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Interprofessional Team-Based Oncology Care: Engaging Primary Care Providers in collaborative oncology care delivery from diagnosis through survivorship

Providing high quality oncology care from diagnosis through survivorship in rural and frontier communities presents unique challenges and opportunities. The use of an interprofessional team-based approach to oncology care with oncologist and primary care providers (PCP) collaboratively managing patients has the potential to improve health outcomes and patient experience.1 Rural and Frontier residents with cancer have worse outcomes than their urban counterparts. This is due to geographic barriers, lower rates of health insurance, and socioeconomic disparities. Further, those living in the most remote areas appear to be forgoing any treatment at rates higher than those living closer to regional cancer centers. In Montana, as in much of the intermountain west, the geographic barrier to care is heightened by the scarcity of oncologists, as well as their clustering in larger regional centers: Nearly 90% of oncologists in Montana are based in just 6 of the 56 counties in the state.

Approximately 90% of direct cancer care in Montana is provided in regional cancer centers. Individuals undergoing treatment are returning to their home community between treatments, often greater than 60 miles from the regional center. This results in the need for the side effects of treatment, follow-up, and survivorship care to be managed, at least in part, by their primary care provider near the patient’s home. Advantages of a team-based approach to care (Figure 1) for patients undergoing oncological treatment include reduced adverse events, decreased care fragmentation, and improved experience measures for patients.

During ongoing treatment most side effects become evident in the days following administration of anti-cancer medications.  For patients living in rural areas, this occurs after they have returned to their home community. This often results in patients with side effects of treatment presenting to their primary care provider for acute management. In addition, patients often have pre-existing medical conditions, some of which may be exacerbated by cancer treatments that the primary care provider will need to take into consideration. However, there are few reported care models regarding the integration of PCPs into the ongoing care of cancer patients actively receiving therapy, although some large academic centers are developing such programs. Not surprisingly, surveys of PCPs indicate the need for education regarding the physical and psychosocial side effects of cancer treatments.

Follow-up and survivorship care is a time where the need for a team-based approach to care is vital as patients transition from active treatment to surveillance and any ongoing care needs. Survivorship is viewed to begin at diagnosis and extend through the lifetime of the patient, however, there are very specific survivorship care needs that begin upon completion of anti-cancer therapy. The goal of survivorship care is to address the physical, psychological, and social impacts of cancer treatment. Models for providing survivorship care have been developed since the Institute of Medicine’s initial report on survivorship in 2006. In large, urban, resource-rich health care settings specific cancer survivorship clinics have been created to address the needs of patients upon completion of therapy. However, these models are not transferrable to small rural health care settings that lack the resources to develop and staff such a clinic. Thus, delivery of survivorship care falls to rural health care providers, as well as critical access hospitals, who may not be prepared to identify and address late and long-term effects of treatment. A survey of PCPs in Montana demonstrated only 1/3 felt fully comfortable with provision of survivorship care, a result that is consistent with national survey data. Thus, there is a need for education of PCPs regarding survivorship.

The development of a team-based oncology care model that includes PCPs in rural areas in both supportive care and survivorship care for cancer patients requires a well-thought-out strategy to improve integration of PCPs into the care of their patients with cancer. Further underlying this need, surveys indicate that as many as 95% of PCPs would prefer a more active role in the care of their patients during all phases a cancer journey. Current models of cancer care are inadequate as oncology clinics focus on navigating the increasing complexity of treating cancer, and the patient’s primary care provider is not consistently incorporated as part of the care team resulting in potential care gaps and poor patient experience.  As noted above, some academic centers are beginning work on incorporation of PCPs into the care of their patients with cancer and publications have championed the need for team-based oncology care. Team-based oncology care incorporates oncologists, PCPs, social workers, nurse navigation, and community support services into the overall care for a patient diagnosed with cancer. However, implementation of team-based practices into the care for rural cancer patients is particularly challenging.

In addition to PCPs, a team-based oncology model needs to include community resources. Bringing these supportive organizations into the care team facilitates uptake of the vital services that they provide. The Montana Cancer Coalition (MTCC), a division of the state Department of Public Health and Human Services, strives to ensure better quality of life and enhance the odds of survivorship through prevention, early detection, and state-of-the-art cancer care.  The MTCC has focused on improving survivorship care in Montana for several years. Most recently the MTCC launched a pilot project utilizing Project ECHO for survivorship education.  Lessons learned from this pilot project have informed a new initiative beginning in 2024. There are 3 goals for this initiative, 1) ENGAGEMENT of the care teams, including both oncology providers and PCPs to emphasize the importance of team-based care for cancer patients, 2) Delivery of an EDUCATIONAL component and 3) Development of a RESOURCE, to provide easily accessible supplemental educational information to providers regarding cancer survivorship. An overriding goal of this effort is to facilitate communication among care providers regarding the benefits of team-based oncology care and to encourage development of team-based care. Current strategies to meet these goals include a presentation scheduled at the annual meeting of the Montana chapter of the American College of Physicians in September 2024 as well as plans to provide this presentation at CME activities in healthcare facilities throughout the state.

While the rationale and the models for team-based care are being developed in academic centers, the greatest need for their application is in smaller communities that receive care from multiple health systems, where efficient utilization of the more limited resources is essential. The need for effective and efficient care delivery will only increase as cancer case numbers increase with the anticipated aging of the population and with the continued improvement in cancer therapies resulting in an increase in the number of cancer survivors. In addition, the national focus on increasing access to cancer care will increase the role of primary care providers as more cancer care is administered in rural areas in collaboration with the local health care system. New models for increasing access to oncology care, including throughout survivorship, in rural areas are already in place in Montana on a small scale including the utilization of telemedicine and the delivery of online psychosocial supportive programs to improve quality of life. With the continued emphasis on the role of access to high quality oncology care in improving outcomes in rural areas utilizing a team-based care model in rural areas has the potential to reduce the urban-rural outcome gaps.

1 For an in-depth review of this subject, see


Jack O. Hensold MD

Bozeman Health Cancer Center

Quality of Life Committee, Montana Cancer Coalition


Marg Hammersla PhD, ANP-BC

Montana State University, Mark & Robyn Jones College of Nursing

Quality of Life Committee, Montana Cancer Coalition


Becky Franks, MA

Cancer Support Community, Montana

Quality of Life Committee, Montana Cancer Coalition

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