Living With and Beyond Cancer (LWBC) and Personalised Care

The number of people living with a cancer diagnosis in the UK is set to double from more than 2 million in 2010 to 4 million by 2030.

In England, the average general practice has 280 patients living with cancer and 70% of people with a diagnosis of cancer are living with at least one other long term condition.

6.5 million people live in the West Midlands and 600 cancer cases are diagnosed per 100,000 people every year – this is set to increase as our population ages. By 2030 there will be some 135,000 people living with and beyond cancer. This is due to a number of factors, including rising incidence related to our ageing population, but also higher rates of early diagnosis and better treatments.

At 600 cases per 100,000 population, cancer incidence in the West Midlands is significantly lower than the England rate of 609 per 100,000. However, the cancer mortality rate in the West Midlands is significantly higher than for England.

Our aim is to make your care personalised to you and support you from your diagnosis, through your treatment and then living with and beyond cancer.

Personalised Care is where “every person diagnosed with cancer will have access to personalised care, including needs assessment, a care plan, health and wellbeing information and support, all delivered in line with the Comprehensive Model for Personalised Care” NHS Long-Term Plan

In line with the national cancer plan, the Alliance aims to do the following for 2025/26:

  • Work with Integrated Care Boards (ICB’s) and Trusts to complete local arrangements for personalised care interventions and Personalised Stratified Follow Up (PSFU) pathways
  • Deliver improvement plans and agreements for delivery, demonstrating community/system collaboration, for:
    1. psychosocial support 
    2. cancer prehabilitation
    3. behaviour change and other interventions across the cancer pathway that support increasing any form of physical activity.

Personalised Care documents

pdfWMCA Cancer Care Review Standards

pdfWMCA Personalised Care Standards

pdfWMCA Prehabilitation Framework

pdfWMCA Breast Cancer Personalised Stratified Follow Up (PSFU) Pathway Guidelines November 2025

pdfColorectal Cancer Personalised Stratified Follow Up (PSFU) Guideline December 2025

pdfWMCA Haematology Cancer Personalised Stratified Follow Up (PSFU) Guidelines October 2025

pdfWMCA Prostate Cancer Personalised Stratified Follow Up (PSFU) Guidelines December 2025

pdfWMCA Endometrial Cancer Personalised Follow Up Guidelines Pathway (PFSU) Guidelines February 2026

pdfWMCA Skin Personalised Stratified Follow-up Guidelines December 2025

Links to other resources

Combined Shape Created with Sketch. Psychosocial Support

Psychosocial Support

This section is currently being developed. Please check back soon for more information.

personalised-care Created with Sketch. Personalised Care & Personalised Stratified Follow Up (PSFU) pathways

Personalised Care & Personalised Stratified Follow Up (PSFU) pathways

What is PSFU?

  • (PSFU) means redesign of cancer follow up* that allows for some patients to stay on ‘traditional’ follow up (with scheduled consultations with the cancer team)
  • This includes scheduled cancer surveillance tests/scans that will continue for a number of years to monitor for cancer recurrence. To manage this, a digital PSFU remote monitoring system (PSFU RMS) for tracking patients and providing a safety net should be in place

National drivers; The Long-Term Plan 2019

  • Improving cancer pathways through implementation of Personalised Stratified follow-up pathways for all clinically appropriate cancers is identified as a priority within the NHS Long Term Plan, including improving access to personalised care of patients diagnosed with cancer through ongoing needs assessment, robust care planning and provision of support
  • This is beneficial both for the patient and for the system as a way of addressing capacity issues within the NHS.

NHSE 2025/26 Cancer Planning Guidance Deliverable for PSFU

  • PSFU to be embedded into cancer pathways and is business as usual

Benefits of PSFU

  • Efficiencies gained through a decrease in face to face out-patient appointments
  • Clinical capacity released through PSFU can be redistributed to improve quality of care and higher value clinical activities
  • Clinical time can be redeployed to activities such as diagnosing more new patients and reducing waiting times; supporting more complex patients; and more clinics for elective care and procedures
  • The treatment plan is tailored to the patient's priorities and requirements
  • Increased skills to self-care for patients
  • Remote monitoring systems provide better safety netting compared to the traditional system as the patient retains direct access to the care team
  • Patients have timely access to their results and care team
  • Patients have a single point of access via the Cancer Support Worker or Cancer Navigator
prehabilitation Created with Sketch. Prehabilitation and physical activity

Prehabilitation and physical activity

Prehabilitation enables people with cancer to prepare for treatment through promoting healthy behaviours and through needs-based prescribing of exercise, nutrition and psychological interventions. It can empower patients to maximise resilience to treatment and improve long-term health.

Prehabilitation can run through the whole cancer pathway and lead into long term engagement in healthy lifestyle behaviours that support the principles of living well with and beyond cancer.

It is split into 3 components: exercise, psychological support and dietic advice.

Prehabilitation can:

  • reduce the length of hospital stay
  • improve cardiorespiratory fitness
  • enhance recovery following treatment
  • improve nutritional status
  • reduce post treatment complications
  • enhance quality of life

There are 3 levels of prehabilitation that can be offered to patients:

  • Universal – applicable to anyone with cancer
  • Targeted – applicable to those people with cancer with and at risk of late effects of the disease and/or treatment, and those with other long-term conditions
  • Specialist – applicable to people with cancer who have complex needs, complex treatment (such as major surgery), severe impairments and/or a disability.

National resources

West Midlands resources