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Learning the landscape: implementation challenges of primary care innovators around cancer survivorship care



This study describes the experiences of early implementers of primary care-focused cancer survivorship delivery models.


Snowball sampling was used to identify innovators. Twelve participants (five cancer survivorship primary care innovators and seven content experts) attended a working conference focused on cancer survivorship population strategies and primary care transformation. Data included meeting discussion transcripts/field notes, transcribed in-depth innovator interviews, and innovators’ summaries of care models. We used a multistep immersion/crystallization analytic approach, guided by a primary care organizational change model.


Innovative practice models included: (1) a consultative model in a primary care setting; (2) a primary care physician (PCP)-led, blended consultative/panel-based model in an oncology setting; (3) an oncology nurse navigator in a primary care practice; and (4) two subspecialty models where PCPs in a general medical practice dedicated part of their patient panel to cancer survivors. Implementation challenges included (1) lack of key stakeholder buy-in; (2) practice resources allocated to competing (non-survivorship) change efforts; and (3) competition with higher priority initiatives incentivized by payers.


Cancer survivorship delivery models are potentially feasible in primary care; however, significant barriers to widespread implementation exist. Implementation efforts would benefit from increasing the awareness and potential value-add of primary care-focused strategies to address survivors’ needs.

Implications for Cancer Survivors

Current models of primary care-based cancer survivorship care may not be sustainable. Innovative strategies to provide quality care to this growing population of survivors need to be developed and integrated into primary care settings.

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  1. Parry C et al. Cancer survivors: a booming population. Cancer Epidemiol Biomarkers Prev. 2011;20(10):1996–2005.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Siegel, R., et al. Cancer treatment and survivorship statistics, 2012. CA Cancer J Clin. 2012.

  3. de Moor JS et al. Cancer survivors in the United States: prevalence across the survivorship trajectory and implications for care. Cancer Epidemiol Biomark Prev. 2013;22(4):561–70.

    Article  Google Scholar 

  4. Hewitt ME, Ganz PA. From cancer patient to cancer survivor: lost in transition: an American Society of Clinical Oncology and Institute of Medicine Symposium. Washington: National Academies Press; 2006.

    Google Scholar 

  5. Grunfeld E et al. Routine follow up of breast cancer in primary care: randomised trial. BMJ. 1996;313(7058):665–9.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  6. Grunfeld E. Looking beyond survival: how are we looking at survivorship? J Clin Oncol Off J Am Soc Clin Oncol. 2006;24(32):5166–9.

    Article  Google Scholar 

  7. Wattchow DA et al. General practice vs surgical-based follow-up for patients with colon cancer: randomised controlled trial. Br J Cancer. 2006;94(8):1116–21.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  8. Grunfeld E et al. Randomized trial of long-term follow-up for early-stage breast cancer: a comparison of family physician versus specialist care. J Clin Oncol. 2006;24(6):848–55.

    Article  PubMed  Google Scholar 

  9. Oeffinger KC, McCabe MS. Models for delivering survivorship care. J Clin Oncol Off J Am Soc Clin Oncol. 2006;24(32):5117–24.

    Article  Google Scholar 

  10. Miller SM, American Psychological Association. Handbook of cancer control and behavioral science: a resource for researchers, practitioners, and policy makers. 1st ed. Washington: American Psychological Association; 2009.

    Book  Google Scholar 

  11. Earle CC. Failing to plan is planning to fail: improving the quality of care with survivorship care plans. J Clini Oncol Off J Am Soc Clin Oncol. 2006;24(32):5112–6.

    Article  Google Scholar 

  12. Grunfeld E, Earle CC. The interface between primary and oncology specialty care: treatment through survivorship. J Natl Cancer Inst Monogr. 2010;2010(40):25–30.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Nekhlyudov L. Integrating primary care in cancer survivorship programs: models of care for a growing patient population. Oncologist. 2014;19(6):579–82.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Tinetti ME, Fried TR, Boyd CM. Designing health care for the most common chronic condition—multimorbidity. JAMA. 2012;307(23):2493–4.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  15. Fortin M et al. Multimorbidity is common to family practice: is it commonly researched? Can Fam Physician. 2005;51(2):244–5.

    PubMed  Google Scholar 

  16. Ritchie CS, Kvale E, Fisch MJ. Multimorbidity: an issue of growing importance for oncologists. J Oncol Pract. 2011;7(6):371–4.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Halpern, M.T., et al. Models of cancer survivorship care: overview and summary of current evidence. J Oncol Pract. 2014.

  18. Oeffinger KC, McCabe MS. Models for delivering survivorship care. J Clin Oncol. 2006;24(32):5117–24.

    Article  PubMed  Google Scholar 

  19. Ogle KS et al. Cancer and comorbidity. Cancer. 2000;88(3):653–63.

    CAS  Article  PubMed  Google Scholar 

  20. Del Giudice ME et al. Primary care physicians’ views of routine follow-up care of cancer survivors. J Clin Oncol. 2009;27(20):3338–45.

    Article  PubMed  Google Scholar 

  21. Cheung W et al. Physician preferences and attitudes regarding different models of cancer survivorship care: a comparison of primary care providers and oncologists. J Cancer Surviv. 2013;7(3):343–54.

    Article  PubMed  Google Scholar 

  22. Klabunde CN et al. Physician roles in the cancer-related follow-up care of cancer survivors. Fam Med. 2013;45(7):463–74.

    PubMed  PubMed Central  Google Scholar 

  23. Tomoaia-Cotisel A et al. Context matters: the experience of 14 research teams in systematically reporting contextual factors important for practice change. Ann Fam Med. 2013;11 Suppl 1:S115–23.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Miller WL et al. Primary care practice development: a relationship-centered approach. Ann Fam Med. 2010;8 Suppl 1:S68–79.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Arrow K et al. Toward a 21st-century health care system: recommendations for health care reform. Ann Intern Med. 2009;150(7):493.

    Article  PubMed  Google Scholar 

  26. Berenson R et al. A house is not a home: keeping patients at the center of practice redesign. Health Aff (Millwood). 2008;27(5):1219–30.

    Article  Google Scholar 

  27. Davis K, Schoenbaum SC, Audet AM. A 2020 vision of patient-centered primary care. J Gen Intern Med. 2005;20(10):953–7.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Green L et al. Task Force 1. Report of the task force on patient experience, core values, reintegration, and the new model of family medicine. Ann Fam Med. 2004;2(Supplement 1):S33–50.

    PubMed Central  Google Scholar 

  29. Scholle SH et al. Patient-centered medical homes in the United States. J Ambul Care Manag. 2011;34(1):20–32.

    Article  Google Scholar 

  30. Sia C et al. History of the medical home concept. Pediatrics. 2004;113(5 Suppl):1473–8.

    PubMed  Google Scholar 

  31. The Robert Graham Center. The patient-centered medical home: History, seven core features, evidence and transformational change. 2007; Available from:

  32. Chesluk BJ, Holmboe ES. How teams work—or don’t—in primary care: a field study on internal medicine practices. Health Aff (Millwood). 2010;29(5):874–9.

    Article  Google Scholar 

  33. Crabtree BF et al. Closing the physician-staff divide: a step toward creating the medical home. Fam Pract Manag. 2008;15(4):20–4.

    PubMed  Google Scholar 

  34. Bitton A. Who is on the home team? Redefining the relationship between primary and specialty care in the patient-centered medical home. Med Care. 2011;49(1):1–3.

    Article  PubMed  Google Scholar 

  35. Fisher ES. Building a medical neighborhood for the medical home. N Engl J Med. 2008;359(12):1202–5.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  36. O’Malley, A.S., et al. Are electronic medical records helpful for care coordination? Experiences of physician practices. J Gen Intern Med. 2009.

  37. Pham HH. Good neighbors: how will the patient-centered medical home relate to the rest of the health-care delivery system? J Gen Intern Med. 2010;25(6):630–4.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Pham HH et al. Primary care physicians’ links to other physicians through Medicare patients: the scope of care coordination. Ann Intern Med. 2009;150(4):236–42.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Rittenhouse, D.R., S.M. Shortell, and E.S. Fisher. Primary care and accountable care—two essential elements of delivery-system reform. N Engl J Med, 2009.

  40. Crosson JC, Bazemore AW, Phillips Jr RL. EHR implementation without meaningful use can lead to worse outcomes. Am Fam Physician. 2011;84(11):1220.

    PubMed  Google Scholar 

  41. Crosson JC et al. Meaningful use of electronic prescribing in 5 exemplar primary care practices. Ann Fam Med. 2011;9(5):392–7.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Crosson JC et al. Early adopters of electronic prescribing struggle to make meaningful use of formulary checks and medication history documentation. J Am Board Fam Med. 2012;25(1):24–32.

    Article  PubMed  Google Scholar 

  43. Nutting PA et al. Transforming physician practices to patient-centered medical homes: lessons from the national demonstration project. Health Aff. 2011;30(3):439–45.

    Article  Google Scholar 

  44. Crabtree BF et al. Summary of the National Demonstration Project and recommendations for the patient-centered medical home. Ann Fam Med. 2010;8 Suppl 1:S80–90.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Patton, M.Q. Qualitative research. 2005: Wiley Online Library.

  46. Crabtree, B.F. and W.L. Miller. Doing qualitative research. 1999: Sage Publications.

  47. Miles, M.B. and A.M. Huberman. Qualitative data analysis: an expanded sourcebook. 2nd ed. Thousand Oaks: Sage Publications. xiv, 338;1994.

  48. Cohen D et al. A practice change model for quality improvement in primary care practice. J Healthc Manag. 2004;49(3):155–68. discussion 169-70.

    PubMed  Google Scholar 

  49. Blanch-Hartigan D et al. Provision and discussion of survivorship care plans among cancer survivors: results of a nationally representative survey of oncologists and primary care physicians. J Clin Oncol. 2014;32(15):1578–85.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Boekhout A et al. A survivorship care plan for breast cancer survivors: extended results of a randomized clinical trial. J Cancer Surviv. 2015;9(4):683–91.

    Article  PubMed  Google Scholar 

  51. Stricker CT, Jacobs LA, Palmer SC. Survivorship care plans: an argument for evidence over common sense. J Clin Oncol. 2012;30(12):1392–3.

    Article  PubMed  Google Scholar 

  52. Smith TJ, Snyder C. Is it time for (survivorship care) plan B? J Clin Oncol. 2011;29(36):4740–2.

    Article  PubMed  Google Scholar 

  53. Campbell MK et al. Adult cancer survivorship care: experiences from the LIVESTRONG centers of excellence network. J Cancer Surviv. 2011;5(3):271–82.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Grant M et al. Facilitating survivorship program development for health care providers and administrators. J Cancer Surviv. 2014;9(2):180–7.

    Article  PubMed  PubMed Central  Google Scholar 

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We thank steering committee members: Carlos Jaen, MD, PhD; Kelly Kelleher, MD; Kurt Stange, MD, PhD; Paul Nutting, MD, MSPH; and William L. Miller, MD, MA.

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Correspondence to Denalee O’Malley.

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Data collection for this article was supported by a conference grant from AHRQ (R13HS021287) awarded to Dr. Crabtree. Drs. Crabtree and Hudson were partially supported by National Cancer Institute grants R01 CA176545 and R01 CA176838. Ms. O’Malley was supported through a Doctoral Training Grant in Oncology Social Work (DSW 13-279-01) from the American Cancer Society. This work also benefitted from support from Cancer Center Support Grant P30 CA072720 to the Rutgers Cancer Institute of New Jersey.

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The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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O’Malley, D., Hudson, S.V., Nekhlyudov, L. et al. Learning the landscape: implementation challenges of primary care innovators around cancer survivorship care. J Cancer Surviv 11, 13–23 (2017).

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  • Cancer survivorship models
  • Primary care
  • Implementation research
  • Qualitative
  • Integration of care