A Year in Review: Components of a Primary Care Cancer Survivorship Clinic

Context: The Institute of Medicine recognized that cancer survivorship care was fragmented and uncoordinated resulting in suboptimal health outcomes with significant costs to the health system. Improvements to coordination of care between oncology and primary care were emphasized yet the practical execution in clinical practice remains inconsistent. To address these needs we developed an integrated primary care cancer survivorship (PCCS) clinic within an academic cancer center.

Objective: To understand the characteristics of patients accessing PCCS clinic, and to evaluate primary prevention including immunization, health promotion, and cancer screening.

Study Design and Analysis: Retrospective chart review, with descriptive analysis using data from February 1, 2021 – January 31, 2022.

Setting or Dataset: A single institution PCCS clinic electronic medical record data.

Population Studied: Patients with a history of non-melanoma cancer accessing a PCCS clinic, N = 88.

Intervention/Instrument: Chart review.

Outcome Measures: Burden of comorbidities; number of cancers and type; screening for second primary cancers; prevention and health promotion.

Results: 88 cancer survivors accessed the PCCS clinic over a one-year period, with 40% in active treatment at their first visit, the remaining a remote history. The most common cancer diagnosis included: breast (29%), lung (9%) and head and neck (9%). 19% of survivors had a history of 2 or more cancers. Most patients were white (76%), female (66%), and an average age of 57. Nearly all had private insurance (58%) or Medicare (40%). Common comorbidities included hypertension (47%), diabetes (18%), coronary artery disease (11%), and asthma (9%). 24% were former smokers, 10% current smokers, and 39% currently use alcohol. The majority had received at least 2 COVID vaccinations, 18% unvaccinated. Most eligible for pneumonia vaccine did not receive it (9%). Only 47% of patients eligible for mammograms, and 41% for colon cancer screening had these exams documented as completed.

Conclusions: Nearly half of our clinic cancer survivors were in active treatment and had at least one co-morbidity; some had more than one cancer. As cancer survivors live longer with a potential high burden of comorbidities, the role of PCPs to optimize the control of chronic conditions, and support reduction of modifiable risks in patients with cancer is crucial, with a pressing need to develop successful models for care delivery.