Oncologist-Led, Survivorship-Focused Primary Care: Feasibility and Outcomes of a Novel Integrated Care Model

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Ramachandran, Ellen Zhang, Natasha Z.R. Steele, Ilana R. Yurkiewicz This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7180545/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: The Primary Care for Cancer Survivorship clinic at Stanford Medicine is a novel program addressing primary care and survivorship-specific needs in a single setting. Care is delivered by a board-certified physician in internal medicine, oncology, and hematology. This study describes patient characteristics and clinical issues managed during its first two years. Methods: Demographic and clinical data for new patients seen from November 1, 2021 to November 1, 2023 were extracted via chart review and analyzed using descriptive statistics. Subgroup analyses focused on adolescents and young adults (AYAs), geriatric patients, patients with hematologic malignancies, and previvors with genetic risk. Results: A total of 226 patients established care, with two-thirds returning for follow-up. The most common cancers were breast (41.4%), leukemia (13.3%), and lymphoma (11.5%). Three-quarters had no active disease. Hereditary cancer syndromes were present in 16.8%. Long-term and late effects were addressed in 99.1%, predominantly cardiovascular risk (92.0%), mental health (75.7%), and bone health (59.7%). Primary care issues were addressed in 96.0%. Secondary cancer screening was performed in 91.2%, with four secondary cancers diagnosed. AYAs (22.4%) had significantly more fertility discussions, while geriatric patients (28.3%) had significantly more telehealth visits. Among patients with hematologic malignancies, 42.4% had undergone a bone marrow transplant (BMT). Conclusions: This study demonstrates the demand for and feasibility of an oncologist-led, survivorship-focused primary care clinic in addressing a range of medical, preventive, and psychosocial issues. Implications for Cancer Survivors: Survivorship-focused primary care offers a comprehensive, longitudinal care model for survivors with diverse and evolving needs. Cancer survivorship primary care integrated care health care delivery Introduction More than one in three Americans will be diagnosed with cancer in their lifetime [ 1 ]. Thanks to advances in early detection, multimodal therapies, prolonged adjuvant and maintenance treatments, novel agents, and improved screening, the five-year survival rate has increased from 49% in the mid-1970s to 69% between 2014 and 2020, with survival now exceeding 90% for some cancer types [ 1 ]. As of January 1, 2022, over 18 million Americans with a history of invasive cancer were alive. This number is projected to reach 26 million by 2040 [ 2 ]. The growing population of individuals living with and after cancer has drawn increasing attention to their distinct care needs. A substantial body of research, including multiple reports from the Institute of Medicine (IOM), has documented persistent gaps in survivorship care, particularly during transitions from active treatment to surveillance, and in managing comorbidities, psychosocial concerns, and long-term quality of life [ 3 – 6 ]. A meta-analysis of cancer survivors showed persistent deficits in physical health, role functioning, and mental health up to 26 years after diagnosis, with variation by age, disease type, and treatment received [ 7 ]. Survivors of childhood cancer are significantly more likely to experience a major cardiovascular event at a young age compared to the general population (18% compared to 0.9%) [ 8 ], while cancer survivors over age 65 have a higher burden of chronic conditions, increased fall risk, and worse self-reported health status than age-matched peers [ 9 ]. To meet these needs, several core components of comprehensive survivorship care along with models to deliver them have been identified. The 2006 IOM report From Cancer Patient to Cancer Survivor outlined four components of survivorship care: prevention of recurrence and late effects, surveillance for disease progression and psychosocial outcomes, interventions for treatment-related consequences, and coordination between specialists and primary care providers [ 10 ]. In 2019, Nekhlyudov et al. proposed a complementary framework organized around five domains: prevention and surveillance for recurrence and new cancers, management of physical effects, psychosocial effects, chronic medical conditions, and promotion of overall health [ 11 ]. In terms of care delivery models, the American Society of Clinical Oncology (ASCO) has broadly classified survivorship care into four categories: oncologist-led, primary care-led, shared care, and specialized survivorship clinics [ 12 , 13 ]. Each model offers distinct strengths and limitations, and all emphasize care coordination, transitions, and risk stratification to match survivors with the most appropriate level of care based on existing resources. Survivorship-focused primary care (sometimes called “onco-primary care”) is an emerging approach that aims to augment the primary care-led model [ 14 , 15 ], which is well positioned to provide longitudinal, comprehensive care but often limited by barriers such as lack of training and unclear role delineation [ 16 ]. However, studies suggest that while primary care physicians are more adept at chronic disease management and preventive care, oncologists are better equipped to manage cancer surveillance and long-term or late treatment effects [ 17 – 20 ]. These insights raise the potential for a new, combined model — namely, oncologist-led primary care — to reduce care transitions and improve outcomes across the survivorship continuum. This model was launched at Stanford Medicine in 2021. The clinic, named Primary Care for Cancer Survivorship, provides ongoing primary care by a physician who is board certified in medical oncology, hematology, and internal medicine, integrating survivorship care and general primary care within a single setting. It is embedded within Stanford’s broader clinical Cancer Survivorship Program, which includes disease-specific survivorship clinics led by oncology advanced practice practitioners (APPs), a pediatric survivorship transition clinic, an adolescent and young adult (AYA) survivorship transition clinic, and primary care-based consultative visits [ 21 ]. Patients accepted to the new clinic included: (1) adults with a history of pediatric cancer; (2) adults who completed treatment for adult-onset malignancies; (3) adults receiving ongoing cancer-directed therapy, including those with metastatic disease; and (4) “previvors” without a cancer history who carry inherited mutations conferring elevated risk. Patients with any type and stage of malignancy were accepted. New patient visits were either 30 minutes or one hour, while return visits were 30 minutes. A range of support services were available through the primary care infrastructure, including pharmacist-led diabetes and hypertension management, behavioral health support, virtual osteoporosis education, and group classes focused on lifestyle and anxiety management. The goal of this study is to describe patient characteristics and clinical issues addressed during the clinic’s first two years of implementation. Methods This descriptive study includes all new patients seen in the Primary Care for Cancer Survivorship clinic from its opening on November 1, 2021 through the data cut-off date of November 30, 2023. This study was deemed exempt from review by the Stanford University Institutional Review Board (IRB) due to its descriptive nature. All demographic and clinical information was collected via electronic chart review by three independent reviewers. Variables included age, gender, city of residence, cancer type, cancer status (active vs. in remission), survival status (alive vs. deceased), referral source, date of first appointment, number of appointments during the study period, and type of appointment (in person vs. telemedicine). Data were extracted and stored in a secure database. Patients who had their care reassigned or who did not establish care with a visit were excluded. For patients who moved during the study period, the location recorded reflected where they lived at the time of their clinic visits. Descriptive data on visit content were collected from physician documentation, including information on cancer recurrence surveillance and secondary screening, exercise, nutrition, goals of care, and long-term and late effect management including mental health, cognitive function, fatigue, neuropathy, insomnia, cardiovascular risk, bone health, sexual health, and fertility preservation. A primary care issue was defined as chronic disease management, health care maintenance such as vaccination, or evaluation of an acute issue. Referrals to subspecialty services were also recorded. Data were summarized using descriptive statistics. Categorical variables were reported as frequencies and percentages, and continuous variables were presented as means and standard deviations. Associations between categorical variables were assessed using Fisher’s exact test. Subgroup analyses were conducted for geriatric patients (defined as aged 65 and old), AYAs (defined as aged 39 or younger), and patients with hematologic malignancies. Previvors were defined as patients carrying a cancer-associated genetic mutation without a cancer diagnosis. Patients with a history of more than one malignancy across groups were excluded from subgroup analyses to preserve interpretability. Results In total, 226 patients established care during the study period. Their characteristics and clinical issues addressed are presented in Table 1. The majority (71.6%) were female. The mean age was 54.1 years (range of 19 to 90). The most common cancer type was breast (41.1%), followed by leukemia (13.3%) and lymphoma (11.5%). In this population, 16.8% of patients had a genetic mutation, including 12 carrying a BRCA mutation and 11 carrying a TP53 mutation. Previvors without a cancer diagnosis comprised 3.1% of the study population. Most patients (75.2%) had no active disease, while 24.8% had active disease. Thirty-four patients (15.0%) had undergone an allogeneic or autologous bone marrow transplant (BMT). Most referrals to the clinic came from medical oncology (41.1%) and self-referrals (27.4%), followed by hematology (7.3%) and BMT (3.7%). Stanford’s pediatric survivorship transition clinic sent 4.6% of referrals. At least one long-term or late effect was addressed in nearly all patients (99.1%). The most common was cardiovascular risk (92.0%), with medications started in 35 patients (16.8%). The next most common were mental health (75.7%) and bone health (59.7%). Referrals were placed to mental health specialists in 15.0% of patients, cardiovascular specialists in 8.4%, and fertility specialists in 8.0%. At least one other primary care issue was managed in 96.0% of patients. Exercise was addressed in 61.5%, and nutrition was addressed in 54.9%. Goals of care conversations, including end-of-life discussions, occurred with 11 patients (4.9%). Among survivors without active disease, surveillance for recurrence of the primary cancer was addressed in 91.9%. Eight recurrences were diagnosed. Among the entire cohort, secondary cancer screening was performed in 91.2% of patients. Four patients were diagnosed with a secondary cancer. The majority of patients (67.3%) returned for at least one follow-up visit during the study period, which included both in-person and telehealth. Overall, 60.7% of visits occurred in-person. Table 1 . Patient Characteristics and Clinical Issues Addressed in the Total Population Total (N = 226) Age in years (mean) 54.1 Gender (% female) 71.6 Hereditary cancer syndrome (%) 16.8 Post BMT (%) 15.0 Surveillance for recurrence addressed (%) 91.9 Secondary cancer screening performed (%) 91.2 Long-term and/or late effects addressed 99.1 Cardiovascular risk (%) 92.0 Mental health (%) 75.7 Bone health (%) 59.7 Sexual health (%) 19.9 Fertility (%) 19.5 Cognitive function (%) 16.8 Fatigue (%) 11.9 Primary care issue(s) addressed (%) 96.0 AYA Patient Population. Among a total of 219 cancer survivors (excluding 7 previvors) who established primary care in the clinic, 49 (22.4%) were AYAs. Their characteristics and clinical issues addressed are presented in Table 2. Their mean age was 31.5 years (range 19 to 39), and 57.1% were female. The most common cancers were lymphoma (24.5%), leukemia (22.4%), and breast cancer (14.3%). Most (89.8%) no longer had active disease, while 5 patients (10.2%) had active disease. The most common referral sources were self-referrals (24.5%), the pediatric oncology survivorship program (20.4%), and oncology (16.3%). Two AYA survivors died during the study period, of which one engaged in end-of-life conversations. Clinical Care . Surveillance for primary cancer recurrence and secondary cancer screening were each conducted in 41 AYA patients (83.7%). No recurrences or secondary cancers were diagnosed. Secondary cancer screening was addressed significantly more often in non-AYAs compared to AYAs (94.0% vs. 83.7%, p = 0.03). Long-term and late effects were managed in all AYA patients, including cardiovascular risk (85.7%), mental health (85.7%), fertility (65.3%), bone health (49.0%), and sexual health (18.4%). Among these issues, only fertility differed significantly between groups, addressed more often in AYAs (65.3% vs. 4.1%, p < 0.05). Referrals for fertility were also significantly higher among AYAs (30.6% vs. 0.6%, p < 0.05). Mental health referrals were more common in AYAs but did not reach significance (18.4% vs. 13.5%, p = 0.09). At least one other primary care issue was addressed in all AYA patients, which was not statistically different from non-AYA patients (p = 0.20). Exercise was discussed in 30 AYA patients (61.2%) and nutrition addressed in 24 (40.8%), with no significant difference to non-AYAs. Table 2. Patient Characteristics and Clinical Issues Addressed in AYA Survivors AYA (N = 49) Age in years (mean) 31.5 Gender (% female) 57.1 Post BMT (%) 30.6 Secondary cancer screening performed (%) 83.7 Long-term and/or late effects addressed 100.0 Cardiovascular risk (%) 85.7 Mental health (%) 85.7 Bone health (%) 49.0 Sexual health (%) 18.4 Fertility (%) 65.3 Primary care issue(s) addressed (%) 100.0 GERIATRICS Patient Population. Among a total of 219 patients with a previous or active malignancy, 62 (28.3%) were geriatric (aged 65 and older). Their characteristics and clinical issues addressed are presented in Table 3. The mean age of the geriatric group was 73, with the range 65 to 90. Seventy-three percent of patients were female, and 27% were male. The most common cancers were breast (38%), lung (10%), leukemia (13%), lymphoma (8%), prostate (8%), and multiple myeloma (6%). Twenty-five patients (40%) had active disease and 37 patients (58%) were post-treatment. One patient over the age of 65, a previvor with Li-Fraumeni syndrome, was excluded from the analysis. Clinical Care. Cancer surveillance was discussed with 80.6% of patients, and 2 patients (5.4% of post-treatment patients) were diagnosed with recurrence. Secondary cancer screening was performed in 85.5% of patients, with no secondary cancers diagnosed. The most common referral sources were oncology (40.3%), self-referrals (25.8%), and hematology (12.9%). The average number of visits per year was 2.8 with 61% in person and 39% via telemedicine (phone or video). Geriatric patients were significantly less likely to have in-person visits compared to non-geriatric patients (p = 0.029). Cardiovascular risk was addressed in 98.4% of patients, which was significantly more frequent than in the non-geriatric population (p = 0.046). At least one cardiovascular medication was started in 32.3% of geriatric patients, and 17.7% were referred to a cardiologist for further management. Long-term and late effects were addressed in 84.0% of geriatric survivors, including mental health (69.4%), bone health (64.5%), cognitive function (21.0%), cancer-related fatigue (12.9%), and sexual health (11.3%). There were no significant differences in the rates of long-term and late effects addressed in geriatric and non-geriatric populations except for fertility, which was not addressed with any geriatric patients. Six patients (10%) had end-of-life issues or goals of care addressed, which was not significantly different from the non-geriatric population (p = 0.08). One geriatric patient with a hematological malignancy and two patients with solid malignancies were deceased by the study’s end, and end-of-life care was discussed with two out of three of these patients. Table 3. Patient Characteristics and Clinical Issues Addressed in Geriatric Survivors Geriatric (N = 62) Age in years (mean) 72.9 Gender (% female) 72.6 Post BMT (%) 9.7 Secondary cancer screening performed (%) 85.5 Long-term and/or late effects addressed 84.0 Cardiovascular risk (%) 98.4 Mental health (%) 69.4 Bone health (%) 64.5 Cognitive function (%) 21.0 Fatigue (%) 12.9 Sexual health (%) 11.3 Primary care issue(s) addressed (%) 100.0 HEMATOLOGY Patient population. A total of 207 patients were included in the analysis: 64 patients (30.9%) with hematological malignancies or bone marrow syndromes (hereafter referred to as hematological malignancies) and 143 patients (69.1%) with solid malignancies. Previvors without a malignancy history and those with a history of both hematological and solid malignancies were excluded. Characteristics and clinical issues addressed in this population are presented in Table 4. The mean (range) age of patients with hematological malignancies was 46.9 (19-88) years, and 50% were female. The mean (range) age of patients with solid malignancies was 56.8 (23-90) years, and 82.3% were female. Patients with hematological malignancies were significantly more likely to be adolescents and young adults (AYA), defined as 39 years of age or younger, compared to those with solid malignancies (p < 0.01). Overall, 23.4% of patients with hematological malignancies and 21.7% of patients with solid malignancies had active disease; the remainder were in the post-treatment phase of survivorship. The most common hematological malignancies treated were non-Hodgkin's lymphoma (25.0%), acute myeloid leukemia (18.8%), Hodgkin's lymphoma (14.1%), and acute lymphoblastic leukemia (10.9%). Twenty-seven hematological malignancy survivors (42.4%) underwent bone marrow transplants. Clinical care. Surveillance for recurrence of the primary malignancy was addressed in 82.3% of patients with hematological malignancies, significantly less often than for patients with solid malignancies (95.3%) (p = 0.005). Screening for secondary cancers was addressed in 87.3% of patients with hematologic malignancies, statistically comparable to 93.7% with solid malignancies. Long-term and late effects were addressed in all patients with hematological malignancies including cardiovascular risk (98.4%), mental health (76.7%), bone health (60.9%), fertility (31.3%), cancer-related fatigue (25.5%) cognitive function (23.4%) and sexual health (9.4%). Among these issues, cardiovascular risk (p = 0.03), fertility (p = 0.04), and cancer-related fatigue (p = 0.04) were significantly more likely and sexual health (p = 0.02) was significantly less likely to be addressed in patients with hematological malignancies. Fertility referrals were significantly higher for patients with hematologic malignancies (18.8%) compared to those with solid malignancies (2.8%) (p < 0.01), but not significantly different for cardiovascular, bone, mental, or cognitive health referrals. At least one other primary care problem was addressed in most patients with hematological malignancies (96.9%), which was not statistically different from patients with solid malignancies (95.1%) (p = 0.72). Exercise was addressed in 37 (57.8%) and nutrition was addressed in 32 (50%) of patients with hematological malignancies, which was comparable to patients with solid malignancies. One patient with a hematological malignancy and four with solid malignancies were deceased by the study’s end. Table 4 . Patient Characteristics and Clinical Issues Addressed in Hematologic Malignancy Survivors Hematological Malignancy (N = 207) Age in years (mean) 46.9 Gender (% female) 50.0 Post BMT (%) 42.4 Secondary cancer screening performed (%) 87.3 Long-term and/or late effects addressed 100.0 Cardiovascular risk (%) 98.4 Mental health (%) 76.7 Bone health (%) 60.9 Sexual health (%) 9.4 Fertility (%) 31.3 Primary care issue(s) addressed (%) 98.4 PREVIVORS Patient population. Of 38 patients with a hereditary cancer syndrome, seven were previvors without a cancer diagnosis. Their mean age was 43 years (range 19 to 74 years). Five were female, and three were AYA. Four were referred by cancer genetics and three were self-referred. Genetic mutations included BRCA1 or BRCA2 (n=4), TP53 (n=2), and POT1 (n=1). Clinical care. The most common issues addressed were cardiovascular risk (n=6), fertility (n=5), and mental health (n=5). Fertility and mental health referrals were each made for two patients. Exercise and nutrition were each addressed in five patients. All patients underwent cancer screening, and no malignancies were diagnosed. All were alive at the end of the study. Discussion This study demonstrates the feasibility of and high demand for a novel oncologist-led, survivorship–focused primary care model, while also highlighting the broad scope and complexity of survivorship needs across a diverse patient population. Compared to a similar model of primary care for cancer survivors at Johns Hopkins, which saw 230 patients over four years across six internists [ 14 ], this clinic saw nearly the same number in less than 1.5 years under the care of a single hematologist/oncologist. Due to capacity constraints, stemming from the physician’s panel being shared with general primary care, the clinic stopped accepting new patients in April 2023. Demand persisted beyond this point (at which time the clinic shifted to a consultative model), suggesting that the number of patients seen during the study period underestimates the volume that would have been observed with continued referral acceptance. Over the study period, patients across genders and a wide age range from AYAs to older adults established care, underscoring the need for age-specific survivorship approaches. Breast cancer was the most common diagnosis, which reflects population-based prevalence. However, the significant representation of hematologic malignancies, including leukemia and lymphoma, as well as patients who had undergone autologous or allogeneic bone marrow transplant (15.0%), reflects the clinical complexity encountered in this setting. Notably, a sizable proportion of patients (16.8%) had known pathogenic germline mutations, most commonly BRCA and TP53, emphasizing the need for ongoing genetic risk assessment, counseling, and cascade testing for family members as part of survivorship care. Patients with pathogenic mutations also contribute to a significant previvor population with a unique set of medical needs and mental health challenges. This population is often underrepresented in survivorship models but is crucial to include in the spectrum of survivorship care, as the literature demonstrates that less than half of individuals with pathogenic germline mutations receive recommended cancer screenings [ 22 , 23 ]. Our findings demonstrate that a survivorship-focused primary care model can address a wide range of long-term and late effects, addressed in nearly all patients. Cardiovascular risk was the most common, with medication initiated in almost one-fifth of the patient cohort. This aligns with well-established literature emphasizing the increased cardiac risks for this patient population, necessitating proactive cardiovascular evaluation and management [ 24 ]. Mental health was addressed in over three-quarters of patients, with referrals placed for 15.0%, reinforcing the need for robust psychological care for cancer survivors. Similarly, bone health, fertility, sexual health, cognitive function, and cancer-related fatigue were often addressed, reflecting the multidimensional impact of cancer and its treatment. Importantly, primary care needs were addressed in the vast majority (96.0%) of survivorship visits, illustrating the feasibility as well as the critical need for combined survivorship and primary care services for this population. Meeting both sets of needs in a single practice setting highlights the potential for survivorship-focused primary care clinics to improve continuity of care and reduce care fragmentation, particularly for patients with complex medical histories. Lifestyle counseling regarding exercise and nutrition was addressed in over half of visits, reflecting the integration of health promotion into survivorship models. While many survivors desire this kind of support [ 25 ], only a minority report receiving adequate guidance [ 26 ]. We found that surveillance for recurrence of primary cancer and screening for secondary cancers were performed in over 90% of patients, resulting in eight diagnoses of recurrence and four diagnoses of secondary cancers. These findings underscore the value of primary-care driven screening tailored to the survivor’s individual treatment history and risk profile, as survivors of adult-onset malignancies face significantly increased risks of incidence and mortality from cancer compared to the general population [ 27 , 28 ]. Lastly, nearly two-thirds of patients returned for at least one follow-up visit, suggesting that the clinic was perceived as a valuable ongoing resource. Longer-term follow-up was not assessed in this study but represents an important metric for understanding survivors’ desire to continue receiving care through this model. Certain long-term and late effects, including sexual health, fertility, cognitive function, and cancer-related fatigue were addressed in less than 20% of visits. These relatively low rates may be explained by a multitude of factors, including time constraints in primary care visits, patient hesitancy to discuss certain topics, or the tendency for clinical encounters to prioritize more immediate concerns. While some differences between subgroups can be explained by disease pathology or age, others require deeper investigation into the sources of care gaps. For example, while fertility discussions and referrals favored in AYAs can be explained by age, further research is needed to determine if additional factors contributed to reduced secondary cancer screening. Fertility and cardiovascular risk were more often addressed in patients with hematologic malignancies, likely reflecting a younger age cohort and known cardiovascular risks after stem cell transplant [ 29 ]. However, neither the more frequent attention to cancer-related fatigue nor the lower rates of sexual health discussions in patients with hematologic malignancies can reasonably be explained by disease pathology or guidelines. Additionally, end-of-life or goals of care conversations occurred with 10% of geriatric patients and 5% of all patients in the clinic. Possible reasons for this low number include younger ages of patients, lack of time, lack of comfort, or perceived lack of need in a population where 75% of patients had no active disease. However, given that survivors are more likely to have chronic medical conditions and recurrent or secondary malignancies [ 7 – 9 ], advance care planning for a geriatric subset is equally if not more important for this patient population. Engaging in goals of care conversations is associated with higher quality of communication, quality of care at the end of life, patient control, and reduced distress for patients [ 30 ]. Future work may focus on optimal timing for integrating advance care planning into survivorship-focused primary care. One potential limitation of this model is scalability. Few, if any, board-certified oncologists or hematologists are likely to enter primary care settings, given the additional training required, misalignment of clinical interests, and lower reimbursement in primary care compared to oncology. However, cancer survivorship may align well with emerging efforts in primary care to develop focused tracks for complex populations, as seen in geriatrics and palliative care. Whether dedicated training in survivorship-focused primary care can achieve similar outcomes to oncologist-led primary care is a key question warranting further investigation. Additionally, given the high demand demonstrated in this study, limiting survivorship-focused primary care to a subset of a general primary care panel may underutilize clinicians’ expertise, drawing attention to implementation that thoughtfully pairs medical skillsets with patient need. Overall, our findings suggest that expert-led, survivorship-focused primary care can play a pivotal role in delivering comprehensive care across medical, psychosocial, and preventive domains. To our knowledge, this represents the first oncologist-led, cancer survivorship-focused primary care clinic, offering a unique model that bridges oncology and general internal medicine. Having demonstrated feasibility, future work should assess this model’s impact on health-related quality of life and healthcare utilization, which may ultimately guide strategies to support broader adoption. Declarations Competing Interests IRY is an advisor to Previvor Edge and consultant to OncoveryCare. NZRS is a consultant to OncoveryCare. No direct or indirect financial support was provided to this study. Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Author Contribution IRY and NZRS contributed to study conception. MKR, IRY, and NZRS contributed to study design and data collection. MKR, EZ, and IRY contributed to data analysis and interpretation. The first draft of the manuscript was written by MKR and all authors commented, read, and approved the final manuscript. Acknowledgement The authors thank Dr. Lidia Schapira and Dr. Jennifer Kim for their work instituting cancer survivorship consultative visits within the primary care setting, which provided important precedent and helped secure institutional support for this model. References Siegel RL, Kratzer TB, Giaquinto AN, Sung H, Jemal A. Cancer statistics, 2025. CA Cancer J Clin. 2025;75(1):10-45. Tonorezos E, Devasia T, Mariotto AB, et al. 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Do cancer survivors have an increased risk of developing subsequent cancer? A population-based study. J Transl Med. 2025;23(1):355. Vasbinder A, Hoeger CW, Catalan T, et al. Cardiovascular events after hematopoietic stem cell transplant: incidence and risk factors. JACC CardioOncol. 2023;5(6):821-832. Stevens J, Elston D, Tan A, et al. Clinicians’ experiences implementing an advance care planning pathway in two Canadian provinces: a qualitative study. BMC Prim Care. 2024;25:217. Additional Declarations Competing interest reported. IRY is an advisor to Previvor Edge and consultant to OncoveryCare. NZRS is a consultant to OncoveryCare. No direct or indirect financial support was provided to this study. Cite Share Download PDF Status: Posted Version 1 posted 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7180545","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":492762892,"identity":"52def15e-6ddc-44c9-8853-2c0889003937","order_by":0,"name":"Maya K. Ramachandran","email":"","orcid":"","institution":"Stanford Medicine","correspondingAuthor":false,"prefix":"","firstName":"Maya","middleName":"K.","lastName":"Ramachandran","suffix":""},{"id":492762893,"identity":"802290f4-aba5-4545-bfd5-3f5378c77122","order_by":1,"name":"Ellen Zhang","email":"","orcid":"","institution":"Stanford Medicine","correspondingAuthor":false,"prefix":"","firstName":"Ellen","middleName":"","lastName":"Zhang","suffix":""},{"id":492762894,"identity":"1942b6e5-86f7-4166-b290-0a0e35695f53","order_by":2,"name":"Natasha Z.R. Steele","email":"","orcid":"","institution":"Stanford Medicine","correspondingAuthor":false,"prefix":"","firstName":"Natasha","middleName":"Z.R.","lastName":"Steele","suffix":""},{"id":492762895,"identity":"115d1aa8-d79f-480b-a326-c9fbae5f55b4","order_by":3,"name":"Ilana R. Yurkiewicz","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/klEQVRIie3OsWrCQBzH8f9xkCx/rONBKb7CQaAIis9yR+BctCguLRXMdC6xs30LoQ/QQCBZfADBRZfMzRZBtGnQzSSOHe4LB8fv+MABmEz/MCs/xOPFhez+FtsDYAD0LkI5CAAMaggU5MLZXaTBBs/pctSVH3acvB2y3gvai/0GXjvSK/sYGzifK66kRqG2KNwJYuy0Yd2vJGTHw6FmEG1BUPnNlMWIDuvIOSdEjzMxk35BTjVkxYOcUAtQhBfiVRBMJmTJ3ZlGRR9RxdLHiLZF1HfKSGvufhH/2HNa83ifZt136duabH6mnacyAk1xa705XnsIql5NJpPJlPcLDl9R86uOvHwAAAAASUVORK5CYII=","orcid":"","institution":"Stanford Medicine","correspondingAuthor":true,"prefix":"","firstName":"Ilana","middleName":"R.","lastName":"Yurkiewicz","suffix":""}],"badges":[],"createdAt":"2025-07-21 19:53:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7180545/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7180545/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":94986143,"identity":"e9dcf1fb-47a9-4077-8764-1e8847dfa18b","added_by":"auto","created_at":"2025-11-03 06:59:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":501572,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7180545/v1/7b134c46-6fdd-45b6-90bd-bf6b3473f32c.pdf"}],"financialInterests":"Competing interest reported. IRY is an advisor to Previvor Edge and consultant to OncoveryCare. NZRS is a consultant to OncoveryCare. No direct or indirect financial support was provided to this study.","formattedTitle":"Oncologist-Led, Survivorship-Focused Primary Care: Feasibility and Outcomes of a Novel Integrated Care Model","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMore than one in three Americans will be diagnosed with cancer in their lifetime [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Thanks to advances in early detection, multimodal therapies, prolonged adjuvant and maintenance treatments, novel agents, and improved screening, the five-year survival rate has increased from 49% in the mid-1970s to 69% between 2014 and 2020, with survival now exceeding 90% for some cancer types [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. As of January 1, 2022, over 18\u0026nbsp;million Americans with a history of invasive cancer were alive. This number is projected to reach 26\u0026nbsp;million by 2040 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe growing population of individuals living with and after cancer has drawn increasing attention to their distinct care needs. A substantial body of research, including multiple reports from the Institute of Medicine (IOM), has documented persistent gaps in survivorship care, particularly during transitions from active treatment to surveillance, and in managing comorbidities, psychosocial concerns, and long-term quality of life [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e–\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. A meta-analysis of cancer survivors showed persistent deficits in physical health, role functioning, and mental health up to 26 years after diagnosis, with variation by age, disease type, and treatment received [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Survivors of childhood cancer are significantly more likely to experience a major cardiovascular event at a young age compared to the general population (18% compared to 0.9%) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], while cancer survivors over age 65 have a higher burden of chronic conditions, increased fall risk, and worse self-reported health status than age-matched peers [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo meet these needs, several core components of comprehensive survivorship care along with models to deliver them have been identified. The 2006 IOM report \u003cem\u003eFrom Cancer Patient to Cancer Survivor\u003c/em\u003e outlined four components of survivorship care: prevention of recurrence and late effects, surveillance for disease progression and psychosocial outcomes, interventions for treatment-related consequences, and coordination between specialists and primary care providers [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In 2019, Nekhlyudov et al. proposed a complementary framework organized around five domains: prevention and surveillance for recurrence and new cancers, management of physical effects, psychosocial effects, chronic medical conditions, and promotion of overall health [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In terms of care delivery models, the American Society of Clinical Oncology (ASCO) has broadly classified survivorship care into four categories: oncologist-led, primary care-led, shared care, and specialized survivorship clinics [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Each model offers distinct strengths and limitations, and all emphasize care coordination, transitions, and risk stratification to match survivors with the most appropriate level of care based on existing resources.\u003c/p\u003e\u003cp\u003eSurvivorship-focused primary care (sometimes called “onco-primary care”) is an emerging approach that aims to augment the primary care-led model [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], which is well positioned to provide longitudinal, comprehensive care but often limited by barriers such as lack of training and unclear role delineation [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, studies suggest that while primary care physicians are more adept at chronic disease management and preventive care, oncologists are better equipped to manage cancer surveillance and long-term or late treatment effects [\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e–\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. These insights raise the potential for a new, combined model — namely, oncologist-led primary care — to reduce care transitions and improve outcomes across the survivorship continuum.\u003c/p\u003e\u003cp\u003eThis model was launched at Stanford Medicine in 2021. The clinic, named Primary Care for Cancer Survivorship, provides ongoing primary care by a physician who is board certified in medical oncology, hematology, and internal medicine, integrating survivorship care and general primary care within a single setting. It is embedded within Stanford’s broader clinical Cancer Survivorship Program, which includes disease-specific survivorship clinics led by oncology advanced practice practitioners (APPs), a pediatric survivorship transition clinic, an adolescent and young adult (AYA) survivorship transition clinic, and primary care-based consultative visits [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Patients accepted to the new clinic included: (1) adults with a history of pediatric cancer; (2) adults who completed treatment for adult-onset malignancies; (3) adults receiving ongoing cancer-directed therapy, including those with metastatic disease; and (4) “previvors” without a cancer history who carry inherited mutations conferring elevated risk. Patients with any type and stage of malignancy were accepted. New patient visits were either 30 minutes or one hour, while return visits were 30 minutes. A range of support services were available through the primary care infrastructure, including pharmacist-led diabetes and hypertension management, behavioral health support, virtual osteoporosis education, and group classes focused on lifestyle and anxiety management. The goal of this study is to describe patient characteristics and clinical issues addressed during the clinic’s first two years of implementation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This descriptive study includes all new patients seen in the Primary Care for Cancer Survivorship clinic from its opening on November 1, 2021 through the data cut-off date of November 30, 2023. This study was deemed exempt from review by the Stanford University Institutional Review Board (IRB) due to its descriptive nature.\u003c/p\u003e\u003cp\u003eAll demographic and clinical information was collected via electronic chart review by three independent reviewers. Variables included age, gender, city of residence, cancer type, cancer status (active vs. in remission), survival status (alive vs. deceased), referral source, date of first appointment, number of appointments during the study period, and type of appointment (in person vs. telemedicine). Data were extracted and stored in a secure database. Patients who had their care reassigned or who did not establish care with a visit were excluded. For patients who moved during the study period, the location recorded reflected where they lived at the time of their clinic visits.\u003c/p\u003e\u003cp\u003eDescriptive data on visit content were collected from physician documentation, including information on cancer recurrence surveillance and secondary screening, exercise, nutrition, goals of care, and long-term and late effect management including mental health, cognitive function, fatigue, neuropathy, insomnia, cardiovascular risk, bone health, sexual health, and fertility preservation. A primary care issue was defined as chronic disease management, health care maintenance such as vaccination, or evaluation of an acute issue. Referrals to subspecialty services were also recorded.\u003c/p\u003e\u003cp\u003eData were summarized using descriptive statistics. Categorical variables were reported as frequencies and percentages, and continuous variables were presented as means and standard deviations. Associations between categorical variables were assessed using Fisher’s exact test. Subgroup analyses were conducted for geriatric patients (defined as aged 65 and old), AYAs (defined as aged 39 or younger), and patients with hematologic malignancies. Previvors were defined as patients carrying a cancer-associated genetic mutation without a cancer diagnosis. Patients with a history of more than one malignancy across groups were excluded from subgroup analyses to preserve interpretability.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn total, 226 patients established care during the study period. Their characteristics and clinical issues addressed are presented in Table 1. The majority (71.6%) were female. The mean age was 54.1 years (range of 19 to 90). The most common cancer type was breast (41.1%), followed by leukemia (13.3%) and lymphoma (11.5%). In this population, 16.8% of patients had a genetic mutation, including 12 carrying a BRCA mutation and 11 carrying a TP53 mutation. Previvors without a cancer diagnosis comprised 3.1% of the study population. Most patients (75.2%) had no active disease, while 24.8% had active disease. Thirty-four patients (15.0%) had undergone an allogeneic or autologous bone marrow transplant (BMT). Most referrals to the clinic came from medical oncology (41.1%) and self-referrals (27.4%), followed by hematology (7.3%) and BMT (3.7%). Stanford\u0026rsquo;s pediatric survivorship transition clinic sent 4.6% of referrals.\u003c/p\u003e\n\u003cp\u003eAt least one long-term or late effect was addressed in nearly all patients (99.1%). The most common was cardiovascular risk (92.0%), with medications started in 35 patients (16.8%). The next most common were mental health (75.7%) and bone health (59.7%). Referrals were placed to mental health specialists in 15.0% of patients, cardiovascular specialists in 8.4%, and fertility specialists in 8.0%. At least one other primary care issue was managed in 96.0% of patients. Exercise was addressed in 61.5%, and nutrition was addressed in 54.9%. Goals of care conversations, including end-of-life discussions, occurred with 11 patients (4.9%).\u003c/p\u003e\n\u003cp\u003eAmong survivors without active disease, surveillance for recurrence of the primary cancer was addressed in 91.9%. Eight recurrences were diagnosed. Among the entire cohort, secondary cancer screening was performed in 91.2% of patients. Four patients were diagnosed with a secondary cancer. The majority of patients (67.3%) returned for at least one follow-up visit during the study period, which included both in-person and telehealth. Overall, 60.7% of visits occurred in-person.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e. Patient Characteristics and Clinical Issues Addressed in the Total Population\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (N = 226)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge in years (mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGender (% female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e71.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHereditary cancer syndrome (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePost BMT (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSurveillance for recurrence addressed (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e91.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSecondary cancer screening performed (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e91.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eLong-term and/or late effects addressed\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e99.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Cardiovascular risk (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e92.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mental health (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e75.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Bone health (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e59.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Sexual health (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Fertility (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Cognitive function (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Fatigue (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePrimary care issue(s) addressed (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e96.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAYA\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePatient Population.\u003c/em\u003e Among a total of 219 cancer survivors (excluding 7 previvors) who established primary care in the clinic, 49 (22.4%) were AYAs. Their characteristics and clinical issues addressed are presented in Table 2. Their mean age was 31.5 years (range 19 to 39), and 57.1% were female. The most common cancers were lymphoma (24.5%), leukemia (22.4%), and breast cancer (14.3%). Most (89.8%) no longer had active disease, while 5 patients (10.2%) had active disease. The most common referral sources were self-referrals (24.5%), the pediatric oncology survivorship program (20.4%), and oncology (16.3%). Two AYA survivors died during the study period, of which one engaged in end-of-life conversations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eClinical Care\u003c/em\u003e. Surveillance for primary cancer recurrence and secondary cancer screening were each conducted in 41 AYA patients (83.7%). No recurrences or secondary cancers were diagnosed. Secondary cancer screening was addressed significantly more often in non-AYAs compared to AYAs (94.0% vs. 83.7%, p = 0.03). Long-term and late effects were managed in all AYA patients, including cardiovascular risk (85.7%), mental health (85.7%), fertility (65.3%), bone health (49.0%), and sexual health (18.4%). Among these issues, only fertility differed significantly between groups, addressed more often in AYAs (65.3% vs. 4.1%, p \u0026lt; 0.05). Referrals for fertility were also significantly higher among AYAs (30.6% vs. 0.6%, p \u0026lt; 0.05). Mental health referrals were more common in AYAs but did not reach significance (18.4% vs. 13.5%, p = 0.09). At least one other primary care issue was addressed in all AYA patients, which was not statistically different from non-AYA patients (p = 0.20). Exercise was discussed in 30 AYA patients (61.2%) and nutrition addressed in 24 (40.8%), with no significant difference to non-AYAs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Patient Characteristics and Clinical Issues Addressed in AYA Survivors\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAYA (N = 49)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge in years (mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGender (% female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e57.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePost BMT (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSecondary cancer screening performed (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e83.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eLong-term and/or late effects addressed\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Cardiovascular risk (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e85.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mental health (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e85.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Bone health (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e49.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Sexual health (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Fertility (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e65.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePrimary care issue(s) addressed (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eGERIATRICS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePatient Population.\u003c/em\u003e Among a total of 219 patients with a previous or active malignancy, 62 (28.3%) were geriatric (aged 65 and older). Their characteristics and clinical issues addressed are presented in Table 3. The mean age of the geriatric group was 73, with the range 65 to 90. Seventy-three percent of patients were female, and 27% were male. The most common cancers were breast (38%), lung (10%), leukemia (13%), lymphoma (8%), prostate (8%), and multiple myeloma (6%). Twenty-five patients (40%) had active disease and 37 patients (58%) were post-treatment. One patient over the age of 65, a previvor with Li-Fraumeni syndrome, was excluded from the analysis.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eClinical Care.\u003c/em\u003e Cancer surveillance was discussed with 80.6% of patients, and 2 patients (5.4% of post-treatment patients) were diagnosed with recurrence. Secondary cancer screening was performed in 85.5% of patients, with no secondary cancers diagnosed. The most common referral sources were oncology (40.3%), self-referrals (25.8%), and hematology (12.9%). The average number of visits per year was 2.8 with 61% in person and 39% via telemedicine (phone or video). Geriatric patients were significantly less likely to have in-person visits compared to non-geriatric patients (p = 0.029). Cardiovascular risk was addressed in 98.4% of patients, which was significantly more frequent than in the non-geriatric population (p = 0.046). \u0026nbsp;At least one cardiovascular medication was started in 32.3% of geriatric patients, and 17.7% were referred to a cardiologist for further management. Long-term and late effects were addressed in 84.0% of geriatric survivors, including mental health (69.4%), bone health (64.5%), cognitive function (21.0%), cancer-related fatigue (12.9%), and sexual health (11.3%). There were no significant differences in the rates of long-term and late effects addressed in geriatric and non-geriatric populations except for fertility, which was not addressed with any geriatric patients. Six patients (10%) had end-of-life issues or goals of care addressed, which was not significantly different from the non-geriatric population (p = 0.08). One geriatric patient with a hematological malignancy and two patients with solid malignancies were deceased by the study\u0026rsquo;s end, and end-of-life care was discussed with two out of three of these patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Patient Characteristics and Clinical Issues Addressed in Geriatric Survivors\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeriatric (N = 62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge in years (mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e72.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGender (% female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e72.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePost BMT (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSecondary cancer screening performed (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e85.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eLong-term and/or late effects addressed\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e84.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Cardiovascular risk (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e98.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mental health (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e69.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Bone health (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e64.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Cognitive function (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Fatigue (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Sexual health (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePrimary care issue(s) addressed (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eHEMATOLOGY\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePatient population.\u003c/em\u003e\u0026nbsp; A total of 207 patients were included in the analysis: 64 patients (30.9%) with hematological malignancies or bone marrow syndromes (hereafter referred to as hematological malignancies) and 143 patients (69.1%) with solid malignancies. Previvors without a malignancy history and those with a history of both hematological and solid malignancies were excluded. Characteristics and clinical issues addressed in this population are presented in Table 4.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe mean (range) age of patients with hematological malignancies was 46.9 (19-88) years, and 50% were female. The mean (range) age of patients with solid malignancies was 56.8 (23-90) years, and 82.3% were female. Patients with hematological malignancies were significantly more likely to be adolescents and young adults (AYA), defined as 39 years of age or younger, compared to those with solid malignancies (p \u0026lt; 0.01). Overall, 23.4% of patients with hematological malignancies and 21.7% of patients with solid malignancies had active disease; the remainder were in the post-treatment phase of survivorship. The most common hematological malignancies treated were non-Hodgkin\u0026apos;s lymphoma (25.0%), acute myeloid leukemia (18.8%), Hodgkin\u0026apos;s lymphoma (14.1%), and acute lymphoblastic leukemia (10.9%). Twenty-seven hematological malignancy survivors (42.4%) underwent bone marrow transplants.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eClinical care.\u003c/em\u003e Surveillance for recurrence of the primary malignancy was addressed in 82.3% of patients with hematological malignancies, significantly less often than for patients with solid malignancies (95.3%) (p = 0.005). Screening for secondary cancers was addressed in 87.3% of patients with hematologic malignancies, statistically comparable to 93.7% with solid malignancies. Long-term and late effects were addressed in all patients with hematological malignancies including cardiovascular risk (98.4%), mental health (76.7%), bone health (60.9%), fertility (31.3%), cancer-related fatigue (25.5%) cognitive function (23.4%) and sexual health (9.4%). Among these issues, cardiovascular risk (p = 0.03), fertility (p = 0.04), and cancer-related fatigue (p = 0.04) were significantly more likely and sexual health (p = 0.02) was significantly less likely to be addressed in patients with hematological malignancies. Fertility referrals were significantly higher for patients with hematologic malignancies (18.8%) compared to those with solid malignancies (2.8%) (p \u0026lt; 0.01), but not significantly different for cardiovascular, bone, mental, or cognitive health referrals. At least one other primary care problem was addressed in most patients with hematological malignancies (96.9%), which was not statistically different from patients with solid malignancies (95.1%) (p = 0.72). Exercise was addressed in 37 (57.8%) and nutrition was addressed in 32 (50%) of patients with hematological malignancies, which was comparable to patients with solid malignancies. One patient with a hematological malignancy and four with solid malignancies were deceased by the study\u0026rsquo;s end.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e. Patient Characteristics and Clinical Issues Addressed in Hematologic Malignancy Survivors\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHematological Malignancy (N = 207)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge in years (mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e46.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGender (% female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePost BMT (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSecondary cancer screening performed (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e87.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eLong-term and/or late effects addressed\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Cardiovascular risk (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e98.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mental health (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e76.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Bone health (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Sexual health (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Fertility (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePrimary care issue(s) addressed (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e98.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003ePREVIVORS\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePatient population.\u003c/em\u003e \u0026nbsp;Of 38 patients with a hereditary cancer syndrome, seven were previvors without a cancer diagnosis.\u0026nbsp;Their mean age was 43 years (range 19 to 74 years). Five were female, and three were AYA.\u0026nbsp;Four were referred by cancer genetics and three were self-referred. Genetic mutations included BRCA1 or BRCA2 (n=4), TP53 (n=2), and POT1 (n=1).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eClinical care.\u0026nbsp;\u003c/em\u003eThe most common issues addressed were cardiovascular risk (n=6), fertility (n=5), and mental health (n=5). Fertility and mental health referrals were each made for two patients. Exercise and nutrition were each addressed in five patients. All patients underwent cancer screening, and no malignancies were diagnosed. All were alive at the end of the study.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrates the feasibility of and high demand for a novel oncologist-led, survivorship\u0026ndash;focused primary care model, while also highlighting the broad scope and complexity of survivorship needs across a diverse patient population. Compared to a similar model of primary care for cancer survivors at Johns Hopkins, which saw 230 patients over four years across six internists [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], this clinic saw nearly the same number in less than 1.5 years under the care of a single hematologist/oncologist. Due to capacity constraints, stemming from the physician\u0026rsquo;s panel being shared with general primary care, the clinic stopped accepting new patients in April 2023. Demand persisted beyond this point (at which time the clinic shifted to a consultative model), suggesting that the number of patients seen during the study period underestimates the volume that would have been observed with continued referral acceptance.\u003c/p\u003e\u003cp\u003eOver the study period, patients across genders and a wide age range from AYAs to older adults established care, underscoring the need for age-specific survivorship approaches. Breast cancer was the most common diagnosis, which reflects population-based prevalence. However, the significant representation of hematologic malignancies, including leukemia and lymphoma, as well as patients who had undergone autologous or allogeneic bone marrow transplant (15.0%), reflects the clinical complexity encountered in this setting. Notably, a sizable proportion of patients (16.8%) had known pathogenic germline mutations, most commonly BRCA and TP53, emphasizing the need for ongoing genetic risk assessment, counseling, and cascade testing for family members as part of survivorship care. Patients with pathogenic mutations also contribute to a significant previvor population with a unique set of medical needs and mental health challenges. This population is often underrepresented in survivorship models but is crucial to include in the spectrum of survivorship care, as the literature demonstrates that less than half of individuals with pathogenic germline mutations receive recommended cancer screenings [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur findings demonstrate that a survivorship-focused primary care model can address a wide range of long-term and late effects, addressed in nearly all patients. Cardiovascular risk was the most common, with medication initiated in almost one-fifth of the patient cohort. This aligns with well-established literature emphasizing the increased cardiac risks for this patient population, necessitating proactive cardiovascular evaluation and management [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Mental health was addressed in over three-quarters of patients, with referrals placed for 15.0%, reinforcing the need for robust psychological care for cancer survivors. Similarly, bone health, fertility, sexual health, cognitive function, and cancer-related fatigue were often addressed, reflecting the multidimensional impact of cancer and its treatment.\u003c/p\u003e\u003cp\u003eImportantly, primary care needs were addressed in the vast majority (96.0%) of survivorship visits, illustrating the feasibility as well as the critical need for combined survivorship and primary care services for this population. Meeting both sets of needs in a single practice setting highlights the potential for survivorship-focused primary care clinics to improve continuity of care and reduce care fragmentation, particularly for patients with complex medical histories. Lifestyle counseling regarding exercise and nutrition was addressed in over half of visits, reflecting the integration of health promotion into survivorship models. While many survivors desire this kind of support [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], only a minority report receiving adequate guidance [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWe found that surveillance for recurrence of primary cancer and screening for secondary cancers were performed in over 90% of patients, resulting in eight diagnoses of recurrence and four diagnoses of secondary cancers. These findings underscore the value of primary-care driven screening tailored to the survivor\u0026rsquo;s individual treatment history and risk profile, as survivors of adult-onset malignancies face significantly increased risks of incidence and mortality from cancer compared to the general population [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Lastly, nearly two-thirds of patients returned for at least one follow-up visit, suggesting that the clinic was perceived as a valuable ongoing resource. Longer-term follow-up was not assessed in this study but represents an important metric for understanding survivors\u0026rsquo; desire to continue receiving care through this model.\u003c/p\u003e\u003cp\u003eCertain long-term and late effects, including sexual health, fertility, cognitive function, and cancer-related fatigue were addressed in less than 20% of visits. These relatively low rates may be explained by a multitude of factors, including time constraints in primary care visits, patient hesitancy to discuss certain topics, or the tendency for clinical encounters to prioritize more immediate concerns. While some differences between subgroups can be explained by disease pathology or age, others require deeper investigation into the sources of care gaps. For example, while fertility discussions and referrals favored in AYAs can be explained by age, further research is needed to determine if additional factors contributed to reduced secondary cancer screening. Fertility and cardiovascular risk were more often addressed in patients with hematologic malignancies, likely reflecting a younger age cohort and known cardiovascular risks after stem cell transplant [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, neither the more frequent attention to cancer-related fatigue nor the lower rates of sexual health discussions in patients with hematologic malignancies can reasonably be explained by disease pathology or guidelines.\u003c/p\u003e\u003cp\u003eAdditionally, end-of-life or goals of care conversations occurred with 10% of geriatric patients and 5% of all patients in the clinic. Possible reasons for this low number include younger ages of patients, lack of time, lack of comfort, or perceived lack of need in a population where 75% of patients had no active disease. However, given that survivors are more likely to have chronic medical conditions and recurrent or secondary malignancies [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], advance care planning for a geriatric subset is equally if not more important for this patient population. Engaging in goals of care conversations is associated with higher quality of communication, quality of care at the end of life, patient control, and reduced distress for patients [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Future work may focus on optimal timing for integrating advance care planning into survivorship-focused primary care.\u003c/p\u003e\u003cp\u003eOne potential limitation of this model is scalability. Few, if any, board-certified oncologists or hematologists are likely to enter primary care settings, given the additional training required, misalignment of clinical interests, and lower reimbursement in primary care compared to oncology. However, cancer survivorship may align well with emerging efforts in primary care to develop focused tracks for complex populations, as seen in geriatrics and palliative care. Whether dedicated training in survivorship-focused primary care can achieve similar outcomes to oncologist-led primary care is a key question warranting further investigation. Additionally, given the high demand demonstrated in this study, limiting survivorship-focused primary care to a subset of a general primary care panel may underutilize clinicians\u0026rsquo; expertise, drawing attention to implementation that thoughtfully pairs medical skillsets with patient need.\u003c/p\u003e\u003cp\u003eOverall, our findings suggest that expert-led, survivorship-focused primary care can play a pivotal role in delivering comprehensive care across medical, psychosocial, and preventive domains. To our knowledge, this represents the first oncologist-led, cancer survivorship-focused primary care clinic, offering a unique model that bridges oncology and general internal medicine. Having demonstrated feasibility, future work should assess this model\u0026rsquo;s impact on health-related quality of life and healthcare utilization, which may ultimately guide strategies to support broader adoption.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eCompeting Interests\u003c/h2\u003e\u003cp\u003eIRY is an advisor to Previvor Edge and consultant to OncoveryCare. NZRS is a consultant to OncoveryCare. No direct or indirect financial support was provided to this study.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eIRY and NZRS contributed to study conception. MKR, IRY, and NZRS contributed to study design and data collection. MKR, EZ, and IRY contributed to data analysis and interpretation. The first draft of the manuscript was written by MKR and all authors commented, read, and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003e The authors thank Dr. Lidia Schapira and Dr. Jennifer Kim for their work instituting cancer survivorship consultative visits within the primary care setting, which provided important precedent and helped secure institutional support for this model.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eSiegel RL, Kratzer TB, Giaquinto AN, Sung H, Jemal A. Cancer statistics, 2025. \u003cem\u003eCA Cancer J Clin.\u003c/em\u003e 2025;75(1):10-45.\u003c/li\u003e\n \u003cli\u003eTonorezos E, Devasia T, Mariotto AB, et al. Prevalence of cancer survivors in the United States. \u003cem\u003eJ Natl Cancer Inst.\u003c/em\u003e 2024;116(11):1784-1790.\u003c/li\u003e\n \u003cli\u003eRowland JH, Hewitt M, Ganz PA. Cancer survivorship: a new challenge in delivering quality cancer care. \u003cem\u003eJ Clin Oncol.\u003c/em\u003e 2006;24(32):5101-5104.\u003c/li\u003e\n \u003cli\u003eInstitute of Medicine. \u003cem\u003eFrom Cancer Patient to Cancer Survivor: Lost in Transition.\u003c/em\u003e Washington, DC: Institute of Medicine; 2005.\u003c/li\u003e\n \u003cli\u003eNational Research Council. \u003cem\u003eChildhood Cancer Survivorship: Improving Care and Quality of Life.\u003c/em\u003e Washington, DC: The National Academies Press; 2003.\u003c/li\u003e\n \u003cli\u003eInstitute of Medicine. \u003cem\u003eCancer Care for the Whole Patient: Meeting Psychosocial Health Needs.\u003c/em\u003e Washington, DC: The National Academies Press; 2008.\u003c/li\u003e\n \u003cli\u003eFirkins J, Hansen L, Driessnack M, Dieckmann N. Quality of life in \u0026quot;chronic\u0026quot; cancer survivors: a meta-analysis. \u003cem\u003eJ Cancer Surviv.\u003c/em\u003e 2020;14(4):504-517.\u003c/li\u003e\n \u003cli\u003eHammoud RA, Liu Q, Dixon SB, et al. The burden of cardiovascular disease and risk for subsequent major adverse cardiovascular events in survivors of childhood cancer: a prospective, longitudinal analysis from the St Jude Lifetime Cohort Study. \u003cem\u003eLancet Oncol.\u003c/em\u003e 2024;25(6):811-822.\u003c/li\u003e\n \u003cli\u003eSulicka J, Pac A, Puzianowska-Kuźnicka M, et al. Health status of older cancer survivors: results of the PolSenior study. \u003cem\u003eJ Cancer Surviv.\u003c/em\u003e 2018;12(3):326-333.\u003c/li\u003e\n \u003cli\u003eNational Research Council, Institute of Medicine, National Cancer Policy Board, et al. \u003cem\u003eFrom Cancer Patient to Cancer Survivor: Lost in Transition.\u003c/em\u003e Washington, DC: National Academies Press; 2006. 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The Johns Hopkins Primary Care for Cancer Survivor Clinic: lessons learned in our first 4 years. \u003cem\u003eJ Cancer Surviv.\u003c/em\u003e 2020;14(1):19-25.\u003c/li\u003e\n \u003cli\u003eOeffinger K, Corbett C, Shah, KP, et al. Oncology, Primary Care, and Survivorship: Time for Onco-primary Care? \u003cem\u003eJCO Oncol Pract.\u003c/em\u003e 2025;21:735-738.\u003c/li\u003e\n \u003cli\u003eMcDonough E, et al. Practice, preferences, and practical tips from primary care physicians to improve the care of cancer survivors. \u003cem\u003eJ Clin Oncol.\u003c/em\u003e 2019.\u003c/li\u003e\n \u003cli\u003eNekhlyudov L, Aziz N, Lerro CC, Virgo KS. Oncologists\u0026rsquo; and primary care providers\u0026rsquo; awareness of late effects of cancer treatment: implications for survivorship care. \u003cem\u003eJ Clin Oncol.\u003c/em\u003e 2012;30(15_suppl):600.\u003c/li\u003e\n \u003cli\u003eSnyder CF, Frick KD, Peairs KS, et al. Comparing care for breast cancer survivors to non-cancer controls: a five-year longitudinal study. \u003cem\u003eJ Gen Intern Med.\u003c/em\u003e 2009;24(4):469-474.\u003c/li\u003e\n \u003cli\u003eHollowell K, Olmsted CL, Richardson AS, et al. ASCO-recommended surveillance and physician specialty among long-term breast cancer survivors. \u003cem\u003eCancer.\u003c/em\u003e 2010;116(9):2090-2098.\u003c/li\u003e\n \u003cli\u003eLafata JE, Salloum RG, Fishman PA, et al. Preventive care receipt and office visit use among breast and colorectal cancer survivors relative to age- and gender-matched cancer-free controls. \u003cem\u003eJ Cancer Surviv.\u003c/em\u003e 2015;9(2):201-207.\u003c/li\u003e\n \u003cli\u003eSmith SM, Steele N, Kim J, et al. Cancer survivorship at Stanford Cancer Institute. \u003cem\u003eJ Cancer Surviv.\u003c/em\u003e 2024;18(1):53-58.\u003c/li\u003e\n \u003cli\u003eKnerr S, Guo B, Wernli KJ, et al. Longitudinal adherence to breast cancer surveillance following cancer genetic testing in an integrated health care system. \u003cem\u003eBreast Cancer Res Treat.\u003c/em\u003e 2023;201(3):461-470.\u003c/li\u003e\n \u003cli\u003eGoh LH, Spigelman AD. Assessing the adherence to guidelines in Lynch syndrome patients: a pilot study. \u003cem\u003eANZ J Surg.\u003c/em\u003e 2020;90(6):1130-1135.\u003c/li\u003e\n \u003cli\u003eFlorido R, Daya NR, Ndumele CE, et al. Cardiovascular disease risk among cancer survivors: the Atherosclerosis Risk In Communities (ARIC) Study. \u003cem\u003eJ Am Coll Cardiol.\u003c/em\u003e 2022;80(1):22-32.\u003c/li\u003e\n \u003cli\u003eRowland JH. What are cancer survivors telling us? \u003cem\u003eCancer J.\u003c/em\u003e 2008;14:361-368.\u003c/li\u003e\n \u003cli\u003eArem H, Duan X, Ehlers DK, et al. Provider discussion about lifestyle by cancer history: a nationally representative survey. \u003cem\u003eCancer Epidemiol Biomarkers Prev.\u003c/em\u003e 2021;30(2):278-285.\u003c/li\u003e\n \u003cli\u003eSung H, Hyun N, Leach CR, et al. Association of first primary cancer with risk of subsequent primary cancer among survivors of adult-onset cancers in the United States. \u003cem\u003eJAMA.\u003c/em\u003e 2020;324(24):2521-2535.\u003c/li\u003e\n \u003cli\u003eWang Y, Jiang Y, Bai Y, Xu H. Do cancer survivors have an increased risk of developing subsequent cancer? A population-based study. \u003cem\u003eJ Transl Med.\u003c/em\u003e 2025;23(1):355.\u003c/li\u003e\n \u003cli\u003eVasbinder A, Hoeger CW, Catalan T, et al. Cardiovascular events after hematopoietic stem cell transplant: incidence and risk factors. \u003cem\u003eJACC CardioOncol.\u003c/em\u003e 2023;5(6):821-832.\u003c/li\u003e\n \u003cli\u003eStevens J, Elston D, Tan A, et al. Clinicians\u0026rsquo; experiences implementing an advance care planning pathway in two Canadian provinces: a qualitative study. \u003cem\u003eBMC Prim Care.\u003c/em\u003e 2024;25:217.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cancer survivorship, primary care, integrated care, health care delivery","lastPublishedDoi":"10.21203/rs.3.rs-7180545/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7180545/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e The Primary Care for Cancer Survivorship clinic at Stanford Medicine is a novel program addressing primary care and survivorship-specific needs in a single setting. Care is delivered by a board-certified physician in internal medicine, oncology, and hematology. This study describes patient characteristics and clinical issues managed during its first two years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003eDemographic and clinical data for new patients seen from November 1, 2021 to November 1, 2023 were extracted via chart review and analyzed using descriptive statistics. Subgroup analyses focused on adolescents and young adults (AYAs), geriatric patients, patients with hematologic malignancies, and previvors with genetic risk.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e A total of 226 patients established care, with two-thirds returning for follow-up. The most common cancers were breast (41.4%), leukemia (13.3%), and lymphoma (11.5%). Three-quarters had no active disease. Hereditary cancer syndromes were present in 16.8%. Long-term and late effects were addressed in 99.1%, predominantly cardiovascular risk (92.0%), mental health (75.7%), and bone health (59.7%). Primary care issues were addressed in 96.0%. Secondary cancer screening was performed in 91.2%, with four secondary cancers diagnosed. AYAs (22.4%) had significantly more fertility discussions, while geriatric patients (28.3%) had significantly more telehealth visits. Among patients with hematologic malignancies, 42.4% had undergone a bone marrow transplant (BMT).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThis study demonstrates the demand for and feasibility of an oncologist-led, survivorship-focused primary care clinic in addressing a range of medical, preventive, and psychosocial issues.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for Cancer Survivors:\u003c/strong\u003eSurvivorship-focused primary care offers a comprehensive, longitudinal care model for survivors with diverse and evolving needs.\u003c/p\u003e","manuscriptTitle":"Oncologist-Led, Survivorship-Focused Primary Care: Feasibility and Outcomes of a Novel Integrated Care Model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-31 13:41:39","doi":"10.21203/rs.3.rs-7180545/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8379940d-3c3c-4b6f-97d2-c7e796f3ca10","owner":[],"postedDate":"July 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-31T18:23:35+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-31 13:41:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7180545","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7180545","identity":"rs-7180545","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}