Baylor College of Medicine

OPTIMISE: Oncology-Primary Care Partnership to Improve Comprehensive Survivorship Care (H-49731)



Introduction: Comorbidities pose significant challenges to the delivery of quality cancer treatment. Medically underserved patients have the highest burden of comorbidities and are at increased risk for poor outcomes during and after cancer treatment. As these patients may lack the knowledge and resources to manage their comorbidities during cancer treatment, their health outcomes and transition to survivorship following curative cancer treatment might be facilitated by enhancing communication and collaboration between their oncologists and primary care providers (PCPs) from point of cancer diagnosis, onward. 

Purpose: To improve coordination of care between oncologists and primary care providers who are caring for cancer patients with comorbidities; and, in the process, patient healthcare outcomes.

Design: Patients who agree to participate will be asked to complete a baseline survey, and then be randomized to either receive OPTIMISE or Usual Medical Care. 
Patients receiving Usual Medical Care will receive their cancer treatment, as directed by their oncologist, a survivorship care plan (SCP) at the end of active treatment, and surveillance visits with their oncologist based on national guidelines. 

Patients in OPTIMISE will:

  • Receive navigation to support ongoing monitoring and management of comorbidities during and after cancer-directed treatment
  • Receive coordinated care between their oncologist and PCP during and after cancer-directed treatment facilitated by a structured communication and referral process
  • Receive a survivorship care plan (SCP) after completing cancer-directed treatment. 
  • Receive a risk-stratified shared care model of post-treatment surveillance

Additionally, both patients receiving OPTIMISE and Usual Medical Care will complete six follow-up surveys. Two will be administered during cancer treatment, one will be administered at SCP delivery, and three will be administered in the first year post-treatment. 

Patients will receive a $20 Clincard per survey for a total of up to $140.


Patients with breast, colon or hematological malignancies who are being treated with curative intent and have chronic or serious health conditions that require ongoing monitoring and management during and after cancer treatment are eligible to participate. 


This study is funded by the National Cancer Institute R01 CA2249474 and registered on NCT05323409.

IRB: H-49731




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