Improving Patient Outcomes Through Primary Care and Oncology Collaboration: An NCCN Policy Summit

Aside from the physical, emotional, and financial stressors that accompany a cancer diagnosis, new patients are often thrown into a medical system that is difficult to navigate—even for individuals who work in health care. Keeping track of appointments with multiple types of providers can be overwhelming for patients, and many feel they lack a consistent “champion” for their care. 

In recognition of this struggle and its impact on the patient experience, the National Comprehensive Cancer Network (NCCN) hosted a policy summit on May 6, 2025, dedicated to collaboration between primary care providers (PCPs) and oncologists. Patients, providers, payers, and patient advocacy organizations came together to thoughtfully discuss policy and practice strategies to strengthen coordination between primary care and oncology across the care continuum, as well as the challenges currently inhibiting this collaboration.

Paving the Way for Better Care Coordination 

The first panel of the summit tackled the challenges that arise from the fragmented nature of the US health care system—namely, many patients fall through the cracks between primary care and oncology. Veronika Panagiotou, PhD, director of advocacy and programs at the National Coalition for Cancer Survivorship, asserted that the consequences of this lack of care coordination can be dire for patients. “When patients don’t have a partner in their primary care provider to walk them through latent long-term effects of treatment, their health and quality of life suffer,” she said. “Without that support, many of them end up wondering what the point was of going through all that arduous treatment if they’re not able to walk to the mailbox or shower without assistance at the end of it all.” 

The group agreed that a lack of PCP-oncologist collaboration creates delays that hamper care as well as create redundancies, such as repeat scans, colonoscopies, or laboratory work. “When this happens, the patient gets double the bills because their PCP didn’t know it had already been done,” commented Andrea Porpiglia, MD, MSc, FACS, associate professor and surgical oncologist at Fox Chase Cancer Center. She also described the feeling of abandonment that can occur in patients when they experience a poor or nonexistent transition between their oncologist and their PCP. 

Linda Overholser, MD, associate professor at the University of Colorado Cancer Center, highlighted the importance of care coordination in addressing new or existing comorbidities throughout cancer treatment. With a growing number of patients living longer after a cancer diagnosis, there is an urgent need for health counseling, more cancer screenings, and preventive health, which require effective communication between primary care and oncology. 

Roadblocks to Effective Communication 

When asked what is preventing this collaboration from happening, panelists cited a lack of time, resources, and reimbursement for PCPs. “We know navigation works and that it improves patient outcomes, but without high ROI [return on investment] for the hospital, it’s difficult to convince them to pay for the salary and benefits of a patient navigator,” said Dorothy Rhoades, MD, MPH, professor in the Department of Medicine at the University of Oklahoma Health Sciences College of Medicine and the director of the Native American Center for Cancer Health Excellence at OU Health Stephenson Cancer Center. 

Other panelists discussed the struggle of antiquated electronic health records (EHRs) that don’t easily facilitate the exchange of medical records between providers and a lack of resources teaching patients how to advocate for themselves with all different types of providers. “There’s typically an onus on the patient to be able to navigate all their specialists and their PCP,” commented Dr. Panagiotou, “but providers still need to be effectively communicating with each other behind the scenes.” 

Pathways to Partnership 

On the topic of positive examples of collaboration, panelists expressed excitement and hope about the future of onco-primary care models that are emerging at different institutions. They agreed that having access to primary care within the cancer center will greatly increase the support of patients’ diverse needs throughout treatment while maintaining a strong sense of trust among patients, PCPs, and oncologists. 

Associations play a role in improving care coordination as well, particularly in developing consistent guidelines and partnering with organizations that PCPs are likely to be familiar with. “There are different guidelines for the American Society of Clinical Oncology, NCCN, and the American Cancer Society, so it can be confusing for PCPs to know which is the best resource,” said Dr. Porpiglia. In addition, Dr. Panagiotou stressed the need for more research on latent long-term effects of cancer treatment to inform national guidelines. “We have over 18 million survivors who need this information,” she stated. “We need more personalized survivorship care.” 

In closing, panelists each listed 1 thing they believe would immediately and definitively advance greater collaboration between PCPs and oncologists, which included more support for navigation roles, using a single EHR to ensure consistency of information between different health systems, more validation of the patient experience, and incentivizing care coordination outside of a clinical care visit. 

The Future of Value-Based Care and Its Implications for Oncology 

Following the panel discussion, the summit featured a keynote address from Elizabeth Fowler, JD, PhD, distinguished scholar of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health and former director of the Center for Medicare and Medicaid Innovation (CMMI) at CMS, about the role of value-based care models in bridging the gap between primary care and oncology. 

With the launch of its Oncology Care Model (OCM) 10 years ago, CMMI made an effort to test whether value-based payment could work in oncology—one of the most complex, variable, and high-cost specialties in medicine. Value-based care focuses on the whole patient, not just the treatment regimen. To reflect this, the OCM required investments in care coordination, 24/7 patient access to a clinician, real-time access to patient medical records, and patient navigation. Practices participating in the model also had to document their evidence-based care standards and provide care at the lowest cost possible. 

According to Dr. Fowler, the final evaluation report showed that practices that had implemented the OCM model reduced episode payments by 2.1% compared with the control group—mainly by reducing unnecessary acute care—and that enhanced services like 24/7 patient access to navigators and advocates led to high patient satisfaction. Challenges identified included variation in how practices adopted the model and the need for a more structured approach in facilitating meaningful patient-provider conversations. “These insights highlight the complexity of implementing the OCM and underscore the importance of continuous model refinement,” said Dr. Fowler. 

Although the OCM and its next iteration, the Enhancing Oncology Model, promote better care coordination within oncology practices, these models don’t directly address or evaluate integration with primary care—an area in which Dr. Fowler sees tremendous opportunity to strengthen the models. “In practice, this may look like developing shared care plans, enhancing data-sharing capabilities, and establishing clear communication pathways to manage comorbid conditions effectively,” she commented. 

Dr. Fowler concluded her keynote with a reminder that for value-based care to succeed, clinical pathways must reflect cost, equity, and real-world feasibility in addition to clinical efficacy. “We need to break down siloes between specialties and primary care because patients can’t be treated in fragments,” she stated. “We need a model of shared accountability where these fields work together for the best patient outcome.” 

“We may not know exactly what the future holds, but we have the tools, the data, the expertise, and the collective will to shape it together,” said Dr. Fowler. “We can define what quality measurement looks like, push for models that reflect the clinical complexity of patient context, and ensure that addressing health disparities is not an afterthought, but a structural feature.” 

Read part 2 recapping the NCCN Policy Summit on the ACCCBuzz Blog.