Bridging the Gap: NCCN Summit Advocates for Primary Care and Oncology Collaboration to Improve Patient Outcomes

For patients with cancer, primary care professionals (PCPs) help promote cancer prevention, early detection, and survivorship care. However, gaps in coordination and collaboration between primary care and oncology may significantly impact long-term survival outcomes.

The National Comprehensive Cancer Network (NCCN) addressed these gaps in their Oncology Policy Summit on May 6, 2025, which facilitated a larger conversation on strengthening collaboration between primary care and oncology and the role of public health policy in advancing patient survival.

The Role of PCPs in Patient Survival

Primary care professionals may be the first to identify patients’ symptoms, refer them to an oncologist, and ultimately facilitate early detection and diagnosis, Veronika Panagiotou, PhD, director of Advocacy and Programs at the National Coalition for Cancer Survivorship and panelist at the NCCN summit, told Blood Cancers Today.

“PCPs promote access to cancer-preventing vaccines like the HPV [human papillomavirus] and HBV [hepatitis B virus] vaccines, promote healthy lifestyles that may reduce cancer risk through diet and exercise, and also facilitate patient engagement with cancer screening,” added Alyssa Schatz, DrPH, MSW, vice president of Policy & Advocacy at the NCCN.

In a 2022 study of 245,425 adult patients with metastatic cancer, some PCP visits—as compared with no previous visit—were associated with a 26% decreased odds of metastatic disease at diagnosis (odds ratio [OR], 0.74; 95% CI, 0.71-0.76; P<0.001) and a 12% reduced risk of cancer-specific mortality (subdistribution hazard ratio [SHR], 0.88; 95% CI, 0.86-0.89; P<0.001). Meanwhile, annual PCP visits were associated with a 39% decreased odds of metastatic disease (OR, 0.61; 95% CI, 0.59-0.63; P< 0.001) and 21% reduced risk of cancer-specific mortality, suggesting that PCPs are vital for early cancer detection.¹

However, the role of PCPs also extends to patients’ long-term, post-treatment journey. “PCPs are also the professionals that patients return to when transitioning into survivorship care after cancer treatment; this requires management of a complex set of healthcare needs,” Dr. Schatz said.

In a database study of 951 cancer survivors, 91.6% had at least one annual PCP visit, 54.6% had a PCP as their main healthcare provider, and 88% only saw a PCP, highlighting the “urgent need for smooth handoffs from oncology back to primary care.”²

“Our primary care providers are best suited to help survivors get through the treatment process, and then more importantly, after the treatment process, to deal with all the other health issues that might be a direct result of that cancer diagnosis or they might have had before their cancer diagnosis,” Dr. Panagiotou explained. “We need that comprehensive care to live long lives. Primary care is foundational to every human regardless of if they have a cancer diagnosis. They should be a part of every person’s care team.”

Bridging the Gaps Between Primary Care and Oncology

According to Dr. Panagiotou, the main gap in primary care and oncology is patient trust.

“Survivors have a real trust issue with primary care because they’re worried about the physical, emotional, and financial costs of cancer. Some are worried that their primary care provider doesn’t have enough information and training,” she explained.

In a 2019 survey, 66% of PCPs reported patient preference to follow up with their oncologists as a barrier in caring for patients with hematologic malignancies. Other reported barriers included lack of resources to facilitate care (69%), lack of awareness of screening and prevention guidelines (55%) and psychosocial needs of survivors (65%), and inadequate time (65%).³

“[PCPs] are not trained in cancer, so [patients] have trouble leaving their oncologists because cancer is their focus,” Dr. Panagiotou explained. “But oncologists can’t do everything. And that’s the burden on the other side of the equation. Oncologists cannot manage hypertension, diabetes, and other chronic conditions that are better suited for primary care.”

Some cancer survivors also travel to different states or communities to receive specialized care, Dr. Panagiotou explained, creating a physical gap in cancer care. One model to overcome this barrier consists of merging primary care practices inside of cancer centers.

“That creates proximity,” she said. “If PCPs see a big group of cancer survivors, they might be able to see trends. It creates an environment where there’s more focus and collaboration. That’s the kind of innovation that hopefully will bring us closer to getting better care for patients.”

Drs. Panagiotou and Schatz also highlighted virtual gaps between primary care and oncology practices regarding medical record systems.

“They have a hard time communicating with each other. They’re not in the same systems, and they don’t have the same electronic health record [EHR] sometimes,” Dr. Panagiotou said. “Oncologists use NCCN guidelines, but primary care has their own set of guidelines, so their guidelines don’t quite match up.”

“A key takeaway for me from the summit was the need to take action toward truly interoperable medical record systems,” Dr. Schatz added. “This is challenging in the US, because we have so many different EHR/HIT [health information technology] vendors. Thankfully, the CMS [Centers for Medicare and Medicaid Services] has made this a priority and has made some progress toward the goal, but we still have a very long way to go.”

Health Reimbursement Policies

As Dr. Schatz noted, improving primary care and oncology collaboration requires policy change.

“Coordination between specialties takes time and resources,” she said. “We need to ensure that reimbursement systems are set up to recognize and reimburse this type of coordination. As we heard from Dr. Liz Fowler during the summit, value-based models of care may also play a key role in advancing better collaboration. The Center for Medicare and Medicaid Innovation recently announced new pillars, including embedding preventive care in all model designs. That may offer an opportunity for improving primary care and oncology collaboration.”

“The federal government is the biggest insurer,” added Dr. Panagiotou. “They take care of the Medicare and Medicaid populations. The rules in how they reimburse influence how private payers reimburse. If Medicare and Medicaid are not adequately paying physicians to provide survivorship care, then we’re not going to get what we need, because we need providers to get the reimbursement they need to provide this service.”

Dr. Panagiotou’s organization, the National Coalition for Cancer Survivorship, advocates for survivorship care plans that provide roadmaps to help survivors navigate the next steps after treatment. With the goal of improving quality of life, these roadmaps include documented patient history as well as recommendations for future care, screening, and supportive services such as physical or occupational therapy.

“We advocate for reimbursement to create those plans because we know that they’re tedious,” she said. “It takes a physician or someone part of the team to create that document and have that conversation to move patients through their transition from treatment.”

As Dr. Schatz noted, the NCCN Guidelines for Survivorship also provide recommendations on survivorship principles, late effects of cancer and cancer treatment, preventive health such as physical activity and nutrition, vaccinations, supplement use, and secondary cancers.⁴

“Survivorship care plans are super important in this space, and we need more reimbursement for supportive services so people can have access to get what they need within the healthcare system,” said Dr. Panagiotou. “What our national centers do does have an impact on how we access healthcare. It starts there.”