The Johns Hopkins Primary Care for Cancer Survivor Clinic: lessons learned in our first 4 years

  • Youngjee ChoiEmail author
  • Archana Radhakrishnan
  • Darshan Mahabare
  • Shalom Patole
  • Sydney M. Dy
  • Craig E. Pollack
  • Zackary D. Berger
  • Kimberly S. Peairs



We established the Primary Care for Cancer Survivor (PCCS) Clinic in 2015 to address transition and care delivery challenges unique to cancer survivors. We describe the clinical program, detail patients from the first 4 years of implementation, and discuss lessons learned during the process.


We abstracted relevant patient information from the electronic medical record, administered a needs assessment survey at initial visits, and collected relative value unit (RVU) data.


Between August 2015 and May 2019, we saw 230 PCCS patients with an increasing number of referrals yearly; nearly half were breast cancer survivors. At the initial visit, patients reported a median of 9 needs, with emotional needs most prevalent; over a third received at least one referral. PCCS patients generated higher billing codes and average RVUs compared with general patients.


In its first 4 years, the PCCS program has thrived as a unique model of cancer survivorship centered in primary care. PCCS patients reported numerous needs, emphasizing the critical need for a multi-disciplinary approach in this population. With increasing referrals, we have considered different risk stratification and staffing models for capacity and expansion. By generating more RVUs per visit compared with the general clinic, PCCS has demonstrated financial sustainability. Buy-in from our oncology colleagues, divisional support from general medicine, along with our collaboration of like-minded internists have allowed us to be a robust program.

Implications for Cancer Survivors

Models of survivorship care embedded in primary care can provide meaningful, patient-centered care for cancer survivors.


Cancer survivors Primary care Continuity of patient care 



We thank Candace Nigrin and Amanda Bertram for their respective clinical and research support. We are grateful to Jamison Kies for her assistance with additional data support. We would like to acknowledge the Merck Foundation and our philanthropic benefactors for their financial support of our research efforts.

Funding information

This work was financially supported by the Merck Foundation (grant number N022890).

Compliance with ethical standards

Conflict of interest

Dr. Kimberly Peairs has received salary support from the Merck Foundation grant. Dr. Craig Pollack owns stock in Gilead Pharmaceuticals. The other authors declare that they have no conflict of interest.

Supplementary material

11764_2019_816_MOESM1_ESM.pdf (310 kb)
ESM 1 (PDF 310 kb)


  1. 1.
    Hewitt M, Greenfield S, Stovall E. From cancer patient to cancer survivor: lost in translation. Washington, DC: National Academies Press.Google Scholar
  2. 2.
    Snyder CF, Frick KD, Kantsiper ME, Peairs KS, Herbert RJ, Blackford AL, et al. Prevention, screening, and surveillance care for breast cancer survivors compared with controls: changes from 1998 to 2002. J Clin Oncol : Off J Am Soc Clin Oncol. 2009;27(7):1054–61.CrossRefGoogle Scholar
  3. 3.
    Earle CC, Neville BA. Under use of necessary care among cancer survivors. Cancer. 2004;101(8):1712–9.CrossRefGoogle Scholar
  4. 4.
    Nekhlyudov L, O’Malley DM, Hudson SV. Integrating primary care providers in the care of cancer survivors: gaps in evidence and future opportunities. Lancet Oncol. 2017;18(1):e30–8.CrossRefGoogle Scholar
  5. 5.
    Rubinstein EB, Miller WL, Hudson SV, Howard J, O’Malley D, Tsui J, et al. Cancer survivorship care in advanced primary care practices: a qualitative study of challenges and opportunities. JAMA Intern Med. 2017;177(12):1726–32.CrossRefGoogle Scholar
  6. 6.
    O’Malley D, Hudson SV, Nekhlyudov L, Howard J, Rubinstein E, Lee HS, et al. Learning the landscape: implementation challenges of primary care innovators around cancer survivorship care. J Cancer Survivorship : Res Pract. 2017;11(1):13–23.CrossRefGoogle Scholar
  7. 7.
    Halpern MT, Viswanathan M, Evans TS, Birken SA, Basch E, Mayer DK. Models of cancer survivorship care: overview and summary of current evidence. J Oncol Pract. 2015;11(1):e19–27.CrossRefGoogle Scholar
  8. 8.
    Ness S, Kokal J, Fee-Schroeder K, Novotny P, Satele D, Barton D. Concerns across the survivorship trajectory: results from a survey of cancer survivors. Oncol Nurs Forum. 2013;40(1):35–42.CrossRefGoogle Scholar
  9. 9.
    Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81.CrossRefGoogle Scholar
  10. 10.
    Tan SY, Turner J, Kerin-Ayres K, Butler S, Deguchi C, Khatri S, Mo C, Warby A, Cunningham I, Malalasekera A et al: Health concerns of cancer survivors after primary anti-cancer treatment. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer 2019.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Johns Hopkins School of MedicineLuthervilleUSA
  2. 2.University of Michigan School of MedicineAnn ArborUSA
  3. 3.Johns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  4. 4.Johns Hopkins Berman Institute of BioethicsBaltimoreUSA
  5. 5.Johns Hopkins Sidney Kimmel Comprehensive Cancer CenterBaltimoreUSA

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