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 might 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 understand how collaboration between a patient’s oncologist and primary care provider contributes to quality of life and health care outcomes in patients with breast, colon, or hematological malignancies that have another health condition requiring management.

Design: Agreeing to participate means you will be asked to complete a baseline survey, and then be randomized to either 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:

  • Be assigned an oncology nurse navigator to facilitate oncologist-PCP communication and continuity of care
  • Receive coordinated care between their oncologist and PCP throughout cancer treatment facilitated by a structured communication and referral process
  • Receive a survivorship care plan (SCP) at the end of treatment
  • Receive a risk-stratified shared care model of post-treatment surveillance

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


Patients with breast, colon, or hematological malignancies who is being treated with curative intent and have comorbidities requiring ongoing management during cancer treatment. 


Grant funding from the National Cancer Institute.

#R01 CA2249474

IRB: H-49731




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