Loss to primary care provider follow-up among survivors five to seven years post-diagnosis.
Authors: Peluso Alexandra G. , Shalowitz David I. , Isom Scott , Wagi Cheyenne R. , Randazzo Aliza , Falk Derek Sean , Weaver Kathryn E. , Bell Ronny A. , Birken Sarah A. 
Published: October 2023

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Background: Cancer survivors experience better outcomes when primary care providers (PCPs) are engaged in their care. Several studies indicate that nearly all survivors have ≥1 PCP visits per year in the initial five years post-diagnosis; however, little is known about sustained PCP engagement in survivors’ care. Our objective was to assess PCP engagement in survivors’ care 5-7 years post-diagnosis, and to characterize survivors who are most vulnerable to loss to PCP follow-up. Methods: We linked electronic health record ambulatory care visit data to Atrium Health Wake Forest Baptist Comprehensive Cancer Center (AHWFBCCC) registry data to identify survivors who were (1) ages ≥18 years, (2) diagnosed with a breast, colorectal, or uterine cancer between January 1, 2014 and December 31, 2015, (3) treated at AHWFBCCC as of September 1, 2019, and (4) had a PCP in the WF Health Network. We used multiple logistic regression to assess associations between survivor demographics, clinical factors, and healthcare utilization and odds of sustained PCP engagement in care, defined as having at least one ambulatory visit per year with a family or internal medicine provider. Results: There were 638 survivors who met our inclusion criteria. Of these, 122 died within the six-year post-diagnosis period and were excluded from analysis. Our analytic sample included 516 survivors who were primarily female (88.4%), white (75.0%), non-Hispanic (95.7%) stage 1 (50.6%) breast cancer survivors (69.2%) with a mean age of 60.7 years. Most (84.7%) survivors lived in an urban area at the time of diagnosis. In years 5-7 post-diagnosis, PCPs were engaged in care for 43% of survivors. Survivors with sustained PCP-engagement were on average 4.6 years older than those without (p<0.0001); survivors had 1.36 greater odds of having regular PCP visits for each decade increase in their age upon cancer diagnosis (p=0.0030). Survivors were less likely to be lost to PCP follow-up in if they were diagnosed at an earlier stage (p=0.0005) and had at least one visit annually with an oncologist 5-7 years post-diagnosis (p<0.0001). Conclusions: Sustained PCP engagement has been endorsed as critical by survivors, PCPs, and oncologists. In this study, we found that in the 5-7 years post-diagnosis, most (57%) survivors were lost to PCP follow-up. Older survivors, those currently engaged in oncology care, and survivors with earlier stage cancer were less likely to be lost to PCP follow-up, perhaps attributable to higher overall healthcare utilization. Our study may overestimate loss to PCP follow-up since we were unable to assess PCP visits outside of the AHWFB network; however, our findings offer evidence in support of calls for interventions to promote sustained PCP engagement among survivors, including the information, care coordination, and self-management support that survivors and PCPs have consistently reported needing for improved survivorship care and outcomes.