevity or ambiguity. 170 responses were coded as barriers, 53 as neutral, and 154 as enablers. Barriers and enablers related to updated CFIR domains (in bold italics) and constructs (in bold) are provided below, with illustrative quotes in Table 3 . Innovation Domain Forty-five enablers, 22 barriers, and 32 neutral factors were identified regarding Innovation , namely the FCR clinical pathway. Innovation design was both an enabler (n = 20) and a barrier (n = 8). Many participants viewed the pathway’s design as aligned with best practice, but some thought screening prior to follow-up appointments may pick up transient peaks in FCR. Innovation complexity was identified as a barrier (n = 7). The two-step screening process was seen as adding administrative burden and concerns were also raised about stepped care leading to ‘double handling’ of the majority of patients likely to need extra support. Innovation adaptability was the most frequently cited enabler (n = 22). Participants emphasised the importance of tailoring implementation to local contexts, especially for rural and remote patients with limited access to in-person care and psychological support. This flexibility was seen as critical to supporting implementation across diverse settings and populations. Individuals Domain Sixty-two enablers, 51 barriers, and 12 neutral factors were identified regarding Individuals , namely the people involved in pathway implementation. Innovation deliverer capability was a key enabler (n = 19). Participants generally viewed FCR screening as within the capabilities of most staff. The capability of allied health professionals to address FCR across severity levels was also highlighted. Building capability through training was considered essential for some pathway elements, such as triage conversations and normalising FCR. Responsiveness of the pathway to innovation recipient need was a strong enabler (n = 25). Screening was seen as empowering patients to discuss FCR. Participants emphasised the importance of supporting patient-centred care by enabling intervention choice within a stepped care model. This construct was also considered a barrier (n = 15) when pathway recommendations were perceived as misaligned with recipient preferences or capacity. For example, some felt oncologists should only provide recurrence risk information if patients wanted it. Similarly, recommendations that treating psychologists/psychiatrists should decide whether further treatment for severe FCR was warranted prompted calls for shared decision-making. Views were mixed regarding innovation deliverer opportunity . Barriers (n = 15) included time and workload constraints limiting screening opportunities for some clinical staff. Integrating FCR triage into routine follow-up was seen as challenging due to the competing demands of medical management. Limited opportunity to provide FCR-related support was noted across roles, with oncologists particularly constrained. While allied health professionals and psychologists were viewed as best suited for moderate FCR interventions, access was limited. Enablers (n = 11) included training non-mental health specialists (e.g., nurses), though workload pressures remained a concern. Expanding access through community or private providers was also proposed. Inner Setting Domain Forty-five enablers, 91 barriers, and 8 neutral were identified regarding the Inner Setting , namely the organisational context of clinical pathway implementation. Access to knowledge and information was the most frequently cited enabler (n = 21). Participants emphasised training and education as critical for pathway uptake. It was noted that modular online training may be sufficient to support healthcare professionals to have triage conversations. Training was viewed as essential for validating and normalising FCR and that training non-mental health specialists (e.g., nurses) to deliver interventions for moderate FCR could extend pathway reach. Mental health specialists were considered to have a fundamental knowledge base regarding FCR treatment but require continuing professional development. Barriers (n = 7) included time constraints and staff turnover. Work infrastructure barriers (n = 30) centred on workforce capacity and service availability. Delivering key components, such as assessment or treatment of severe FCR, was seen as dependent on availability of mental health specialists, with access particularly limited in regional centres. Even where mental health specialists were present, demand often exceeded capacity. Enablers (n = 35) included using non-mental health specialist staff for screening and triage to address workforce gaps. Extending support into community settings was also proposed, though some raised concerns about GP coordination, long waitlists, and affordability. Available resources barriers (n = 31) reflected similar concerns about funding and staffing. Universal or repeated care elements – such as rescreening or booster sessions – were seen as resource-intensive. Some suggested prioritising triage for moderate–high FCR due to constraints. Additional hours for social workers and psychologists were viewed as essential. Equity concerns were raised regarding lack of culturally appropriate measures, limited resources (e.g., care co-ordinators) for some cancer types, and FCR treatment by allied health/psychology, which may not be present in rural/remote areas. Only one response was coded as an enabler, highlighting the tension between need and feasibility. Structural characteristics barriers (n = 15) related to organisational processes, such as difficulty capturing all patients at treatment completion and variation across public/private systems. Two-step screening was questioned when referral options were limited: Enablers (n = 4) included shared ownership of screening and designated private providers. Compatibility with existing workflows was largely seen as an enabler (n = 6). Aligning screening with follow-up appointments was viewed as facilitating timely referral. Administrative barriers (n = 3) were noted if FCR screening timing did not align with standard schedules. Outer Setting Domain Three enablers, six barriers, and one neutral factor were identified regarding the Outer Setting , namely external factors influencing pathway implementation. Partnerships and connections were the main enabler (n = 3). Participants highlighted opportunities to deliver FCR interventions outside cancer centres to reduce burden and improve access. Local conditions barriers (n = 6) included limited availability of psychological services, long wait times, and costs. Differing cultural attitudes regarding discussing mental health were also noted. Financing for specialist FCR care was questioned. These findings underscore the need for cross-sector partnerships and funding strategies to ensure equitable access. Table 3 Most common implementation barriers and enablers according to updated CFIR domains and constructs. CFIR Domain Construct Type Coding Frequency Illustrative Quotes Innovation Innovation Design Enabler 20 This [FCR triage conversations with all survivors and caregivers] is consistent with best practice. Innovation Design Barrier 8 Screening in the immediate window prior to a follow-up appointment may pick up a lot of transient peaks (not the persistent/disabling FCR). Innovation Complexity Barrier 7 [Two-step screening] increases administration burden and reduces feasibility. While simple/straightforward, long term this [stepped care] impacts feasibility, as it will lead to increased 'double handling' (i.e., for the ~ 60% of patients that will need to be stepped up). Innovation Adaptability Enabler 22 A variety of means for administering the [FCR screening] tool should be used, especially for rural & remote patients. “[FCR treatment] may need to be tailored around geographical location and availability of services.” Individuals Innovation Deliverer Capability Enabler 19 Any clinician could administer the [brief FCR screening] tool – novice to expert. Social workers and mental health occupational therapists are well positioned to address FCR. Innovation Recipient Need Enabler 25 [FCR screening] Can assist patients identify and name their emotions and give permission to talk. Important to be patient-centred and facilitate their autonomy of choice. Innovation Deliverer Opportunity Barrier 15 Not all clinical staff have the time or capacity to do this [FCR screening] in their clinic. Accessing [allied health professionals/psychologists] within a timely manner [is] often difficult due to workload demands. Innovation Recipient Need Barrier 15 Joint decision with the patient and psychologist [regarding further treatment for severe FCR]. Innovation Deliverer Opportunity Enabler 11 Would be feasible if the screening was initiated by other clinical staff (e.g. clinical trials or care coordinators) Inner Setting Access to Knowledge and Information Enabler 21 Education of all staff will increase uptake. Online / module-based training (e.g., via EviQ) may be sufficient. Access to Knowledge and Information Barrier 7 Maintaining training to ensure all staff are upskilled is a challenge. Work Infrastructure Barrier 30 [Assessment or treatment for severe FCR is] dependent on whether a service has a mental health specialist on staff. We barely cover significantly distressed active treatment patients, who have to take priority. Work Infrastructure Enabler 35 Always more nurses than psycho-oncology staff. Available Resources Barrier 31 Most social workers or psychologists would be unable to undertake this work unless additional hours were funded for that purpose. Not all rural and remote have access to either [allied health/psychology]. Structural Characteristics Barrier 15 If there is really only one service, this [two-step screening] is likely a waste of time. Structural Characteristics Enabler 4 Staff go on leave etc, so needs widespread ownership. Compatibility Enabler 6 [FCR triage conversations are feasible] If implemented as routine screening practice within consultation. Compatibility Barrier 3 Administratively, this [6 month post-intervention rescreening] would be very difficult to determine. Outer Setting Partnerships and Connections Enabler 3 FCR interventions can be well delivered outside the treatment environment… these can be funded through other streams – Medicare, Private Health. Local Conditions Barrier 6 In the community setting there can be barriers to accessing psychological support; wait times for appointments, lack of oncology experienced psychology services in the area, costs associated with this. Culturally and linguistically diverse survivors, especially elderly people, don't like to talk about mental health. Recommended Implementation Strategies (Aim 3) Figure 1 outlines implementation strategies addressing identified barriers and enablers according to the CFIR-ERIC matching tool. Recommended strategies included educational meetings and tailored training resources to foster pathway awareness, ownership, and delivery capability across diverse health professional roles. Emphasis was placed on the pathway’s adaptability and potential for local tailoring to address geographical and resource variability. To overcome limited opportunity among innovation deliverers, preparing local champions to model and support implementation was proposed. Engaging patients and families in shared decision-making was advised to meet varied recipient needs. Organisational strategies – such as building coalitions beyond cancer centres, securing implementation funding, and aligning pathway components with existing workflows – were recommended to support implementation. Discussion This analysis found varied feasibility across FCR clinical pathway elements and multiple implementation barriers and enablers. Triage to stepped care was widely seen as feasible, while recommendations involving universal or repeated screening/intervention posed a feasibility challenge. Key implementation enablers included building capability through training and access to information. Major barriers were resource limitations and structural constraints. Multifaceted implementation strategies, including education provision and adapting pathway delivery to local contexts, may enhance feasibility. Most participants agreed that pathway elements were feasible, though feasibility ratings were consistently lower than for optimality. Resource-intensive recommendations, such as training all staff in screening, or holding triage conversations with all survivors, were considered least feasible. Feedback underscored tension between what is best for patients and what providers can realistically deliver. Similar concerns were raised regarding implementation of an Australian clinical pathway for anxiety and depression in cancer, with support for structured screening and after care, but concerns about resource and role constraints [ 28 ]. Prioritising high-impact pathway elements and tailoring to local capacity – such as training selected staff to do screening and focusing triage on those with moderate/severe FCR – may improve feasibility in resource-limited settings. The pathway design was generally viewed as an enabler, though elements such as two-step screening and delivering universal care before stepping up were seen as adding complexity. While following a single-item FCR screen (e.g., FCR-1r [ 29 ]) with a more comprehensive measure (e.g., FCRI-SF [ 8 ]) increases administrative burden, it is critical for guiding care based on FCR severity, as per guidelines [ 18 ]. Automated electronic patient reported outcome measure (PROM) administration could reduce complexity, and future AI-supported triage may further streamline processes. For now, the second screening tool could be incorporated into triage conversations alongside questions about FCR impact and support needs. Clinician-patient conversations that build on PROMs results can help develop relationships [ 30 ] and normalise patients’ FCR [ 31 ]. Whether progressive stepped care (starting with universal care) or stratified stepped care (direct allocation to the appropriate level) is preferable likely depends on available resources – another key implementation barrier identified. Progressive stepped care may conserve specialist capacity but risk delaying intensive support, whereas stratified stepped care may improve timeliness but increase costs. Evidence shows minimal outcome differences between approaches in oncology [ 32 ], while mental health literature suggests stratified stepped care is more effective but also more costly [ 33 ]. Ultimately, while the pathway provides consensus-based, guideline-concordant recommendations, local adaptation is essential. The need for local adaptation to enable equitable access to FCR treatment despite resource constraints has also been identified in Canadian sites implementing the Fear of Recurrence Therapy (FORT) intervention [ 17 ]. Developing an implementation blueprint with clear strategies, timelines, and roles, supported by local consensus discussions, is recommended. Process mapping to align new pathways with existing workflows and address context-specific barriers has demonstrated promise in developing implementation plans for other complex aspects of cancer care [ 34 ]. Building capability and leveraging existing capacity through training and access to information were key enablers. This aligns with evidence showing lack of accessible training is a major barrier to implementing PROMs in oncology [ 35 ]. Recommended strategies include development of training materials and educational sessions. Previous research found 99% of clinical and psychosocial professionals were interested in FCR training [ 36 ]. However, training all staff in every aspect of pathway delivery, while ideal, may not be feasible. A modular approach, tailored to roles and resource constraints, may be needed. Existing FCR training programs for primary care (in-person) [ 37 ] and oncologists (online) [ 31 ] have been found to be acceptable and feasible, but programs for multidisciplinary teams are limited. Face-to-face sessions may improve engagement and visibility, while centralised online resources could support scalability and address staff turnover. Uptake of online training for similar pathways has been low (7%) [ 38 ], highlighting the need for organisational support and incentives to encourage participation. Most pathway implementation barriers pertained to the Inner Setting, largely relating to resources and infrastructure. Staffing, funding, and service limitations – especially in regional and community settings – mirror challenges implementing a cancer clinical pathway for anxiety and depression [ 28 ]. These barriers may be mitigated by building capacity across multiple disciplines rather than relying on a single speciality. Identifying local champions is recommended to support uptake, integration, and troubleshooting. Effective champions typically demonstrate influence, ownership, and physical presence at the point of change, combined with persuasiveness, resilience, and a participative leadership style [ 39 ]. Building a coalition of implementers is also recommended, and expanding primary care capacity could reduce pressure on tertiary services, particularly in rural areas and for First Nations, ethnic and racial minority populations, who may prefer community-based support [ 40 ]. To enhance equitable pathway implementation and reduce health professional burden, coalitions of implementers could include trained lay workers, such as people affected by cancer. With appropriate training, these individuals could assist with patient navigation, help identify those experiencing FCR, connect them with suitable services, and provide emotional support. An umbrella review of patient navigation in cancer care found potential improvements in quality of life and psychological wellbeing, with no clear differences in effectiveness between health professional and lay navigators [ 41 ]. Additional funding is critical to enable these strategies, whether for workforce expansion, training, or integration of lay navigators. Investment in FCR care may lower overall healthcare costs [ 6 ], making a strong case for prioritising resource allocation for pathway implementation. Compatibility with existing practices and adaptability to local needs were key implementation enablers. Adaptability has supported PROMs implementation [ 35 ] and appears equally important here. Local tailoring – such as defining roles responsible for each pathway element and adjusting referral pathways based on available resources – was also critical to implementing an anxiety and depression clinical pathway [ 42 ]. Tailoring to individual needs, including cultural background and health literacy, was strongly endorsed and considered feasible. While co-production of culturally appropriate FCR measures and interventions with communities and end-users is essential [ 40 ], collating existing resources for diverse groups could aid tailored pathway implementation in the meantime. Shared decision-making regarding FCR treatment was seen as vital for facilitating engagement, particularly with self-management interventions, consistent with broader survivorship care recommendations [ 43 ]. Preferences for FCR support vary [ 44 ], and some patients with severe FCR prefer less intensive options [ 20 ], despite recommendations for specialist care. Strengths and Limitations Study strengths include applying an established implementation determinant framework to a large multidisciplinary dataset and using a recognised taxonomy to map tailored strategies. The updated CFIR was useful for categorising implementation determinants, though some brief responses were difficult to classify. This was mitigated through double-coding and consensus. While multidisciplinary, the sample was lacking in primary and palliative care clinicians, surgeons, patients, and cultural diversity. Most participants were experienced health professionals working in secondary or tertiary cancer services within Australian public hospitals, so findings may not generalise beyond this context. However, resource constraints appear common across settings [ 45 ], suggesting broader applicability of strategies addressing this barrier. Patient perspectives and adaptations for First Nations, ethnic and racial minority populations are being explored in ongoing work. Conclusion Implementing the FCR clinical pathway requires pragmatic adaptation to overcome resource and structural barriers. Resource-intensive recommendations were least feasible, underscoring the need to prioritise high-impact elements, tailor delivery to local contexts and patient needs, and use shared decision-making to optimise engagement. Key implementation strategies include modular training, integration into existing workflows, and use of local champions, supported by implementation coalitions that extend beyond cancer hospitals. Future research should engage stakeholders to contextualise and prioritise strategies and test these in real-world settings using hybrid effectiveness-implementation designs to ensure sustainable delivery and address cancer survivors’ greatest unmet need through routine FCR screening and tailored support. Declarations Competing Interests Ben Smith has received honorarium from Novartis to participate in a podcast on fear of cancer recurrence. Andrea Smith sits on Patient Advisory Groups for Menarini Stemline and Gilead and has received travel funding and honorarium payments. No other authors have any other conflicts of interest to declare. Funding This research was supported by the New South Wales Government through a Cancer Institute NSW Career Development Fellowship awarded to Allan ‘Ben’ Smith (2021/CDF1138). Conflicts of Interest Ben Smith has received honorarium from Novartis to participate in a podcast on fear of cancer recurrence. Andrea Smith sits on Patient Advisory Groups for Menarini Stemline and Gilead and has received travel funding and honorarium payments. No other authors have any other conflicts of interest to declare. Ethics Approval The study was approved by the University of New South Wales Human Research Ethics Committee (HC230052). Consent to Participate Informed consent was obtained from all individual participants included in the study. Author Contribution Ben Smith and Afaf Girgis contributed to study conception. All authors contributed to study design and material preparation. Data collection and analysis were performed by Ben Smith, Verena S Wu, Agamjot Kaur Virk, and Joy Gao. All authors contributed to interpretation of the study results. The first draft of the manuscript was written by Ben Smith and Verena S Wu, and all authors reviewed and commented on manuscript drafts. All authors read and approved the final manuscript. Acknowledgement Thank you to Dianne Gibbs, Shannon Philp, Dr Lahiru Russell, Dr Penelope Stephens, and all the other health professionals and researchers who generously donated their time and expertise to participate in this study. Thanks also to Prof Michael Jefford and Prof Bogda Koczwara for providing feedback on the initial draft of the Delphi survey. Finally, thanks to the Cancer Council NSW, Cancer Nurses Society of Australia, Cancer Symptoms Trials Group, Clinical Oncology Society of Australia, McGrath Foundation, Oncology Network, Oncology Social Work Australia New Zealand, Primary Care Collaborative Cancer Clinical Trials Group, Psycho-Oncology Co-operative Research Group and South Western Sydney Local Health District for promoting the study. Data Availability The datasets generated and analysed during the current study are available from the corresponding author on reasonable request. References Ferlay J, E.M., Lam F, Laversanne M, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F. Global Cancer Observatory: Cancer Today (version 1.1) . 2024 28/11/2025]; Available from: https://gco.iarc.who.int/today . Lebel, S., et al., From normal response to clinical problem: definition and clinical features of fear of cancer recurrence . Supportive Care in Cancer, 2016. 24(8): p. 3265–3268. Luigjes-Huizer, Y.L., et al., What is the prevalence of fear of cancer recurrence in cancer survivors and patients? A systematic review and individual participant data meta-analysis . Psychooncology, 2022. 31(6): p. 879–892. Mutsaers, B., et al., Identifying the key characteristics of clinical fear of cancer recurrence: An international Delphi study . Psycho-Oncology, 2020. 29(2): p. 430–436. Simard, S., et al., Fear of cancer recurrence in adult cancer survivors: A systematic review of quantitative studies . Journal of Cancer Survivorship, 2013. 7(3): p. 300–322. Williams, J.T.W., A. Pearce, and A.B. Smith, A systematic review of fear of cancer recurrence related healthcare use and intervention cost-effectiveness . Psycho-Oncology, 2021. 30(8): p. 1185–1195. Lisy, K., et al., Identifying the most prevalent unmet needs of cancer survivors in Australia: A systematic review . Asia-Pacific Journal of Clinical Oncology, 2019. Simard, S. and J. Savard, Fear of Cancer Recurrence Inventory: Development and initial validation of a multidimensional measure of fear of cancer recurrence . Supportive Care in Cancer, 2009. 17(3): p. 241–251. Humphris, G.M., et al., Unidimensional scales for fears of cancer recurrence and their psychometric properties: the FCR4 and FCR7 . Health and Quality of Life Outcomes, 2018. 16(1): p. 30. Giguère, L., et al., The Ottawa clinical fear of recurrence instruments: A screener, self-report, and clinical interview . Psycho-Oncology, 2024. 33(6): p. e6364. Butow, P.N., et al., Randomized Trial of ConquerFear: A Novel, Theoretically Based Psychosocial Intervention for Fear of Cancer Recurrence . Journal of Clinical Oncology, 2017. 35(36): p. 4066–4077. Maheu, C., et al., Fear of cancer recurrence therapy (FORT): A randomized controlled trial . Health Psychol, 2023. 42(3): p. 182–194. van de Wal, M., et al., Efficacy of Blended Cognitive Behavior Therapy for High Fear of Recurrence in Breast, Prostate, and Colorectal Cancer Survivors: The SWORD Study, a Randomized Controlled Trial . Journal of Clinical Oncology, 2017. 35(19): p. 2173–2183. Maheu, C., et al., Systematic Review of Fear of Cancer Recurrence Patient-Reported Outcome Measures: Evaluating Methodological Quality and Measurement Properties Using the COSMIN Checklist . Healthcare (Basel), 2025. 13(17). Tauber, N.M., et al., Effect of Psychological Intervention on Fear of Cancer Recurrence: A Systematic Review and Meta-Analysis . J Clin Oncol, 2019. 37(31): p. 2899–2915. Deuning-Smit, E., et al., Barriers and facilitators for implementation of the SWORD evidence-based psychological intervention for fear of cancer recurrence in three different healthcare settings . Journal of Cancer Survivorship, 2023. 17(4): p. 1057–1071. Lebel, S., et al., Investigating the Pre-Implementation Facilitators and Barriers of the Implementation of the Fear of Recurrence Therapy (FORT) Intervention in Canadian Cancer Centers . Psychooncology, 2025. 34(10): p. e70293. Lebel, S., et al., Fear of Cancer Recurrence Guideline . 2024, Ontario Health (Cancer Care Ontario): Toronto (ON). Smith, A.B., et al., Step-by-step: A clinical pathway for stepped care management of fear of cancer recurrence—results of a three-round online delphi consensus process with Australian health professionals and researchers . Journal of Cancer Survivorship, 2024. Tran, M.J., et al., Feasibility and Acceptability of the Fear-Less Screening and Stratified-Care Model for Fear of Cancer Recurrence Among People Affected by Early-Stage Cancer . Psycho-Oncology, 2025. 34(2): p. e70070. Shaw, J., et al., Setting an International Research Agenda for Fear of Cancer Recurrence: An Online Delphi Consensus Study . Front Psychol, 2021. 12: p. 596682. Pereira, V.C., et al., Strategies for the implementation of clinical practice guidelines in public health: an overview of systematic reviews . Health Research Policy and Systems, 2022. 20(1): p. 13. Jünger, S., et al., Guidance on Conducting and REporting DElphi Studies (CREDES) in palliative care: Recommendations based on a methodological systematic review . Palliat Med, 2017. 31(8): p. 684–706. Pinnock, H., et al., Standards for Reporting Implementation Studies (StaRI) Statement . Bmj, 2017. 356: p. i6795. Damschroder, L.J., et al., The updated Consolidated Framework for Implementation Research based on user feedback . Implementation Science, 2022. 17(1): p. 75. Perry, C.K., et al., Specifying and comparing implementation strategies across seven large implementation interventions: a practical application of theory . Implementation Science, 2019. 14(1): p. 32. Powell, B.J., et al., A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project . Implementation Science, 2015. 10(1): p. 21. Rankin, N.M., et al., Everybody wants it done but nobody wants to do it: An exploration of the barrier and enablers of critical components towards creating a clinical pathway for anxiety and depression in cancer . BMC Health Services Research, 2015. 15(1). Smith, A.B., et al., Evaluation of the validity and screening performance of a revised single-item fear of cancer recurrence screening measure (FCR-1r). Psycho-Oncology, 2023. 32(6): p. 961–971. Greenhalgh, J., et al., How do patient reported outcome measures (PROMs) support clinician-patient communication and patient care? A realist synthesis . J Patient Rep Outcomes, 2018. 2: p. 42. Liu, J., et al., Novel Clinician-Lead Intervention to Address Fear of Cancer Recurrence in Breast Cancer Survivors . JCO Oncology Practice, 2021: p. OP.20.00799. Abdalla, T., et al., Stepped-care models for cancer symptom management: a systematic review of efficacy and cost-effectiveness. JNCI: Journal of the National Cancer Institute, 2025: p. djaf153. Delgadillo, J., et al., Stratified Care vs Stepped Care for Depression: A Cluster Randomized Clinical Trial . JAMA Psychiatry, 2022. 79(2): p. 101–108. Taylor, N., et al., Advancing the Speed and Science of Implementation Using Mixed-Methods Process Mapping – Best Practice Recommendations . International Journal of Qualitative Methods, 2025. 24: p. 16094069251340908. Lyu, J., et al., Facilitators and barriers to implementing patient-reported outcomes in clinical oncology practice: a systematic review based on the consolidated framework for implementation research . Implementation Science Communications, 2024. 5(1): p. 120. Thewes, B., et al., Current approaches to managing fear of cancer recurrence; a descriptive survey of psychosocial and clinical health professionals . Psycho-Oncology, 2014. 23(4): p. 390–396. Berrett-Abebe, J., et al., Impact of an Interprofessional Primary Care Training on Fear of Cancer Recurrence on Clinicians’ Knowledge, Self-Efficacy, Anticipated Practice Behaviors, and Attitudes Toward Survivorship Care . Journal of Cancer Education, 2019. 34(3): p. 505–511. Shaw, J., et al., Development, acceptability and uptake of an on-line communication skills education program targeting challenging conversations for oncology health professionals related to identifying and responding to anxiety and depression . BMC Health Services Research, 2022. 22(1): p. 132. Bonawitz, K., et al., Champions in context: which attributes matter for change efforts in healthcare? Implementation Science, 2020. 15(1): p. 62. Anderson, K., et al., A Systematic Review of Fear of Cancer Recurrence Among Indigenous and Minority Peoples . Frontiers in Psychology, 2021. 12. Chan, R.J., et al., Patient navigation across the cancer care continuum: An overview of systematic reviews and emerging literature. CA: A Cancer Journal for Clinicians, 2023. 73(6): p. 565–589. Butow, P.N., et al., From ideal to actual practice: Tailoring a clinical pathway to address anxiety or depression in patients with cancer and planning its implementation across individual clinical services . Journal of Psychosocial Oncology Research and Practice, 2021. 3(4). Howell, D., et al., Management of Cancer and Health After the Clinic Visit: A Call to Action for Self-Management in Cancer Care . J Natl Cancer Inst, 2021. 113(5): p. 523–531. Luigjes-Huizer, Y.L., et al., Patient-reported needs for coping with worry or fear about cancer recurrence and the extent to which they are being met: a survey study . J Cancer Surviv, 2022: p. 1–9. Jabbour, M., et al., Defining barriers and enablers for clinical pathway implementation in complex clinical settings . Implementation Science, 2018. 13(1): p. 139. Additional Declarations Competing interest reported. Ben Smith has received honorarium from Novartis to participate in a podcast on fear of cancer recurrence. Andrea Smith sits on Patient Advisory Groups for Menarini Stemline and Gilead and has received travel funding and honorarium payments. No other authors have any other conflicts of interest to declare. Supplementary Files SupplementaryFile1.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 01 Apr, 2026 Editor assigned by journal 01 Apr, 2026 Submission checks completed at journal 25 Feb, 2026 First submitted to journal 15 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Ben Smith has received honorarium from Novartis to participate in a podcast on fear of cancer recurrence. Andrea Smith sits on Patient Advisory Groups for Menarini Stemline and Gilead and has received travel funding and honorarium payments. No other authors have any other conflicts of interest to declare.","formattedTitle":"Designing for Delivery: A Delphi Study of Feasibility-Informed Implementation Strategies for a Fear of Cancer Recurrence Clinical Pathway","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe number of people living with and beyond cancer is growing rapidly, currently estimated to be over 53\u0026nbsp;million people globally [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Most people affected by cancer experience some degree of fear, worry, or concern about their cancer coming back or getting worse, which is referred to as fear of cancer recurrence (FCR) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. An international individual participant data meta-analysis (n\u0026thinsp;=\u0026thinsp;9311) found 39% of people affected by cancer experience moderate FCR, while 19% experience severe/clinical FCR [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] equating to more than 30\u0026nbsp;million people affected by FCR globally. People with clinically severe FCR experience high and persistent levels of preoccupation and worry, hypervigilance to physical symptoms, and functional impairment [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Moreover, people with more severe FCR experience poorer mental health and quality of life [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], and use more healthcare services [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eReceiving help with FCR has been identified as the greatest unmet supportive care need in people with cancer [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In response, a wide range of measures (e.g., the Fear of Cancer Recurrence Inventory [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], FCR-4/7 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], Ottawa Clinical Fear of Recurrence instruments [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]) and treatments (e.g., ConquerFear [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], FORT [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], SWORD [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]) have been developed and shown to effectively identify, assess, and treat FCR [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, translating these resources into routine clinical practice has proven challenging. Documented implementation barriers include limited awareness of FCR, inadequate referral pathways, concerns about equitable access, health professional capacity constraints, and challenges applying manualised FCR interventions in diverse clinical contexts [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Until recently, there was limited formal guidance on how to systematically address FCR in clinical settings. In 2024, this gap was addressed through the publication of Canadian FCR guidelines [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and a complementary Australian FCR clinical pathway developed by our team [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Both advocate for routine FCR screening, followed by further assessment and triage to stepped care. Pilot studies have demonstrated the acceptability, feasibility, and preliminary efficacy of this approach [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], but there is limited evidence of successful implementation in routine care. Enhancing the translation of FCR research into clinical care and improving access to FCR treatment have been identified as international [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] research priorities.\u003c/p\u003e \u003cp\u003eClinical pathways are a well-established strategy for translating evidence into practice. By offering standardised, context-specific recommendations for multidisciplinary care, they help bridge the gap between research and routine clinical delivery [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. To support implementation of FCR research, we developed a clinical pathway incorporating contemporary evidence and consensus-based guidance on optimal FCR screening, assessment, and triage to stepped care [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The pathway was developed through a three-stage Delphi process, whereby n\u0026thinsp;=\u0026thinsp;94 participants \u0026ndash; primarily health professionals working across varied disciplines and settings \u0026ndash; reached consensus on 35/38 (92%) of proposed pathway elements based on alignment with best-practice and potential to improve patient outcomes (optimality). With consensus achieved regarding the optimal clinical pathway, the next critical step is to ensure feasibility of pathway elements. Feasibility was also assessed in the Delphi study and has been identified as a key antecedent of successful implementation. Analysis of qualitative feedback regarding feasibility can identify strategies to overcome perceived implementation barriers and enablers.\u003c/p\u003e \u003cp\u003eThis secondary analysis of data from the Delphi study conducted to establish the optimal FCR clinical pathway aimed to facilitate the successful future implementation of the pathway by:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eReporting the perceived feasibility of optimal pathway elements;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIdentifying pathway implementation barriers and enablers; and\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDeveloping pathway implementation strategies.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Context\u003c/h2\u003e \u003cp\u003eThis study is a secondary analysis of data collected during a previously published three-round Delphi study that established consensus on optimal elements of a clinical pathway for identifying and managing FCR in routine care of early-stage cancer survivors [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study was approved by the University of New South Wales Human Research Ethics Committee (HC230052), conducted in accordance with the Conducting and Reporting Delphi Studies (CREDES) guidelines [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and reported following the Standards for Reporting Implementation Studies (StaRI) Statement [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and Recruitment\u003c/h3\u003e\n\u003cp\u003e Eligible participants included Australian health professionals involved in the care of adult cancer survivors (\u0026ge;\u0026thinsp;18 years) and researchers who had co-authored a peer-reviewed paper on FCR within the past five years. Participants working primarily with paediatric populations were excluded due to contextual differences in FCR presentation and management. Participants were recruited via professional oncology organisations, conference presentations, and social media. All participants gave informed consent. Participants who completed Round 1 were invited to subsequent rounds; no new participants were recruited after Round 1.\u003c/p\u003e\n\u003ch3\u003eOutcomes and Analysis\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eFeasibility assessment (Aim 1)\u003c/h2\u003e \u003cp\u003eParticipants rated the feasibility (i.e., likelihood of implementation in routine care) of each pathway element using a 5-point Likert scale from \u0026ldquo;strongly disagree\u0026rdquo; to \u0026ldquo;strongly agree,\u0026rdquo; with a \u0026ldquo;Not my expertise\u0026rdquo; option for items outside a participant\u0026rsquo;s scope.\u003c/p\u003e \u003cp\u003eThe proportion of participants agreeing/strongly agreeing that an item was feasible was analysed descriptively.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eIdentifying pathway implementation barriers and enablers (Aim 2)\u003c/h3\u003e\n\u003cp\u003eOpen-ended comments were collected alongside the Delphi item for each pathway element and at the end of each pathway component to capture perceived implementation barriers and enablers.\u003c/p\u003e \u003cp\u003eDirected content analysis was conducted on open-ended qualitative responses using the updated Consolidated Framework for Implementation Research (CFIR) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Only responses related to pathway elements included in the final clinical pathway were analysed. The updated CFIR is one of the most widely used and validated frameworks for categorising implementation barriers and enablers (i.e., determinants). It comprises five domains: Innovation (intervention attributes), Outer Setting (external context), Inner Setting (organisational context), Individuals (characteristics of those involved in implementation), and Implementation Process (implementation activities) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Each domain includes multiple constructs representing potential barriers and enablers to implementation. As the clinical pathway is currently in the pre-implementation phase, the Implementation Process domain was not coded.\u003c/p\u003e \u003cp\u003eA codebook was developed by the research team based on the updated CFIR template (available at cfirguide.org) and adapted to the study context to aid consistent interpretation of constructs and support inter-rater reliability (see Appendix 1). Each qualitative response was independently coded by two researchers (AKV and JG) to the single most relevant CFIR domain and construct. Coders also classified whether the response reflected an implementation barrier, enabler, or neutral factor. The number of barriers and enablers relating to each construct was counted.\u003c/p\u003e \u003cp\u003eCoding followed an iterative process. AKV and JG met regularly with the broader research team to discuss and refine coding decisions. Discrepancies were resolved through team consensus involving experienced qualitative/implementation researchers (ABS, AS, and VW). To enhance reliability, ABS and VW subsequently each coded half of the dataset, so every response was reviewed by three researchers. All coding was conducted using Microsoft Excel.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDeveloping implementation strategies (Aim 3)\u003c/h2\u003e \u003cp\u003eOnce key implementation determinants were identified, the CFIR-ERIC matching tool [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] was used to identify implementation strategies addressing the most common barriers and enablers. The CFIR-ERIC matching tool is a theory-informed resource that links specific implementation barriers and enablers identified using the CFIR, to evidence-based implementation strategies from the Expert Recommendations for Implementing Change (ERIC) taxonomy [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. It enables systematic selection of strategies most likely to address identified contextual challenges, thereby enhancing the feasibility and likely success of implementation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eOf the 94 individuals who consented to participate in the Delphi study, 89 completed Round 1 (April\u0026ndash;June 2023), 69 completed Round 2 (July\u0026ndash;August 2023), and 73 completed Round 3 (November\u0026ndash;December 2023). Participants (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) were primarily health professionals (86%), spanning disciplines including mental and allied health (n\u0026thinsp;=\u0026thinsp;31, 33%), nursing (n\u0026thinsp;=\u0026thinsp;30, 32%), and medical/radiation/surgical oncology (n\u0026thinsp;=\u0026thinsp;18, 19%) working in metropolitan (84%) tertiary referral centres (47%) in public settings (54%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%) of respondents\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25 (26.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28 (29.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24 (25.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61\u0026ndash;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (13.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrefer not to say\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (1.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMan/male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (10.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWoman/female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84 (89.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCountry of birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71 (75.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23 (24.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLanguage spoken at home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnglish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82 (87.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (12.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAboriginal/Torres Strait Islander status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-Indigenous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e94 (100.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eGeographic area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMetropolitan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79 (84.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRegional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (5.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (10.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePrimary role\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e81 (86.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResearcher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (10.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEducator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003ePrimary focus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePsychology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (19.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocial work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (13.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNursing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30 (31.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedical oncology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (12.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRadiation oncology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (5.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgical oncology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (1.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePalliative care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (1.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (14.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eWork setting (clinician/educator; n\u0026thinsp;=\u0026thinsp;84)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTertiary referral cancer centre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44 (46.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDistrict/local hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (23.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon inpatient cancer treatment centre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (19.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-hospital based\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (10.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (2.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunity centre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (6.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (6.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003ePublic/private (clinician/educator; n\u0026thinsp;=\u0026thinsp;84)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51 (54.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (7.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublic and private\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (18.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublic charitable organisation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate charitable organisation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (5.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (2.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eYears worked with cancer survivors (clinician/educator; n\u0026thinsp;=\u0026thinsp;84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (11.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (23.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48 (51.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eRole caring for cancer survivors with FCR (clinician/educator; n\u0026thinsp;=\u0026thinsp;84)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScreening and/or assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49 (52.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReferral to psychosocial support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55 (58.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProvision of psychosocial support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eYears conducting research (researcher; n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (7.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003ea\u003c/sup\u003e Respondents could select multiple responses\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFeasibility of pathway elements (Aim 1)\u003c/h2\u003e \u003cp\u003eFeasibility ratings for clinical pathway elements ranged from 49.4% (\u0026ldquo;All clinical staff should be trained to implement FCR screening and respond appropriately\u0026rdquo;) to 90.1% (\u0026ldquo;It is important that all health care professionals validate and normalise FCR\u0026rdquo;) (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Average feasibility ratings were highest for the post-screening/triage stepped-care treatment pathway component (75.9%) and lowest for the supported self-management for moderate FCR pathway component (61.0%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOptimal and feasible ratings for elements included in the FCR clinical pathway\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathway Component\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOptimal % \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFeasible % \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScreening\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e66.8%\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScreening for FCR should commence at the completion of hospital-based treatment (e.g. surgery, chemotherapy, or radiotherapy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52/72 (72.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68/89 (76.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScreening for FCR should be conducted prior to a cancer survivor\u0026rsquo;s follow-up appointment to aid discussion during the appointment if needed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74/89 (83.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61/89 (68.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScreening for FCR should be repeated after a cancer survivor\u0026rsquo;s follow-up appointment, to characterise the persistence of FCR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74/89 (83.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57/89 (64.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA brief validated tool, administered either in written or verbal form, should be used to identify cancer survivors experiencing FCR needing further assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88/89 (98.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75/89 (84.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTwo-step screening should be used: (1) A brief (e.g. single-item) screening tool to identify individuals with potential FCR; (2) A longer (approx. 10-item) screening tool to assess FCR severity in those above cut-off on the initial measure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77/87 (88.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60/89 (67.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecific clinical staff should be designated to review the results of FCR screening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76/89 (85.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51/89 (57.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll clinical staff should be trained to implement FCR screening and respond appropriately\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75/89 (84.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44/89 (49.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTriage, assessment, referral\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e71.4%\u003c/b\u003e \u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA triage conversation including discussion of results of FCR screening should take place with all cancer survivors (and their family caregiver if desired)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57/68 (83.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37/69 (53.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-mental health specialists (e.g. cancer care nurses/coordinators) are well-placed to have triage conversations with cancer survivors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71/86 (82.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63/86 (73.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraining is needed to support health care professionals to have triage conversations with cancer survivors about FCR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84/86 (97.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72/86 (83.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhen the results of screening and the triage conversation suggest a cancer survivor has severe FCR they should be assessed by a mental health specialist (e.g. psychologist/psychiatrist) to confirm the recommendation of specialist FCR care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75/86 (87.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53/86 (61.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient education is needed to encourage uptake of recommended FCR interventions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77/86 (89.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73/86 (84.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost-screening/triage stepped-care treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e75.9%\u003c/b\u003e \u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA stepped-care model is appropriate for managing FCR in cancer survivors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76/84 (90.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64/85 (75.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll cancer survivors should firstly be allocated to Step 1 (Universal care) regardless of initial FCR levels, then be stepped up to higher levels based on results of subsequent screening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72/84 (85.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60/85 (70.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntervention recommendations for cancer survivors with moderate-severe FCR should consider their FCR level and their preference and capacity for engaging with self-management versus clinician-delivered interventions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59/66 (89.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48/66 (72.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe specific FCR treatment recommended to a cancer survivor should be guided by the stepped-care algorithm, but should be discussed and agreed on by patients and clinicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63/66 (95.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55/66 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIf a cancer survivor does not engage with the initially agreed on FCR intervention alternative interventions within the same step should be discussed. If none appeal, less intensive interventions from the step below could be considered.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55/66 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50/66 (75.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRescreening cancer survivors for FCR at routine follow-up appointments is an appropriate way of monitoring progress and guiding referral for further treatment if needed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78/85 (91.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64/85 (75.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKey team members need to tailor the FCR clinical pathway for their service\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73/85 (85.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63/85 (74.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTailoring should take into consideration the local cancer survivor population (e.g., cultural background and health literacy) and resources available\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81/84 (96.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68/85 (80.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStep 1: Universal care for Minimal to Mild FCR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabd\" border=\"1\"\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e64.4%\u003c/b\u003e \u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCancer survivors should initially be provided with information about risk of recurrence, possible symptoms of recurrence and how they relate to FCR from their oncologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70/81 (86.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54/81 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOncology specialists and nursing staff are the ideal people to address mild FCR as part of routine care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69/81 (85.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49/81 (60.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary healthcare professionals (e.g., general practitioners/GPs or GP nurses) could play an important role in addressing mild FCR in routine care, if trained appropriately\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58/66 (87.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38/66 (57.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIt is important that all health care professionals validate and normalise FCR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78/81 (96.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73/81 (90.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll cancer survivors with mild FCR should receive FCR psychoeducational materials provided by cancer support organisations (e.g., Cancer Council or Australian Cancer Survivorship Centre)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75/80 (93.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66/81 (81.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIf cancer survivors report minimal/mild FCR in rescreening, then they should continue to be screened for FCR and provided with information about FCR self-management and support options in case FCR worsens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58/66 (87.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48/66 (72.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStep 2: Supported self-management for Moderate FCR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabe\" border=\"1\"\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e61.0%\u003c/b\u003e \u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate FCR could primarily be addressed using online or group interventions, but other options should be offered to people who prefer/need other forms of support (e.g., elderly or culturally and linguistically diverse survivors)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57/65 (87.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47/65 (72.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurvivors with moderate FCR should be presented with FCR treatment options either within or outside the hospital setting to accommodate their preferences and circumstances\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53/65 (81.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45/65 (69.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith further training, oncology health professionals without specialist psychology training (e.g., oncology nurses), could play an important role in delivering interventions recommended for moderate FCR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58/72 (80.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33/65 (50.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAllied health (e.g. social workers) or psychologists are the best people to deliver the interventions recommended\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65/78 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48/80 (60.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthcare professional-delivered booster sessions should be offered to patients whose FCR is improved but not remitted at rescreening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59/72 (81.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42/80 (52.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients should be rescreened for FCR 6 months post-intervention to determine long-term progress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74/80 (92.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49/80 (61.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStep 3: Specialist care for severe FCR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e69.0%\u003c/b\u003e \u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA mental health specialist (i.e. a psychologist or psychiatrist) should deliver interventions for severe FCR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72/78 (92.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50/78 (64.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA progress review should be conducted at completion or discontinuation of psychological treatment for FCR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75/78 (96.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60/78 (76.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRescreening is appropriate for monitoring progress at FCR treatment completion/discontinuation and in the longer-term (e.g., 6 months post-FCR treatment)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72/78 (92.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51/78 (65.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUltimately the treating psychologist or psychiatrist should decide whether a patient requires further treatment (e.g. booster sessions)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65/78 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56/78 (71.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRescreening is appropriate for monitoring progress at treatment completion/discontinuation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66/76 (86.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52/78 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003ea\u003c/sup\u003e Reported percentages represent the number of participants who agreed or strongly agreed with the item divided by the number of people who responded to that item, excluding those who indicated \u0026ldquo;Not my expertise\u0026rdquo;. The highest optimal rating was taken from across rounds, and items were rated for feasibility once across all rounds, which is why denominators differ for the optimality and feasibility ratings within items and feasibility ratings across items\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003eb\u003c/sup\u003e Average feasibility for each pathway component was calculated by summing the percentage for each individual element included in the pathway and dividing by the total number of included elements in that component\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Shading denotes strength of feasibility ratings. Blue indicates 90\u0026ndash;100% agreement; purple indicates 80\u0026ndash;90% agreement; pink indicates 70\u0026ndash;80% agreement; orange indicates 60\u0026ndash;70% agreement; dark yellow indicates 50\u0026ndash;60% agreement; and light yellow indicates\u0026thinsp;\u0026lt;\u0026thinsp;50% agreement.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDeterminants of pathway feasibility (Aim 2)\u003c/h2\u003e \u003cp\u003eOf the 639 qualitative responses collected, 410 related to elements ultimately included in the FCR clinical pathway, which were coded to the Innovation (n\u0026thinsp;=\u0026thinsp;99), Individuals (n\u0026thinsp;=\u0026thinsp;125), Inner Setting (n\u0026thinsp;=\u0026thinsp;144), and Outer Setting (n\u0026thinsp;=\u0026thinsp;9) updated CFIR domains. Thirty-three responses were coded as \u0026lsquo;not applicable\u0026rsquo; due to brevity or ambiguity.\u003c/p\u003e \u003cp\u003e170 responses were coded as barriers, 53 as neutral, and 154 as enablers. Barriers and enablers related to updated CFIR domains (in bold italics) and constructs (in bold) are provided below, with illustrative quotes in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eInnovation Domain\u003c/h2\u003e \u003cp\u003eForty-five enablers, 22 barriers, and 32 neutral factors were identified regarding \u003cb\u003eInnovation\u003c/b\u003e, namely the FCR clinical pathway.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInnovation design\u003c/b\u003e was both an enabler (n\u0026thinsp;=\u0026thinsp;20) and a barrier (n\u0026thinsp;=\u0026thinsp;8). Many participants viewed the pathway\u0026rsquo;s design as aligned with best practice, but some thought screening prior to follow-up appointments may pick up transient peaks in FCR.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInnovation complexity\u003c/b\u003e was identified as a barrier (n\u0026thinsp;=\u0026thinsp;7). The two-step screening process was seen as adding administrative burden and concerns were also raised about stepped care leading to \u0026lsquo;double handling\u0026rsquo; of the majority of patients likely to need extra support.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInnovation adaptability\u003c/b\u003e was the most frequently cited enabler (n\u0026thinsp;=\u0026thinsp;22). Participants emphasised the importance of tailoring implementation to local contexts, especially for rural and remote patients with limited access to in-person care and psychological support. This flexibility was seen as critical to supporting implementation across diverse settings and populations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eIndividuals Domain\u003c/h2\u003e \u003cp\u003eSixty-two enablers, 51 barriers, and 12 neutral factors were identified regarding \u003cb\u003eIndividuals\u003c/b\u003e, namely the people involved in pathway implementation.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInnovation deliverer capability\u003c/b\u003e was a key enabler (n\u0026thinsp;=\u0026thinsp;19). Participants generally viewed FCR screening as within the \u003cb\u003ecapabilities\u003c/b\u003e of most staff. The \u003cb\u003ecapability\u003c/b\u003e of allied health professionals to address FCR across severity levels was also highlighted. Building \u003cb\u003ecapability\u003c/b\u003e through training was considered essential for some pathway elements, such as triage conversations and normalising FCR.\u003c/p\u003e \u003cp\u003eResponsiveness of the pathway to \u003cb\u003einnovation recipient need\u003c/b\u003e was a strong enabler (n\u0026thinsp;=\u0026thinsp;25). Screening was seen as empowering patients to discuss FCR. Participants emphasised the importance of supporting patient-centred care by enabling intervention choice within a stepped care model. This construct was also considered a barrier (n\u0026thinsp;=\u0026thinsp;15) when pathway recommendations were perceived as misaligned with recipient preferences or capacity. For example, some felt oncologists should only provide recurrence risk information if patients wanted it. Similarly, recommendations that treating psychologists/psychiatrists should decide whether further treatment for severe FCR was warranted prompted calls for shared decision-making.\u003c/p\u003e \u003cp\u003eViews were mixed regarding \u003cb\u003einnovation deliverer opportunity\u003c/b\u003e. Barriers (n\u0026thinsp;=\u0026thinsp;15) included time and workload constraints limiting screening opportunities for some clinical staff. Integrating FCR triage into routine follow-up was seen as challenging due to the competing demands of medical management. Limited opportunity to provide FCR-related support was noted across roles, with oncologists particularly constrained. While allied health professionals and psychologists were viewed as best suited for moderate FCR interventions, access was limited. Enablers (n\u0026thinsp;=\u0026thinsp;11) included training non-mental health specialists (e.g., nurses), though workload pressures remained a concern. Expanding access through community or private providers was also proposed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eInner Setting Domain\u003c/h2\u003e \u003cp\u003eForty-five enablers, 91 barriers, and 8 neutral were identified regarding the \u003cb\u003eInner Setting\u003c/b\u003e, namely the organisational context of clinical pathway implementation.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAccess to knowledge and information\u003c/b\u003e was the most frequently cited enabler (n\u0026thinsp;=\u0026thinsp;21). Participants emphasised training and education as critical for pathway uptake. It was noted that modular online training may be sufficient to support healthcare professionals to have triage conversations. Training was viewed as essential for validating and normalising FCR and that training non-mental health specialists (e.g., nurses) to deliver interventions for moderate FCR could extend pathway reach. Mental health specialists were considered to have a fundamental knowledge base regarding FCR treatment but require continuing professional development. Barriers (n\u0026thinsp;=\u0026thinsp;7) included time constraints and staff turnover.\u003c/p\u003e \u003cp\u003e \u003cb\u003eWork infrastructure\u003c/b\u003e barriers (n\u0026thinsp;=\u0026thinsp;30) centred on workforce capacity and service availability. Delivering key components, such as assessment or treatment of severe FCR, was seen as dependent on availability of mental health specialists, with access particularly limited in regional centres. Even where mental health specialists were present, demand often exceeded capacity. Enablers (n\u0026thinsp;=\u0026thinsp;35) included using non-mental health specialist staff for screening and triage to address workforce gaps. Extending support into community settings was also proposed, though some raised concerns about GP coordination, long waitlists, and affordability.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAvailable resources\u003c/b\u003e barriers (n\u0026thinsp;=\u0026thinsp;31) reflected similar concerns about funding and staffing. Universal or repeated care elements \u0026ndash; such as rescreening or booster sessions \u0026ndash; were seen as resource-intensive. Some suggested prioritising triage for moderate\u0026ndash;high FCR due to constraints. Additional hours for social workers and psychologists were viewed as essential. Equity concerns were raised regarding lack of culturally appropriate measures, limited resources (e.g., care co-ordinators) for some cancer types, and FCR treatment by allied health/psychology, which may not be present in rural/remote areas. Only one response was coded as an enabler, highlighting the tension between need and feasibility.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStructural characteristics\u003c/b\u003e barriers (n\u0026thinsp;=\u0026thinsp;15) related to organisational processes, such as difficulty capturing all patients at treatment completion and variation across public/private systems. Two-step screening was questioned when referral options were limited: Enablers (n\u0026thinsp;=\u0026thinsp;4) included shared ownership of screening and designated private providers.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCompatibility\u003c/b\u003e with existing workflows was largely seen as an enabler (n\u0026thinsp;=\u0026thinsp;6). Aligning screening with follow-up appointments was viewed as facilitating timely referral. Administrative barriers (n\u0026thinsp;=\u0026thinsp;3) were noted if FCR screening timing did not align with standard schedules.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eOuter Setting Domain\u003c/h2\u003e \u003cp\u003eThree enablers, six barriers, and one neutral factor were identified regarding the \u003cb\u003eOuter Setting\u003c/b\u003e, namely external factors influencing pathway implementation.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePartnerships and connections\u003c/b\u003e were the main enabler (n\u0026thinsp;=\u0026thinsp;3). Participants highlighted opportunities to deliver FCR interventions outside cancer centres to reduce burden and improve access.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLocal conditions\u003c/b\u003e barriers (n\u0026thinsp;=\u0026thinsp;6) included limited availability of psychological services, long wait times, and costs. Differing cultural attitudes regarding discussing mental health were also noted.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFinancing\u003c/b\u003e for specialist FCR care was questioned. These findings underscore the need for cross-sector partnerships and funding strategies to ensure equitable access.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMost common implementation barriers and enablers according to updated CFIR domains and constructs.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCFIR Domain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConstruct\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eType\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCoding Frequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIllustrative Quotes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInnovation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInnovation Design\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnabler\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThis [FCR triage conversations with all survivors and caregivers] is consistent with best practice.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInnovation Design\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eScreening in the immediate window prior to a follow-up appointment may pick up a lot of transient peaks (not the persistent/disabling FCR).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInnovation Complexity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[Two-step screening] increases administration burden and reduces feasibility.\u003c/p\u003e \u003cp\u003eWhile simple/straightforward, long term this [stepped care] impacts feasibility, as it will lead to increased 'double handling' (i.e., for the ~\u0026thinsp;60% of patients that will need to be stepped up).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInnovation Adaptability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnabler\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eA variety of means for administering the [FCR screening] tool should be used, especially for rural \u0026amp; remote patients.\u003c/p\u003e \u003cp\u003e\u0026ldquo;[FCR treatment] may need to be tailored around geographical location and availability of services.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndividuals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInnovation Deliverer Capability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnabler\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAny clinician could administer the [brief FCR screening] tool \u0026ndash; novice to expert.\u003c/p\u003e \u003cp\u003eSocial workers and mental health occupational therapists are well positioned to address FCR.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInnovation Recipient Need\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnabler\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[FCR screening] Can assist patients identify and name their emotions and give permission to talk.\u003c/p\u003e \u003cp\u003eImportant to be patient-centred and facilitate their autonomy of choice.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInnovation Deliverer Opportunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot all clinical staff have the time or capacity to do this [FCR screening] in their clinic.\u003c/p\u003e \u003cp\u003eAccessing [allied health professionals/psychologists] within a timely manner [is] often difficult due to workload demands.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInnovation Recipient Need\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eJoint decision with the patient and psychologist [regarding further treatment for severe FCR].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInnovation Deliverer Opportunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnabler\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWould be feasible if the screening was initiated by other clinical staff (e.g. clinical trials or care coordinators)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInner Setting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAccess to Knowledge and Information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnabler\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEducation of all staff will increase uptake.\u003c/p\u003e \u003cp\u003eOnline / module-based training (e.g., via EviQ) may be sufficient.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAccess to Knowledge and Information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMaintaining training to ensure all staff are upskilled is a challenge.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWork Infrastructure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[Assessment or treatment for severe FCR is] dependent on whether a service has a mental health specialist on staff.\u003c/p\u003e \u003cp\u003eWe barely cover significantly distressed active treatment patients, who have to take priority.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWork Infrastructure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnabler\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAlways more nurses than psycho-oncology staff.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAvailable Resources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMost social workers or psychologists would be unable to undertake this work unless additional hours were funded for that purpose.\u003c/p\u003e \u003cp\u003eNot all rural and remote have access to either [allied health/psychology].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStructural Characteristics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIf there is really only one service, this [two-step screening] is likely a waste of time.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStructural Characteristics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnabler\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStaff go on leave etc, so needs widespread ownership.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompatibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnabler\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[FCR triage conversations are feasible] If implemented as routine screening practice within consultation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompatibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAdministratively, this [6 month post-intervention rescreening] would be very difficult to determine.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOuter Setting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePartnerships and Connections\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnabler\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFCR interventions can be well delivered outside the treatment environment\u0026hellip; these can be funded through other streams \u0026ndash; Medicare, Private Health.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLocal Conditions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIn the community setting there can be barriers to accessing psychological support; wait times for appointments, lack of oncology experienced psychology services in the area, costs associated with this.\u003c/p\u003e \u003cp\u003eCulturally and linguistically diverse survivors, especially elderly people, don't like to talk about mental health.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eRecommended Implementation Strategies (Aim 3)\u003c/h2\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e outlines implementation strategies addressing identified barriers and enablers according to the CFIR-ERIC matching tool. Recommended strategies included educational meetings and tailored training resources to foster pathway awareness, ownership, and delivery capability across diverse health professional roles. Emphasis was placed on the pathway\u0026rsquo;s adaptability and potential for local tailoring to address geographical and resource variability. To overcome limited opportunity among innovation deliverers, preparing local champions to model and support implementation was proposed. Engaging patients and families in shared decision-making was advised to meet varied recipient needs. Organisational strategies \u0026ndash; such as building coalitions beyond cancer centres, securing implementation funding, and aligning pathway components with existing workflows \u0026ndash; were recommended to support implementation.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis analysis found varied feasibility across FCR clinical pathway elements and multiple implementation barriers and enablers. Triage to stepped care was widely seen as feasible, while recommendations involving universal or repeated screening/intervention posed a feasibility challenge. Key implementation enablers included building capability through training and access to information. Major barriers were resource limitations and structural constraints. Multifaceted implementation strategies, including education provision and adapting pathway delivery to local contexts, may enhance feasibility.\u003c/p\u003e \u003cp\u003eMost participants agreed that pathway elements were feasible, though feasibility ratings were consistently lower than for optimality. Resource-intensive recommendations, such as training all staff in screening, or holding triage conversations with all survivors, were considered least feasible. Feedback underscored tension between what is best for patients and what providers can realistically deliver. Similar concerns were raised regarding implementation of an Australian clinical pathway for anxiety and depression in cancer, with support for structured screening and after care, but concerns about resource and role constraints [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Prioritising high-impact pathway elements and tailoring to local capacity \u0026ndash; such as training selected staff to do screening and focusing triage on those with moderate/severe FCR \u0026ndash; may improve feasibility in resource-limited settings.\u003c/p\u003e \u003cp\u003eThe pathway design was generally viewed as an enabler, though elements such as two-step screening and delivering universal care before stepping up were seen as adding complexity. While following a single-item FCR screen (e.g., FCR-1r [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]) with a more comprehensive measure (e.g., FCRI-SF [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]) increases administrative burden, it is critical for guiding care based on FCR severity, as per guidelines [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Automated electronic patient reported outcome measure (PROM) administration could reduce complexity, and future AI-supported triage may further streamline processes. For now, the second screening tool could be incorporated into triage conversations alongside questions about FCR impact and support needs. Clinician-patient conversations that build on PROMs results can help develop relationships [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] and normalise patients\u0026rsquo; FCR [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhether progressive stepped care (starting with universal care) or stratified stepped care (direct allocation to the appropriate level) is preferable likely depends on available resources \u0026ndash; another key implementation barrier identified. Progressive stepped care may conserve specialist capacity but risk delaying intensive support, whereas stratified stepped care may improve timeliness but increase costs. Evidence shows minimal outcome differences between approaches in oncology [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], while mental health literature suggests stratified stepped care is more effective but also more costly [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Ultimately, while the pathway provides consensus-based, guideline-concordant recommendations, local adaptation is essential. The need for local adaptation to enable equitable access to FCR treatment despite resource constraints has also been identified in Canadian sites implementing the Fear of Recurrence Therapy (FORT) intervention [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Developing an implementation blueprint with clear strategies, timelines, and roles, supported by local consensus discussions, is recommended. Process mapping to align new pathways with existing workflows and address context-specific barriers has demonstrated promise in developing implementation plans for other complex aspects of cancer care [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBuilding capability and leveraging existing capacity through training and access to information were key enablers. This aligns with evidence showing lack of accessible training is a major barrier to implementing PROMs in oncology [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Recommended strategies include development of training materials and educational sessions. Previous research found 99% of clinical and psychosocial professionals were interested in FCR training [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. However, training all staff in every aspect of pathway delivery, while ideal, may not be feasible. A modular approach, tailored to roles and resource constraints, may be needed.\u003c/p\u003e \u003cp\u003eExisting FCR training programs for primary care (in-person) [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] and oncologists (online) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] have been found to be acceptable and feasible, but programs for multidisciplinary teams are limited. Face-to-face sessions may improve engagement and visibility, while centralised online resources could support scalability and address staff turnover. Uptake of online training for similar pathways has been low (7%) [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], highlighting the need for organisational support and incentives to encourage participation.\u003c/p\u003e \u003cp\u003eMost pathway implementation barriers pertained to the Inner Setting, largely relating to resources and infrastructure. Staffing, funding, and service limitations \u0026ndash; especially in regional and community settings \u0026ndash; mirror challenges implementing a cancer clinical pathway for anxiety and depression [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. These barriers may be mitigated by building capacity across multiple disciplines rather than relying on a single speciality. Identifying local champions is recommended to support uptake, integration, and troubleshooting. Effective champions typically demonstrate influence, ownership, and physical presence at the point of change, combined with persuasiveness, resilience, and a participative leadership style [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Building a coalition of implementers is also recommended, and expanding primary care capacity could reduce pressure on tertiary services, particularly in rural areas and for First Nations, ethnic and racial minority populations, who may prefer community-based support [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo enhance equitable pathway implementation and reduce health professional burden, coalitions of implementers could include trained lay workers, such as people affected by cancer. With appropriate training, these individuals could assist with patient navigation, help identify those experiencing FCR, connect them with suitable services, and provide emotional support. An umbrella review of patient navigation in cancer care found potential improvements in quality of life and psychological wellbeing, with no clear differences in effectiveness between health professional and lay navigators [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Additional funding is critical to enable these strategies, whether for workforce expansion, training, or integration of lay navigators. Investment in FCR care may lower overall healthcare costs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], making a strong case for prioritising resource allocation for pathway implementation.\u003c/p\u003e \u003cp\u003eCompatibility with existing practices and adaptability to local needs were key implementation enablers. Adaptability has supported PROMs implementation [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] and appears equally important here. Local tailoring \u0026ndash; such as defining roles responsible for each pathway element and adjusting referral pathways based on available resources \u0026ndash; was also critical to implementing an anxiety and depression clinical pathway [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Tailoring to individual needs, including cultural background and health literacy, was strongly endorsed and considered feasible. While co-production of culturally appropriate FCR measures and interventions with communities and end-users is essential [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], collating existing resources for diverse groups could aid tailored pathway implementation in the meantime. Shared decision-making regarding FCR treatment was seen as vital for facilitating engagement, particularly with self-management interventions, consistent with broader survivorship care recommendations [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Preferences for FCR support vary [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], and some patients with severe FCR prefer less intensive options [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], despite recommendations for specialist care.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eStudy strengths include applying an established implementation determinant framework to a large multidisciplinary dataset and using a recognised taxonomy to map tailored strategies. The updated CFIR was useful for categorising implementation determinants, though some brief responses were difficult to classify. This was mitigated through double-coding and consensus.\u003c/p\u003e \u003cp\u003eWhile multidisciplinary, the sample was lacking in primary and palliative care clinicians, surgeons, patients, and cultural diversity. Most participants were experienced health professionals working in secondary or tertiary cancer services within Australian public hospitals, so findings may not generalise beyond this context. However, resource constraints appear common across settings [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], suggesting broader applicability of strategies addressing this barrier. Patient perspectives and adaptations for First Nations, ethnic and racial minority populations are being explored in ongoing work.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eImplementing the FCR clinical pathway requires pragmatic adaptation to overcome resource and structural barriers. Resource-intensive recommendations were least feasible, underscoring the need to prioritise high-impact elements, tailor delivery to local contexts and patient needs, and use shared decision-making to optimise engagement. Key implementation strategies include modular training, integration into existing workflows, and use of local champions, supported by implementation coalitions that extend beyond cancer hospitals. Future research should engage stakeholders to contextualise and prioritise strategies and test these in real-world settings using hybrid effectiveness-implementation designs to ensure sustainable delivery and address cancer survivors\u0026rsquo; greatest unmet need through routine FCR screening and tailored support.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003cp\u003e Ben Smith has received honorarium from Novartis to participate in a podcast on fear of cancer recurrence. Andrea Smith sits on Patient Advisory Groups for Menarini Stemline and Gilead and has received travel funding and honorarium payments. No other authors have any other conflicts of interest to declare.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003e This research was supported by the New South Wales Government through a Cancer Institute NSW Career Development Fellowship awarded to Allan \u0026lsquo;Ben\u0026rsquo; Smith (2021/CDF1138).\u003c/p\u003e \u003cp\u003eConflicts of Interest\u003c/p\u003e \u003cp\u003eBen Smith has received honorarium from Novartis to participate in a podcast on fear of cancer recurrence. Andrea Smith sits on Patient Advisory Groups for Menarini Stemline and Gilead and has received travel funding and honorarium payments. No other authors have any other conflicts of interest to declare.\u003c/p\u003e \u003cp\u003eEthics Approval\u003c/p\u003e \u003cp\u003eThe study was approved by the University of New South Wales Human Research Ethics Committee (HC230052).\u003c/p\u003e \u003cp\u003eConsent to Participate\u003c/p\u003e \u003cp\u003e Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eBen Smith and Afaf Girgis contributed to study conception. All authors contributed to study design and material preparation. Data collection and analysis were performed by Ben Smith, Verena S Wu, Agamjot Kaur Virk, and Joy Gao. All authors contributed to interpretation of the study results. The first draft of the manuscript was written by Ben Smith and Verena S Wu, and all authors reviewed and commented on manuscript drafts. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003e Thank you to Dianne Gibbs, Shannon Philp, Dr Lahiru Russell, Dr Penelope Stephens, and all the other health professionals and researchers who generously donated their time and expertise to participate in this study. Thanks also to Prof Michael Jefford and Prof Bogda Koczwara for providing feedback on the initial draft of the Delphi survey. Finally, thanks to the Cancer Council NSW, Cancer Nurses Society of Australia, Cancer Symptoms Trials Group, Clinical Oncology Society of Australia, McGrath Foundation, Oncology Network, Oncology Social Work Australia New Zealand, Primary Care Collaborative Cancer Clinical Trials Group, Psycho-Oncology Co-operative Research Group and South Western Sydney Local Health District for promoting the study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFerlay J, E.M., Lam F, Laversanne M, Colombet M, Mery L, Pi\u0026ntilde;eros M, Znaor A, Soerjomataram I, Bray F. \u003cem\u003eGlobal Cancer Observatory: Cancer Today (version 1.1)\u003c/em\u003e. 2024 28/11/2025]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://gco.iarc.who.int/today\u003c/span\u003e\u003cspan address=\"https://gco.iarc.who.int/today\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLebel, S., et al., \u003cem\u003eFrom normal response to clinical problem: definition and clinical features of fear of cancer recurrence\u003c/em\u003e. Supportive Care in Cancer, 2016. 24(8): p. 3265\u0026ndash;3268.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuigjes-Huizer, Y.L., et al., \u003cem\u003eWhat is the prevalence of fear of cancer recurrence in cancer survivors and patients? A systematic review and individual participant data meta-analysis\u003c/em\u003e. Psychooncology, 2022. 31(6): p. 879\u0026ndash;892.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMutsaers, B., et al., \u003cem\u003eIdentifying the key characteristics of clinical fear of cancer recurrence: An international Delphi study\u003c/em\u003e. Psycho-Oncology, 2020. 29(2): p. 430\u0026ndash;436.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimard, S., et al., \u003cem\u003eFear of cancer recurrence in adult cancer survivors: A systematic review of quantitative studies\u003c/em\u003e. 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Supportive Care in Cancer, 2009. 17(3): p. 241\u0026ndash;251.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHumphris, G.M., et al., \u003cem\u003eUnidimensional scales for fears of cancer recurrence and their psychometric properties: the FCR4 and FCR7\u003c/em\u003e. Health and Quality of Life Outcomes, 2018. 16(1): p. 30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGigu\u0026egrave;re, L., et al., \u003cem\u003eThe Ottawa clinical fear of recurrence instruments: A screener, self-report, and clinical interview\u003c/em\u003e. Psycho-Oncology, 2024. 33(6): p. e6364.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eButow, P.N., et al., \u003cem\u003eRandomized Trial of ConquerFear: A Novel, Theoretically Based Psychosocial Intervention for Fear of Cancer Recurrence\u003c/em\u003e. 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Healthcare (Basel), 2025. 13(17).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTauber, N.M., et al., \u003cem\u003eEffect of Psychological Intervention on Fear of Cancer Recurrence: A Systematic Review and Meta-Analysis\u003c/em\u003e. J Clin Oncol, 2019. 37(31): p. 2899\u0026ndash;2915.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeuning-Smit, E., et al., \u003cem\u003eBarriers and facilitators for implementation of the SWORD evidence-based psychological intervention for fear of cancer recurrence in three different healthcare settings\u003c/em\u003e. Journal of Cancer Survivorship, 2023. 17(4): p. 1057\u0026ndash;1071.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLebel, S., et al., \u003cem\u003eInvestigating the Pre-Implementation Facilitators and Barriers of the Implementation of the Fear of Recurrence Therapy (FORT) Intervention in Canadian Cancer Centers\u003c/em\u003e. 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Psycho-Oncology, 2025. 34(2): p. e70070.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShaw, J., et al., \u003cem\u003eSetting an International Research Agenda for Fear of Cancer Recurrence: An Online Delphi Consensus Study\u003c/em\u003e. Front Psychol, 2021. 12: p. 596682.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePereira, V.C., et al., \u003cem\u003eStrategies for the implementation of clinical practice guidelines in public health: an overview of systematic reviews\u003c/em\u003e. Health Research Policy and Systems, 2022. 20(1): p. 13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJ\u0026uuml;nger, S., et al., \u003cem\u003eGuidance on Conducting and REporting DElphi Studies (CREDES) in palliative care: Recommendations based on a methodological systematic review\u003c/em\u003e. Palliat Med, 2017. 31(8): p. 684\u0026ndash;706.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePinnock, H., et al., \u003cem\u003eStandards for Reporting Implementation Studies (StaRI) Statement\u003c/em\u003e. Bmj, 2017. 356: p. i6795.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDamschroder, L.J., et al., \u003cem\u003eThe updated Consolidated Framework for Implementation Research based on user feedback\u003c/em\u003e. Implementation Science, 2022. 17(1): p. 75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerry, C.K., et al., \u003cem\u003eSpecifying and comparing implementation strategies across seven large implementation interventions: a practical application of theory\u003c/em\u003e. Implementation Science, 2019. 14(1): p. 32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePowell, B.J., et al., \u003cem\u003eA refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project\u003c/em\u003e. Implementation Science, 2015. 10(1): p. 21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRankin, N.M., et al., \u003cem\u003eEverybody wants it done but nobody wants to do it: An exploration of the barrier and enablers of critical components towards creating a clinical pathway for anxiety and depression in cancer\u003c/em\u003e. BMC Health Services Research, 2015. 15(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith, A.B., et al., \u003cem\u003eEvaluation of the validity and screening performance of a revised single-item fear of cancer recurrence screening measure (FCR-1r).\u003c/em\u003e Psycho-Oncology, 2023. 32(6): p. 961\u0026ndash;971.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreenhalgh, J., et al., \u003cem\u003eHow do patient reported outcome measures (PROMs) support clinician-patient communication and patient care? A realist synthesis\u003c/em\u003e. J Patient Rep Outcomes, 2018. 2: p. 42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu, J., et al., \u003cem\u003eNovel Clinician-Lead Intervention to Address Fear of Cancer Recurrence in Breast Cancer Survivors\u003c/em\u003e. JCO Oncology Practice, 2021: p. OP.20.00799.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbdalla, T., et al., \u003cem\u003eStepped-care models for cancer symptom management: a systematic review of efficacy and cost-effectiveness.\u003c/em\u003e JNCI: Journal of the National Cancer Institute, 2025: p. djaf153.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDelgadillo, J., et al., \u003cem\u003eStratified Care vs Stepped Care for Depression: A Cluster Randomized Clinical Trial\u003c/em\u003e. JAMA Psychiatry, 2022. 79(2): p. 101\u0026ndash;108.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaylor, N., et al., \u003cem\u003eAdvancing the Speed and Science of Implementation Using Mixed-Methods Process Mapping \u0026ndash; Best Practice Recommendations\u003c/em\u003e. International Journal of Qualitative Methods, 2025. 24: p. 16094069251340908.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLyu, J., et al., \u003cem\u003eFacilitators and barriers to implementing patient-reported outcomes in clinical oncology practice: a systematic review based on the consolidated framework for implementation research\u003c/em\u003e. Implementation Science Communications, 2024. 5(1): p. 120.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThewes, B., et al., \u003cem\u003eCurrent approaches to managing fear of cancer recurrence; a descriptive survey of psychosocial and clinical health professionals\u003c/em\u003e. Psycho-Oncology, 2014. 23(4): p. 390\u0026ndash;396.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerrett-Abebe, J., et al., \u003cem\u003eImpact of an Interprofessional Primary Care Training on Fear of Cancer Recurrence on Clinicians\u0026rsquo; Knowledge, Self-Efficacy, Anticipated Practice Behaviors, and Attitudes Toward Survivorship Care\u003c/em\u003e. Journal of Cancer Education, 2019. 34(3): p. 505\u0026ndash;511.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShaw, J., et al., \u003cem\u003eDevelopment, acceptability and uptake of an on-line communication skills education program targeting challenging conversations for oncology health professionals related to identifying and responding to anxiety and depression\u003c/em\u003e. BMC Health Services Research, 2022. 22(1): p. 132.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBonawitz, K., et al., \u003cem\u003eChampions in context: which attributes matter for change efforts in healthcare?\u003c/em\u003e Implementation Science, 2020. 15(1): p. 62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson, K., et al., \u003cem\u003eA Systematic Review of Fear of Cancer Recurrence Among Indigenous and Minority Peoples\u003c/em\u003e. Frontiers in Psychology, 2021. 12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChan, R.J., et al., \u003cem\u003ePatient navigation across the cancer care continuum: An overview of systematic reviews and emerging literature.\u003c/em\u003e CA: A Cancer Journal for Clinicians, 2023. 73(6): p. 565\u0026ndash;589.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eButow, P.N., et al., \u003cem\u003eFrom ideal to actual practice: Tailoring a clinical pathway to address anxiety or depression in patients with cancer and planning its implementation across individual clinical services\u003c/em\u003e. Journal of Psychosocial Oncology Research and Practice, 2021. 3(4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHowell, D., et al., \u003cem\u003eManagement of Cancer and Health After the Clinic Visit: A Call to Action for Self-Management in Cancer Care\u003c/em\u003e. J Natl Cancer Inst, 2021. 113(5): p. 523\u0026ndash;531.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuigjes-Huizer, Y.L., et al., \u003cem\u003ePatient-reported needs for coping with worry or fear about cancer recurrence and the extent to which they are being met: a survey study\u003c/em\u003e. J Cancer Surviv, 2022: p. 1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJabbour, M., et al., \u003cem\u003eDefining barriers and enablers for clinical pathway implementation in complex clinical settings\u003c/em\u003e. Implementation Science, 2018. 13(1): p. 139.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"fear of cancer recurrence, cancer survivorship, clinical pathway, supportive care, implementation, Delphi study","lastPublishedDoi":"10.21203/rs.3.rs-8889572/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8889572/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eFear of cancer recurrence (FCR) is pervasive among cancer survivors, yet evidence-based care is rarely implemented. Clinical pathways offer a structured approach to translating evidence into practice. This study identified key implementation barriers, enablers, and strategies for feasibly integrating an FCR clinical pathway comprising screening, assessment, and triage to stepped care into practice.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA three-round Delphi study was conducted with Australian health professionals and FCR researchers. Participants rated and provided qualitative feedback on the feasibility of FCR clinical pathway elements. Qualitative responses were content analysed using the updated Consolidated Framework for Implementation Research. Recommended strategies were mapped using the Expert Recommendations for Implementing Change taxonomy.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eEighty-nine participants completed Round 1, 69 Round 2, and 73 Round 3. Feasibility ratings varied across pathway elements (49\u0026ndash;90%). Stepped care elements were widely endorsed as feasible (71\u0026ndash;83% agreement), while resource-intensive recommendations (e.g., training \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eall\u003c/span\u003e staff for screening) were perceived as least feasible. Key implementation enablers included \u003cb\u003eAdaptability\u003c/b\u003e, \u003cb\u003eAccess to Knowledge and Information\u003c/b\u003e, and strong \u003cb\u003eInnovation Recipient Need\u003c/b\u003e. Major barriers were \u003cb\u003eAvailable Resources\u003c/b\u003e, \u003cb\u003eWork Infrastructure\u003c/b\u003e and limited \u003cb\u003eInnovation Deliverer Opportunity\u003c/b\u003e. Recommended strategies included tailoring delivery to local contexts and patient needs supported by modular training and local champions.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eImplementing the FCR clinical pathway requires pragmatic adaptation and system-level support. Prioritising high-impact elements, providing training, integration into existing workflows, and shared decision-making to meet patient needs are critical. Future research should evaluate these strategies using hybrid effectiveness\u0026ndash;implementation designs to ensure sustainable implementation and improved patient outcomes.\u003c/p\u003e","manuscriptTitle":"Designing for Delivery: A Delphi Study of Feasibility-Informed Implementation Strategies for a Fear of Cancer Recurrence Clinical Pathway","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-08 05:23:14","doi":"10.21203/rs.3.rs-8889572/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-04-01T15:22:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-01T15:17:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-26T04:40:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2026-02-16T04:30:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"7c076832-0932-4fff-8cfc-70cae05e94b1","owner":[],"postedDate":"April 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-08T05:23:14+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-08 05:23:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8889572","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8889572","identity":"rs-8889572","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}