There are currently over 15 million cancer survivors in the US, and this number is expected to exceed 20 million by 2026 due to population aging and growth. The majority of these patients are older; many are ethnically diverse and face unique health care challenges and comorbidities due to their cancer treatment. Despite this recognition, research clearly documents the persistence of unmet needs among cancer survivors, including less than optimal preventive and cancer surveillance screening rates. Several barriers have been identified in the effort to achieve optimal survivorship care: the current health care system is fragmented, difficult to navigate, and communication between oncologists and primary care providers is often minimal. While research has been devoted to developing integrated care models, systematic reviews conclude that no standard of care exists for survivorship models. Further, given the variability of cancer survivors in terms of health needs, socioeconomic circumstances, and health care environment, it is likely that such models will need to be adaptive. Building on prior formative research, our research team at the University of New Mexico Comprehensive Cancer Center (UNMCCC) is creating a survivorship care model for implementation. New Mexico, a large, rural, minority-majority state, with deep socioeconomic disparities that limit access to care, presents an ideal environment to address the current evidence gap in survivorship care transitions. Our developing research program features the following major components to this survivorship care model: 1) identifying risk-stratified patients at the UNMCCC and delivering a survivorship care plan; 2) using the Project ECHO telementoring platform, implement a survivorship care training curriculum with primary care providers; 3) an oncology nurse navigator based at the UNMCCC will actively navigate patients to the community-based providers; and 4) all components of the model will be assessed using implementation science research and evaluation strategies. We are in the early phases of developing and implementing this model and we will report on the content and process associated with each of the major components. Identified outcomes pertain to feasibility and acceptability of implementation, and we will categorize these using the RE-AIM and Consolidated Framework for Implementation Research frameworks.

Citation Format: Andrew L. Sussman, Teresa Rutledge, Zoneddy Dayao, Miria Kano, Amy Gundelach, Stephanie McGirt, Jolene Lobo, Shiraz Mishra. Women in survivorship health using Project ECHO: Creating a model for navigated care transitions [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B015.