Cancer is a complex and daunting disease that renders physical, emotional, and financial hardship to patients impacting more than 17 million cancer survivors in the US today with a projected 22 million by 2030.¹ Proper communication and care coordination between the patient, their primary care physician, and oncologist is critical to achieving the best possible outcome. Poor communication and gaps in coordination can lead to catastrophic results and dramatically increased costs.

Cancer treatment is a significant driver of rising health care costs in the US² exceeding $200 billion annually.² Evident in this escalating economic burden are two primary problems where a collective untapped opportunity lies.

First, with the substantial increase in cure rates for many cancers and the extended life expectancy for patients with a chronic cancer, the risk of dying from a cardiovascular event as a result of their cancer treatment exceeds the risk of dying from their cancer.³ Why do these unnecessary and preventable deaths occur? They occur as patients are inadequately managed due to lack of communication between oncologists and primary care physician (PCP)4-6 and lack of PCP involvement during active cancer treatment.7

There is a compelling imperative for care delivery strategies and facilitative tools to bridge care gaps by enhancing communication and explicitly incorporating the PCP, and other specialties as needed, as active members of the cancer care team to improve clinician knowledge and preparedness to better monitor and care for patients with cancer.

Health systems have addressed this problem, in part, with nurse navigators who coordinate care among the patient, physicians, and extended care team. However, this solution presents a second problem. The nurse navigator tools available today are operational in nature (i.e., helping patients set appointments, answer questions, provide access, etc.). Although valuable, they lack in their ability to monitor, alert and educate on the special care needs of patients on active cancer therapy. This impedes vital patient-PCP-oncologist communications and effective care coordination across siloed healthcare environments.

These cumulative open loops of communication and gaps in care are detrimental to patient outcomes and incur higher costs resulting from higher use of services. This reflects poor health system performance and as a result drives provider profits down while patients and payers are left to cover escalating costs.


  1. American Cancer Society, Population of US Cancer Survivors Grows to Nearly 17 Million, June 11, 2019; NIH NCI Cancer Statistics
  2. Panchal R, Brendle M, Ilham S, Kharat A, Schmutz HW, Huggar D, McBride A, Copher R, Au T, Willis C, and Brixner D. The implementation of value-based frameworks, clinical care pathways, and alternative payment models for cancer care in the United States. J Manag Care Spec Pharm. 2023 Jun;29(7):1-10. DOI: 10.18553/jmcp.2023.22352
  3. Oeffinger, K. (2022). Transforming Cancer Care: Bringing PCPs “Back” into Cancer Care through Onco-Primary Care. Duke Institute for Health Innovation
  4. Calip GS, Elmore JG, Boudreau DM. Characteristics associated with nonadherence to medications for hypertension, diabetes, and dyslipidemia among breast cancer survivors. Breast Cancer Res Treat. 2017;161(1):161-172.
  5. Jiang L, Lofters A, Moineddin R, et al. Primary care physician use across the breast cancer care continuum: CanIMPACT study using Canadian administrative data. Can Fam Physician. 2016;62(10):e589-e598.
  6. Worndl E, Fung K, Fischer HD, Austin PC, Krzyzanowska MK, Lipscombe LL. Preventable Diabetic Complications After a Cancer Diagnosis in Patients With Diabetes: A Population-Based Cohort Study. JNCI Cancer Spectr. 2018;2(1):pky008.
  7. Stewart, P. (2022, June). Collaboration Among Oncologists and Primary Care Physicians Is Key to Closing the “Black Hole” in Cancer Survivorship Care. Oncology Practice Management.