Who this is for
Adults with any cancer diagnosis - new, in-treatment, or within 12 months post-treatment. Pediatric cancer navigation is not in scope (2026 roadmap with St. Jude). For metastatic and palliative-stage members, the pathway prioritizes quality of life, distress management, and family support over surveillance.
What brings people here
New cancer diagnosis (any stage); in-treatment member; within 12 months of completing treatment; or member with recurrence. Members find the pathway through self-referral, partner referral, or biometric/HRA flag.
Clinical framework
Cancer Support Community.
How the 8 weeks run
Baseline assessments, your first SMART goal, and the 1:1 that sets up everything after it.
Specialist coaches rotate in, and sessions come thickest here. One change at a time, in the domains your baseline flagged.
Re-score, refresh the care plan, and check in 1:1 on what is and is not working.
The remaining domains, at a lighter cadence, and the work of making the early weeks hold under pressure.
Final re-score, relapse prevention, and the plan for what happens next.
When your sessions fall
The program is built in four-week modules. Sessions come thickest at the start, when what you decide matters most, and step down as things settle. That is 5 sessions of 45 minutes across 8 weeks, counting the visit before week 1.
| Module | Weeks | Sessions | Cadence |
|---|---|---|---|
| Module 1 | Weeks 1 to 4 | 2 | every other week |
| Module 2 | Weeks 5 to 8 | 2 | every other week |
Week by week
- Before you beginBefore you begin
This pathway covers a long stretch: a new diagnosis, active treatment, and the first year after treatment ends. Those are different situations, so every week says which parts apply when. Read the parts that are yours and skim the rest, because most people move through all of them eventually.
- Week 1Exercise, and why it comes first
Most cancer programs open with distress screening. This one opens with exercise, because that is where the evidence is strongest and because almost nobody is told this at diagnosis.
- Week 2Movement that survives treatment
This week you meet Melissa Tuell, MOT, OTR/L, for a 45-minute functional movement therapy session. Occupational therapy is the right discipline for this week because the question during treatment is rarely how to train. It is how to spend a limited amount of energy on the things that matter to you.
- Week 3Fatigue
Ask people who have been through cancer treatment what bothered them most and fatigue comes up more often than pain or nausea. Ask how much time their appointments spent on it and the answer is usually none. This week is that conversation.
- Week 4Mid-program: symptoms, side effects and the bills
This is the second of your three visits with Cindy Cathcart. Halfway through, two things reliably go unmentioned: side effects people have decided to put up with, and money. This visit asks about both directly.
- Week 5Eating, during and after
Nutrition during active treatment and nutrition in survivorship are two different problems with two different goals. Almost all the confusion in this area comes from advice written for one being applied to the other.
- Week 6Distress, mood and the fear of it coming back
This week you meet Kimberly Macon for a 45-minute mindset coaching session. Read this first, including the part about where coaching stops.
- Week 7Sleep, and thinking clearly
Two problems that arrive together and are usually dismissed together. Both are real, both have literature behind them, and both have something that can be done about them.
- Week 8Survivorship, and making it hold
This is your third and last 45-minute visit with Cindy Cathcart. If you are still in treatment, this is a handover into the treatment phase of the pathway rather than an ending. If you have finished, it is where the survivorship plan gets written down.
Who you will work with
Your Whole Health Coach takes your first visit and closes every module, so it is the same person from the first session to the last. The specialists below lead the weeks where their work is the focus.
Professionally, Cindy has been a clinical nurse for nearly a decade. She served in both clinical and administrative capacities throughout her career and holds a Master's degree in Nursing Leadership. As a staff nurse, nurse leader, and quality improvement specialist, she led multidisciplinary teams in academic medical settings throughout Boston, New York, and Ohio to deliver high-quality care to patients across complex diagnoses.
Melissa Tuell, MOT, OTR/L is a licensed Occupational Therapist with more than 30 years of experience helping people restore function, manage chronic conditions, and rebuild confidence in the activities that matter most to daily life.
Meet Kimberly Macon, Professional Certified Coach (PCC), wife, mother, and a cancer survivor specialized in helping OneVillage members build mental resilience in the face of difficult situations and life changing events. Kimberly spent more than 15 years working in various roles across the Consumer Packaged Goods Industry within Marketing, Brand Management, Sales and Business Development.
What we work on
| Domain | What this pathway does |
|---|---|
| Nutrition & Metabolism | Tx-tolerant during chemo/radiation (energy, mucositis, taste changes). Plant-based diet and diet to support anticancer lifestyle.. Weight stabilization, not loss, during active tx. |
| Movement & Mobility | Active tx: light movement to tolerance, fatigue mgmt. Survivorship: reconditioning, bone-density support, lymphedema-aware progression. |
| Sleep & Recovery | Insomnia in 30-50% of survivors. CBT-I principles. Steroid-related sleep disruption tracked. Pittsburgh Sleep Quality Index (PSQI) scored during intake and q4 weeks survivorship. STOP-BANG screener on intake. |
| Stress & Resilience | The Distress Thermometer is the spine. Family communication, financial toxicity, identity all tracked. |
| Mind & Mood | Depression and anxiety baseline rates 2-3x general population. PHQ-9 + GAD-7 monthly during active tx, q4 weeks survivorship. FCRI in survivorship. Screening for cancer related cognitive symptoms monthly during active tx, q4 weeks survivorship. |
| Preventive care | Surveillance imaging per oncology plan. Other preventive care (mammogram other breast, colonoscopy, dental) per age guidance. |
How progress is measured
These are the validated tools this pathway uses: at your first visit, at the mid-program review, and at the end.
| Tool | Cadence | Owned by |
|---|---|---|
| CSC Distress Thermometer + problem list | Onboard, weekly during active tx, monthly survivorship | WHC + LCSW |
| PHQ-9 + GAD-7 | Monthly active tx, q4 weeks survivorship | LCSW |
| Edmonton Symptom Assessment Scale | Per cycle in active tx | RN Nav |
| FCRI (Fear of Cancer Recurrence) | q4 weeks survivorship | WHC + LCSW |
| Weight + nutrition log | Weekly during active tx | Nutrition Coach |
| PAR-Q+ + 6-min walk | Survivorship onset, then quarterly | Exercise Coach |
| ISI + PSQI + STOP-BANG | Survivorship onset, q4 weeks | Sleep Coach |
| Cognitive Screening questions reflex to FACT-cog PCI subscale | Survivorship onset | Brain Health Coach |
The research behind this pathway
Your clinician playbook was built from the guidelines and studies below. They are listed so you can read them yourself: every one is a real, published paper and the number at the end of each line is its PubMed ID.
Guidelines this pathway follows
- Cancer Support Community distress framework · Cancer Support Community
Distress is screened at diagnosis, through treatment and into survivorship, with a problem list attached to the score. PMID 9587123
- NCCN Distress Management · National Comprehensive Cancer Network
The standard this pathway's screening cadence and escalation thresholds follow. PMID 37156476
- Exercise Guidelines for Cancer Survivors · International Multidisciplinary Roundtable (ACSM)
Specific doses of aerobic and resistance training for fatigue, anxiety, depression and physical function. PMID 31626055
- ACS Nutrition and Physical Activity Guideline for Cancer Survivors · American Cancer Society
What this pathway asks of you about food, weight and movement after treatment. PMID 35294043
Key studies
- Riba MB et al. (2023). J Natl Compr Canc NetwNCCN Guidelines® Insights: Distress Management, Version 2.2023
The NCCN distress management guideline: screen every patient for distress, at diagnosis and at points of change, and treat what the screen finds. PMID 37156476
- Roth AJ et al. (1998). CancerRapid screening for psychologic distress in men with prostate carcinoma: a pilot study
The pilot that introduced the one-question Distress Thermometer. It is the screen this pathway repeats, and the reason a single number can open a conversation. PMID 9587123
- Campbell KL et al. (2019). Med Sci Sports ExercExercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable
The international roundtable's exercise guidance for cancer survivors: specific doses of aerobic and resistance training improve fatigue, anxiety, depression and physical function. PMID 31626055
- Mustian KM et al. (2017). JAMA OncolComparison of Pharmaceutical, Psychological, and Exercise Treatments for Cancer-Related Fatigue: A Meta-analysis
Compared the four most-recommended treatments for cancer-related fatigue across 113 studies and 11,525 people. Exercise and psychological approaches worked, and both beat the available drugs. PMID 28253393
- Simard S et al. (2009). Support Care CancerFear of Cancer Recurrence Inventory: development and initial validation of a multidimensional measure of fear of cancer recurrence
Developed and validated the Fear of Cancer Recurrence Inventory, which is why this pathway measures that fear rather than treating it as something to reassure away. PMID 18414902
- Rock CL et al. (2022). CA Cancer J ClinAmerican Cancer Society nutrition and physical activity guideline for cancer survivors
The American Cancer Society's nutrition and physical activity guideline for survivors, and the source of what this pathway asks of you about food and movement after treatment. PMID 35294043
- Chen M et al. (2024). Curr Oncol RepPatient Navigation in Cancer Treatment: A Systematic Review
Reviewed 59 studies of cancer patient navigation. Most found better treatment initiation, better adherence and higher satisfaction, and the benefit was largest for disadvantaged patients. PMID 38581470