OPTIMISE: A Shared Care Approach for Improving Comprehensive Care of Cancer Patients with Comorbidities in A Safety-Net System

PROJECT SUMMARY. Cancer survivors have unique healthcare needs including risk for serious late effects,
ongoing surveillance, lifestyle modifications to reduce second cancer risk, and psychosocial support. Nearly
70% are considered “complex cancer survivors” because they have at least one comorbid chronic condition in
addition to cancer. Comorbidities pose significant challenges to the delivery of quality cancer care because they
adversely affect and are affected by cancer treatment. Medically underserved patients have the highest burden
of multiple chronic conditions and are at increased risk for poor outcomes during and after cancer treatment. As
medically underserved complex cancer patients may lack healthcare knowledge and access to supportive care,
their health outcomes and care transitions might be improved by enhancing communication and collaboration
between their oncologists and primary care providers (PCPs). This study tests and evaluates a novel shared
care model for complex cancer survivors called OPTIMISE (Oncology-Primary Care Partnership to Improve
Comprehensive Survivorship Care) in the largest safety-net healthcare system in Houston, TX. Three-hundred
newly diagnosed breast, GI, and hematological cancer patients who are being treated with curative intent and
who have comorbidities requiring ongoing management during cancer treatment will complete baseline surveys
and be randomized to either OPTIMISE or Usual Medical Care (UMC). Patients receiving UMC 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 1) have an
oncology nurse navigator assigned to their care team at diagnosis to facilitate oncologist-PCP communication
and continuity of care; 2) receive coordinated care between their oncologist and PCP throughout cancer
treatment and surveillance facilitated by a structured communication and referral process; 3) receive a
survivorship care plan (SCP) at the end of treatment that incorporates comorbidity management; and, 4) receive
a risk-stratified shared care model of post-treatment surveillance where one or more routine oncologist follow-
up visits is replaced by a PCP visit. AIM 1 evaluates the impact of OPTIMISE on patient chronic disease self-
management (primary outcome) and quality of life (secondary outcome). Aim 2 explores the effects of OPTIMISE
on healthcare use and patient unmet needs during and after active cancer treatment. Aim 3 examines the effects
of OPTIMISE on oncologist and PCP attitudes and coordination of care. Aim 4 seeks to elucidate patient- and
system-level factors that may influence implementation outcomes. OPTIMISE shifts the timing of thinking about
survivorship to point of diagnosis and seeks to develop a clinical infrastructure to support continuity of care from
cancer diagnosis through post-treatment survivorship. If found effective, OPTIMISE could be expanded to other
cancers, igniting a potentially rich area of research. It may also have significant downstream impact in other
medical settings by enhancing care transitions from specialty to primary care.

Grant Number: 7R01CA258040-06
NIH Institute/Center: NIH
Principal Investigator: Hoda Badr