As the number of cancer survivors continues to rise, enhancing their experience during both active treatment and follow-up care has emerged as a paramount priority in healthcare. Remarkably, recent estimates identify more than 18 million cancer survivors living in the United States alone—a testament to the tremendous advances in detection and treatment. However, despite these progressions, a significant challenge remains unresolved: improving communication and collaboration between oncology specialists and primary care providers (PCPs). This gap in coordination can inadvertently hinder patient outcomes, underscoring the urgent need for models that integrate these two critical facets of care.
In response to this pressing issue, the National Comprehensive Cancer Network (NCCN) convened a landmark policy summit titled “Primary Care and Oncology Collaboration to Improve Patient Outcomes” at the National Press Club in Washington, DC. This summit gathered a diverse panel of experts, including oncologists, primary care physicians, healthcare advocates, and policy leaders, to dissect the challenges and potential solutions surrounding cancer survivorship care. They highlighted that while payment models introduced over the past decade—such as the Oncology Care Model (OCM) and its successor, the Enhancing Oncology Model (EOM)—have driven improvements within oncology practices, neither directly addresses the deeply entrenched problem of fragmented communication with primary care. The OCM was hailed as “transformative,” yet it fell short of Medicare certification due to insufficient savings to offset increased service payments, marking both a milestone and a call to action.
One of the most poignant takeaways from the summit was the real-world impact of communication breakdowns on cancer survivors’ health journeys. Repeated diagnostic tests, missing electronic health record (EHR) entries, and disjointed discharge instructions often leave patients vulnerable to unnecessary emergency department visits or treatment delays. For example, Skyler Taylor, MD, a hematology/oncology fellow at Mayo Clinic, revealed that because many EHR systems do not interface seamlessly, patients often become the unintended messengers for their own test results—a precarious workaround that emphasizes the systemic gaps. In contrast, innovative programs like Fox Chase Cancer Center’s Care Connect have started bridging these gaps by granting PCPs direct, secure access to patients’ oncology records, easing the communication while reducing reliance on outdated methods like fax and phone calls.
The summit’s discussions also cast a spotlight on the growing segment of the population known as childhood cancer survivors, who confront unique and often overlooked late effects of treatment. Studies reveal that over half of childhood cancer survivors experience enduring health issues ranging from cardiac complications to cognitive impairments and infertility. Advocates like Veronika Panagiotuo, herself an eleven-year survivor, stressed that survivors need PCPs who truly understand the nuanced long-term effects of cancer therapy—not just the cancer itself. Moreover, she underscored the emotional necessity for validation and trust in doctor-patient relationships, sentiments echoed by many survivors who find themselves navigating contrasting medical advice throughout their lifelong care. This need for empathetic, well-informed primary care is becoming ever more urgent as the “silver tsunami” of aging survivors shifts survivorship from a niche concern to a routine feature of healthcare.
Additionally, experts outlined the complexities of managing comorbidities that often accompany cancer, especially in elderly or chronically ill patients. As Linda Overholser, MD, highlighted, cancer is rarely an isolated diagnosis; patients frequently grapple with diabetes, hypertension, or other chronic conditions whose management can be compromised during intensive cancer therapy. Without effective collaboration between oncologists and primary care physicians, vital prevention strategies may be missed, exacerbating health problems and inflating healthcare costs. The question of who acts as the “quarterback” for a patient’s comprehensive care emerged as a major theme—a common frustration among patients unsure of who ultimately coordinates their treatment across specialties. Incentivizing shared accountability and seamless transitions could empower PCPs to take a more active leadership role in survivorship care.
Perhaps no issue resonated more than the “handoff” process—the critical moments when responsibility shifts from oncology to primary care, or between different providers during active therapy. Poorly managed transitions can result in missed tests, delayed follow-ups, and patient frustration. For instance, Dorothy A. Rhoades, MD, MPH, noted that ordering the right scans before oncology visits sometimes falls through the cracks, causing patients to undertake long, inconvenient trips only to find their care incomplete. Small practices especially struggle with limited resources to manage these complexities, relying heavily on cancer centers that may themselves be stretched thin. As a remedy, enhanced patient navigation services and unified EHR systems topped the panelists’ wish lists, aiming to create more transparent and accessible care pathways.
The summit closed on a hopeful note, emphasizing that despite the complexities, ongoing dialogue between oncology and primary care is fundamental to advancing the cancer care continuum—from prevention and screening to lifelong survivorship and end-of-life care. Efforts to integrate payment models with a focus on cross-disciplinary collaboration hold promise for reducing waste and improving quality. As Crystal Denlinger, MD, NCCN President and a pioneer in survivorship guidelines, aptly put it, solving these issues cannot be accomplished in “one day,” but requires sustained commitment and innovation guided by evidence-based standards and, importantly, patient voices.
In summary, the rising tide of cancer survivors presents a unique challenge and opportunity for the healthcare system. Bridging the communication gap between oncologists and primary care providers is not just a logistical imperative—it is essential for enhancing patient outcomes, managing complex comorbidities, and ensuring a dignified and healthful survivorship experience. Programs like OCM and EOM have laid a critical foundation but must evolve to encompass integrated care models that recognize the vital role of PCPs in managing both the late effects of cancer and overall chronic health. With collaboration, technological innovation, and policy support, the vision of truly coordinated cancer care becomes an achievable horizon.
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