A randomized controlled study for the long term follow-up of breast cancer survivors: A primary care physician (PCP) coordinated care delivery model.

36 Background: Generalist involvement in cancer survivorship care is becoming a global trend, however, significant barriers exist. As a major cancer center in Taiwan, KF-SYSCC is implementing an academic institution-based comprehensive survivorship program, a PCP-coordinated care delivery model. Our goal is to promote health, manage chronic diseases, attend to psychosocial needs, and optimize health care resources without compromising cancer-related clinical outcome or patient satisfaction. Methods: We designed a randomized study with staggered transition of stage 0-3 breast cancer patients from oncologist care to the PCP-coordinated program at one or two years after cancer surgery. The outcomes for comparing the two care models include late effects of breast cancer treatment, anxiety and depression, health-related quality of life, recurrence-related clinical outcome, preventive care, chronic disease management, patient satisfaction, and health services utilization. Questionnaires were given every 6 month...