More than follow-up: Outcomes from an integrated cancer survivorship wellness clinic.

Abstract

e13796 Background: Studies have identified persistent gaps in survivorship care coordination, particularly fragmented communication with primary care providers (PCPs) during and after cancer treatment. As a result, many survivors disengage from primary care despite ongoing needs related to late effects, health promotion, and preventive screening, while PCPs report limited confidence in providing care to cancer survivors. To address these gaps, an advanced practice provider (APP)–led Survivorship Wellness Clinic (SWC) was established to deliver personalized, evidence-based survivorship care and care plans, proactively identify and refer patients for symptom management; support lifestyle modification; and strengthen coordination and collaboration with PCPs. Methods: We prospectively collected data on all patients seen in SWC from February 2023 to December 2025, including demographics, symptom burden, PCP access status, lifestyle recommendations, cancer screening and surveillance, and referrals to supportive oncology care or other specialty clinics. Descriptive statistics were used to summarize outcomes. Results: A total of 329 patients were seen at baseline; 45 completed the first follow-up visit (median time 366 days). The cohort was predominantly female (76%) and White (80%), with 55% identifying as Hispanic/Latino. The most common cancer types were breast (60%), gastrointestinal (13%), and genitourinary (10%). At baseline, 12% lacked a PCP, and 95% of these were subsequently referred to one. Most patients (85%) received at least one lifestyle modification recommendation (exercise: 82%, nutrition: 82%). Seventy-five percent reported at least one treatment-related side effect, most commonly fatigue (21%), peripheral neuropathy (14%), and arthralgias (12%). To address treatment-related side effects and unmet needs, 57% of patients received referrals to various supportive care services. The highest referrals were nutrition (31%), exercise (30%), and massage therapy (22%). Additionally, referrals to specialists were provided for 34%, with psychology (8%) and sexual health (7%) being the most common. Cancer screenings were ordered for most patients, with follow-up compliance rates ranging from 63% to 96%, depending on screening type. Among follow-up patients, 93% visited a PCP after SWC, and 45% discussed their survivorship care plan with their PCP. Conclusions: This large analysis, with follow-up data, underscores the need for survivorship clinics, particularly in lifestyle modification, care coordination, and PCP engagement. These descriptive findings highlight the feasibility and importance of implementing survivorship programs and suggest potential benefits in bridging gaps between oncology and primary care. Further research is needed to evaluate long-term outcomes and comparative effectiveness.