PROJECT SUMMARY The US has over 18 million cancer survivors (persons diagnosed with cancer no matter where they are in the course of their disease), estimated to increase to 22 million by 2030. The majority of formalized cancer survivorship care is organized and delivered by oncology, often through academic and private cancer centers. Because 70% of cancer survivors also have other chronic conditions and receive care from multiple clinical teams, suboptimal coordination of that care poses a significant barrier to optimal health outcomes. The growing number of survivors and anticipated shortage of oncology subspecialists pose significant additional challenges to delivering high quality survivorship care. Primary care is uniquely suited to deliver whole person and coordinated care for cancer survivors because, at its core, it prioritizes, personalizes, and integrates health care for all conditions. This view is endorsed by the National Academy of Medicine and National Comprehensive Cancer Network (NCCN) guidelines recommend that cancer survivors stay connected with their primary care clinicians (PCCs). Despite this growing recognition of the importance of primary care, primary care teams experience key challenges in delivering high-quality survivorship care especially for under- and uninsured cancer survivors who experience disproportionately worse health outcomes and rely on community health centers (CHCs) for consistent health care. Leveraging our team has a 10-year program of research in Texas CHCs, we propose a pragmatic trial testing implementation and effectiveness of a primary care-based survivorship care delivery intervention among eight Texas CHC sites. Specifically, we propose to: (1) Implement a system-level cancer survivorship care delivery intervention in partnership with CHC clinicians, patients, and community representatives. (2) Test effectiveness of the intervention to improve patient and clinician outcomes using a stepped-wedge cluster-randomized trial design. (3) Evaluate implementation of the intervention using an iterative, concurrent mixed-methods approach guided by the Practice Change Model. Our overall study is guided by the Practical, Robust, Implementation, & Sustainability Model (PRISM) to maximize implementation and sustainment within each CHC’s local context. Our study recognizes the reality that care of underserved cancer survivors is increasingly occurring in primary care CHCs. Together with our CHC partners, we will generate the evidence-base needed for a generalist primary care-based care delivery model with the goal of disseminating and scaling to optimize cancer survivorship care equitably.

PROJECT NARRATIVE Primary care clinicians are rarely part of the multi-disciplinary survivorship care delivered by oncology teams, despite National Comprehensive Cancer Network guidelines and National Academy of Medicine reports recommending that cancer survivors stay connected with their primary care clinicians. Leveraging our team’s program of research in primary care and cancer survivorship care delivery, we will conduct a pragmatic trial testing implementation and effectiveness of a survivorship care delivery intervention among eight Community Health Center sites across Texas. Guided by theory-based conceptual models to maximize the likelihood of successful implementation and sustainment within each local context, our evaluation will generate rich and actionable lessons to scale this generalist primary care-based care delivery model to improve cancer survivorship care equitably.