As cancer survival rates continue to rise, so does the need for effective long-term care. More than 18 million Americans are living after a cancer diagnosis—a number expected to reach 26 million by 2040. Yet for many survivors, the journey doesn’t end when treatment stops. Ongoing risks such as heart disease, metabolic complications, and secondary cancers require coordinated care that bridges oncology and primary care.
Despite their central role in long-term follow-up, many primary care providers (PCPs) report feeling underprepared to manage cancer survivorship. Surveys suggest that PCPs are often “somewhat uncomfortable” with this responsibility, citing limited familiarity with survivorship guidelines and uncertainty about which screenings or lifestyle recommendations to prioritize. Oncologists, in turn, may be unsure when and how to re-engage PCPs, further fragmenting care.
To address these challenges, national standards have emphasized the use of treatment summaries and survivorship care plans (TS/SCPs)—documents outlining each survivor’s cancer history, treatment exposures, potential long-term effects, and follow-up recommendations. These plans are designed to improve communication between oncologists, PCPs, and patients. However, their implementation has been slow. Many cancer programs lack the time, personnel, or informatics support to routinely generate and share these plans, and research suggests that simply providing a printed TS/SCP—without personalization or later follow-up—has little impact on adherence or patient outcomes.
In a new study at the Journal of Cancer Survivorship, researchers from Fred Hutch and the University of Washington sought to understand the needs and perspectives of PCPs themselves: What barriers do they face in caring for cancer survivors? How do they currently use TS/SCPs? And what tools—especially within the electronic health record—could make the transition from oncology to primary care smoother?
Led by Dr. Jean Yi, a staff scientist in Dr. Scott Baker’s group in the Clinical Research Division at Fred Hutch, the team interviewed and analyzed data from 18 PCPs. Their study population was from a mix of backgrounds and practiced in both rural and urban areas.
“Primary care providers are an important part of the health care team for cancer survivors,” share Yi and Dr. Allison Cole, a family physician and Professor at the University of Washington School of Medicine. “However, their needs have not consistently been incorporated into our understanding of survivorship care. The goal of our study was to interview a broad range of primary care physicians to get their perspectives on what would be helpful for them in managing the care of cancer survivors.”
Several common themes emerged from these interviews. Better communication between a patient’s PCP and their oncologist was identified as a key need during the transition period following active treatment. While TS/SCPs can be helpful, many PCPs found them overly complex and suggested streamlining them to focus on core details—such as surveillance schedules, treatment timelines, and records of long-term or late effects.
“We want to develop interventions to assist primary care providers in delivering high quality care for cancer survivors,” said the study’s authors. “In this study, we identified several potential intervention points that we are curious to develop and test. Primary care providers reported that they would like the electronic health record to be configured in a way to better help them manage the surveillance needs of cancer survivors and also valued additional education opportunities. Our research group that includes Drs. Baker, Chow [Eric Chow, Clinical Research Division] and Mendoza [Jason Mendoza, Public Health Sciences Division] are planning a research project to test various interventions in primary care settings to see what would be the most beneficial for primary care providers.”
By capturing the perspectives of PCPs, Yi and colleagues highlight an often-overlooked piece of survivorship care—ensuring that those responsible for long-term follow-up have the tools and confidence they need. As the population of cancer survivors continues to grow, improving the communication, clarity, and digital infrastructure that support this handoff will be key to ensuring that every survivor’s ongoing care is as comprehensive as their treatment.
Fred Hutch/University of Washington/Seattle Children’s Cancer Consortium Members Drs. Eric Chow, Scott Baker, Jason Mendoza and Allison Cole contributed to this research.
The spotlighted research was funded by National Center for Advancing Translational Sciences of the National Institutes of Health and by the Cancer Consortium Survivorship Grant.
Yi JC, Walsh CA, Chow EJ, Baker S, Mendoza JA, Cole A. 2025. Primary care providers and their needs caring for cancer survivors: a qualitative study. Journal of Cancer Survivorship. DOI: 10.1007/s11764-025-01852-y.
Science Spotlight writer Jenny Waters is a postdoctoral research fellow in the Hsieh lab at Fred Hutch. She studies how mRNA translation coordinates bladder cancer transformation and metastasis by post-transcriptionally regulating expression of oncogenic proteins. Outside of the lab, Jenny enjoys spending time with her dogs, convincing her husband to join her on trail runs, and pretending every steep hill is just a "gentle incline."
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