Stronger Coordination with PCP a Necessity in Caring for Cancer Survivors


A recent study identified some of the key challenges in coordinated care for underinsured and uninsured cancer survivors who have initiated the surveillance stage of their journey.

Coordination between oncology and primary care teams to care for underinsured and uninsured cancer survivors remains a challenge, suggested a new study published in JAMA Network.1

Investigators interviewed 93 health care providers in a qualitative study and asked them to describe opportunities and challenges to coordinate care between oncology and primary care teams. The study defined survivors as patients with a stage I, II, or II diagnosis, who have completed cancer treatment (including chemotherapy, radiation, and/or surgery) and who have initiated the surveillance stage of their cancer care journey.

Key challenges included difficulties accessing primary care providers (PCPs), a lack of communication between oncology and primary care teams, role delineation from both sides of the care continuum, and a lack of clinician knowledge and preparedness.

“These findings suggest that, given interdependencies between levels within a single health system, awareness and engagement by system leadership may be needed to create the conditions necessary to actualize and sustain communication across teams to support comprehensive cancer survivorship care,” wrote Bijal A. Balasubramanian, MBBS, PhD, and colleagues, in the paper. “One immediate target is closed-loop communication, ensuring both vertical and horizontal communication pathways. Health information technology tools may also foster team effectiveness by better identifying high-risk patients, monitoring outcomes, and managing task interdependence during transitions in care.”

Difficulty accessing primary care was 1 of the most common problems reported by patients, particularly for those without a preexisting PCP. Although oncology nurses routinely referred patients with chronic conditions such as diabetes and hypertension to primary care, many patients faced wait times longer than 6 months before being seen.

Communication was another critical issue that concerned both oncology teams and PCPs. Investigators noted that oncology teams often expect the patient to communicate treatment symptoms to their PCP; however, because patient’s communication with PCPs are often less frequent and/or regular than their communication with their oncology team, and because cancer therapies can worsen preexisting chronic conditions, substantial consequences are a potential concern.

The lack of communication often translated into role delineation for cancer surveillance testing. For example, in the case of mammograms for survivors of breast cancers, both groups agreed that the oncology care team should manage surveillance for the first 5 years, however, they disagreed on who should manage surveillance for survivors of 10 years or more.

“Who is supposed to follow that cancer follow-up frequency? Is Oncology [going to] do it or primary care has to do it?” remarked one PCP in the study. “So, if they can put ‘We continue to follow’ [in the EMR], or if the patient is discharged from oncology and primary care has to follow up or whatever, then make that really more clear.”

“The ideal thing would be a survivorship program to see all survivors, at all stages. But [the Medical Oncology Clinic] doesn’t have the bandwidth to take all survivors now,” added an oncology clinician.

Some PCPs felt that it would be better for the oncology care team to maintain surveillance because it is common for patients to fall out of their primary care routine. One PCP even expressed that “Cancer is not like any other disease. We really have to be very careful. If you leave [cancer surveillance] with the PCP … [patients] might not show up ... I don’t want patients to fall through the cracks.”

Furthermore, a number of PCPs expressed that they felt uncomfortable managing cancer-related pain and prescribing medications to help manage long-term treatment-related adverse events (AEs). Many PCPs shared that they were unfamiliar with the AEs their patients were experiencing and the prescriptions commonly used to treat them.

“I have a patient with [brain metastases]…and he was started on 3 seizure medications, and he doesn’t have seizures but I guess they have a role in treating headaches. He’s on 3 medications that I am not familiar with. The last 3 [or] 4 months, the medication refill comes to me ... I am uncomfortable with these 3 medications. I don’t prescribe 3 seizure medications to treat a headache,” said a PCP.

“Care coordination for underinsured and uninsured cancer survivors with comorbidities will continue to be an important issue given changing US demographics, early detection, and advances in cancer therapies that have extended cancer survivorship,” concluded the study authors. “Without robust communication systems and care pathways between primary care and oncology, such patients are at risk of increasingly poor outcomes, exacerbated by the patchwork nature of the US health care system. Closed-loop communication, role clarification, leadership support, and health information technology improvements to comanage patients during care transitions may provide a start toward enhanced team-based care.”

One notable limitation was that investigators spoke to providers whose patients sought oncology and primary clinics that were owned and operated under the same governance. The authors acknowledged that patients who seek specialty care independent of their primary care might face more severe access barriers. Future research should seek to assess how to better facilitate communication across external oncology practice partners, in addition to clinics operating under the same governance as the PCP.


Balasubramanian BA, Higashi RT, Rodriguez SA, Sadeghi N, Santini NO, Lee SC. Thematic analysis of challenges of care coordination for underinsured and uninsured cancer survivors with chronic conditions. JAMA Netw Open. 2021;4(8):e2119080. doi:10.1001/jamanetworkopen.2021.19080

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