For example, survivorship care plans developed by the oncologist in coordination with an MDC team either during or following the initial MDC meeting are intended to outline routine follow-up at the completion of the treatment regimen. The plan, transferred from the oncologist on an MDC team, includes monitoring for new or recurrent tumors and ongoing health promotion, all of which is presumably coordinated by the PCP. If a tumor recurs or a new tumor is found, then intervention of the MDC team would be necessary again. Thus, the interfaces between specialists and PCPs in follow-up care are critical, but the specific pathways and methods for handling those interfaces are not well understood (18–20). Further, Haward et al. (21) have described the difficulties in defining the actual MDC team for breast cancer, given team members will sometimes exist or join midstream over the entire process of treatment.