Model for bridging the gap: establishing an oncology primary care clinic for comprehensive survivorship care

Objective To describe the development, implementation and impact of an oncology primary care clinic within a tertiary cancer centre, designed to enhance survivorship care and ensure continuity for patients with complex cancer histories. Design Descriptive review of clinic formation, team structure, training and patient outcomes. Data were collected from electronic medical records, a Patient Outcomes Registry in Research Electronic Data Capture (REDCap) and institutional dashboards. Patient experience was assessed using the Consumer Assessment of Healthcare Providers and Systems Survey, and oncology provider feedback was obtained through written testimonials. Descriptive statistics and frequencies summarise findings. Setting University of Cincinnati Cancer Center, a Midwestern tertiary care facility, where the oncology primary care clinic was established in 2020. Participants Patients who visited the clinic between January 2021 and June 2025 (N=1138). Patient satisfaction data were available for 288 respondents. Results Through June 2025, the clinic saw 1138 unique patients. The majority had adult-onset cancers (87.8%), while a smaller, yet substantial number had childhood (4%), adolescent or young adult (8.3%) onset cancers. Second primary malignancies were documented in 15.7% of the clinic population. Over half of the patients had cardiovascular conditions. Between January 2021 and April 2025, patient satisfaction was high across all domains (N=288). Oncology provider feedback highlights the critical role of an integrated oncology primary care clinic in the management of patients with complex cancer diagnoses. Conclusions The establishment of an oncology primary care clinic within a tertiary cancer centre is both feasible and impactful. The clinic’s growth and high satisfaction scores underscore its value in addressing the complex needs of cancer survivors. Integrating primary care into oncology settings enhances continuity of care, improves management of comorbidities and supports long-term survivorship. The use of a Patient Outcomes Registry enables ongoing evaluation and quality improvement. This model offers a scalable framework for other institutions seeking to advance comprehensive survivorship care.