Descriptive analysis of the PCP-ONC CARES Program: Integrating primary care into oncology in a value-based system.
Authors: Samantha Blair Siegel, Brandon Anderson, Maria Carissa Ferrer Santos Vistan, Olga Egorova, Anahat Singh, Dawn Dupirak, Shiyun Zhu, Angelica Paule, Raymond Liu
Journal: Journal of Clinical Oncology (2025)

e13865 Background: Survivorship care is a critical component of oncology, yet many systems lack comprehensive models addressing the needs of patients across the cancer continuum. The PCP-ONC CARES program, piloted at Kaiser Permanente San Francisco (KPSFO), matches newly diagnosed cancer patients with primary care physicians (PCP) knowledgeable in cancer survivorship. These physicians and their team deliver comprehensive, whole-person care, including guidance through diagnosis and staging, education, psychosocial support, and co-management with oncologists and other specialists. Care begins at the moment of diagnosis and continues through end of life, aligning with the National Cancer Institute's definition of survivorship. Unlike traditional fee-for-service systems, this program is embedded within a value-based care model, aiming to improve quality while promoting long-term cost avoidance and effectiveness. Herein we describe the characteristics of patients empaneled in PCP-ONC CARES compared with KPSFO’s general population. Methods: This descriptive analysis evaluated all adult and family medicine patients within KPSFO from 4/1/24 - 1/7/25. Demographic and utilization variables of PCP-ONC CARES patients were compared with the general KPSFO population, stratified by cancer and non-cancer groups. PUMA score, an internal metric, balances provider panels by accounting for patient sickness. Results: A total of 189,399 patients were included, with 9,244 (4.9%) cancer patients and 180,155 (95.1%) non-cancer patients in the general KPSFO population. A PCP-ONC CARES physician had 202 patients empaneled, with most (87%) having a cancer diagnosis. Compared with the general KPSFO population with and without cancer, those in PCP-ONC CARES were intermediate in age (median age: 70 / 45, vs 60 years) and had higher comorbidity burden (median Elixhauser score: 1 / 0, vs 2). PUMA scores were equal for the PCP-ONC CARES and general cancer populations (1.32) and notably higher than the general non-cancer population (0.83). Compared with the general KPSFO population with and without cancer, those in PCP-ONC CARES more likely had &gt;3 PCP visits (14% / 6%, vs 32%), and ≥1 emergency department visit (21% / 11%, vs 32%) or hospitalization (9% / 3%, vs 15%). PCP-ONC CARES patients died at an increased frequency (0.3% / &lt;0.1%, vs 0.6%). Conclusions: The PCP-ONC CARES program enrolls a distinct population of cancer patients, characterized by greater illness severity, more healthcare utilization, and increased death rate compared with KPSFO’s general population. These findings underscore the unique role of PCP-ONC CARES in addressing complex survivorship needs within an integrated, value-based care system. As the program grows, further research is needed to evaluate patient-centered outcomes, including quality of life and overall survival, to inform broader implementation and scalability.