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



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.

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Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.


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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.


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

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Correspondence to Youngjee Choi.

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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.

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Choi, Y., Radhakrishnan, A., Mahabare, D. et al. The Johns Hopkins Primary Care for Cancer Survivor Clinic: lessons learned in our first 4 years. J Cancer Surviv 14, 19–25 (2020).

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  • Cancer survivors
  • Primary care
  • Continuity of patient care