Oncologist-Led, Survivorship-Focused Primary Care: Feasibility and Outcomes of a Novel Integrated Care Model

Purpose: The Primary Care for Cancer Survivorship clinic at Stanford Medicine is a novel program addressing primary care and survivorship-specific needs in a single setting. Care is delivered by a board-certified physician in internal medicine, oncology, and hematology. This study describes patient characteristics and clinical issues managed during its first two years. Methods: Demographic and clinical data for new patients seen from November 1, 2021 to November 1, 2023 were extracted via chart review and analyzed using descriptive statistics. Subgroup analyses focused on adolescents and young adults (AYAs), geriatric patients, patients with hematologic malignancies, and previvors with genetic risk. Results: A total of 226 patients established care, with two-thirds returning for follow-up. The most common cancers were breast (41.4%), leukemia (13.3%), and lymphoma (11.5%). Three-quarters had no active disease. Hereditary cancer syndromes were present in 16.8%. Long-term and late effects were addressed in 99.1%, predominantly cardiovascular risk (92.0%), mental health (75.7%), and bone health (59.7%). Primary care issues were addressed in 96.0%. Secondary cancer screening was performed in 91.2%, with four secondary cancers diagnosed. AYAs (22.4%) had significantly more fertility discussions, while geriatric patients (28.3%) had significantly more telehealth visits. Among patients with hematologic malignancies, 42.4% had undergone a bone marrow transplant (BMT). Conclusions: This study demonstrates the demand for and feasibility of an oncologist-led, survivorship-focused primary care clinic in addressing a range of medical, preventive, and psychosocial issues. Implications for Cancer Survivors: Survivorship-focused primary care offers a comprehensive, longitudinal care model for survivors with diverse and evolving needs.