Rural cancer survivors experience a higher risk of negative health outcomes and require coordinated care to address the many effects of cancer and its treatment. Primary care providers recognize the importance of providing high-quality, evidence-based survivorship care and are well-positioned to meet survivor needs, however, these needs are often unmet due to limitations in knowledge, lack of resources, and administrative demands. Practical strategies are needed to help PCPs improve cancer survivorship care, and this proposal will test implementation strategies to optimize the adoption of evidence-based practices for cancer survivorship care in rural primary care settings.

Cancer survivors require long-term and coordinated care to address the physical, emotional, and psychosocial effects of cancer and its treatment. Rural cancer survivors are disproportionately affected by chronic illness and face a higher risk of negative health outcomes. Primary care providers (PCPs) recognize the importance of delivering evidence-based practice (EBP) cancer survivorship care and are well-positioned to provide comprehensive and coordinated care, however, the needs of cancer survivors are frequently unmet, and providers describe limitations in knowledge of risk-based surveillance, long-term effects of cancer treatment and their management, inadequate resources, and growing administrative demands as barriers to improving survivorship care. The overall goal of this project is to test the effectiveness of pragmatic strategies to promote high quality, evidence-based guideline concordant care for rural adult cancer survivors in primary care practice and utilizing tools from implementation science to gain a better understanding of the decision making and actions taken that facilitate or hinder implementation across multiple healthcare systems. To achieve this objective, we propose a three-arm cluster-randomized, multi-level intervention to provide education, tele-mentoring, and whether 1) virtual scribes filling the role as trained medical assistants, 2) a team-based approach, 3) or usual care produces more guideline concordant cancer survivorship care. The primary outcome is provider adherence to EBP cancer survivorship guidelines as measured using a previously developed composite scoring system that compares electronic health record (EHR) documented activity to National Comprehensive Cancer Network guidelines. The secondary outcome is to assess intervention sustainability of arm 1 and 2 activities at 12 and 24-months post implementation; measured as a function of virtual scribe or team-based actions to promote prior cancer diagnoses coding (ICD-10), use of EHR tools and health maintenance order sets and annual ordering of appropriate screenings for cancer survivors. Prior to implementation, formative evaluations will assess current systems of care and practice-level barriers and facilitators for the delivery of EBP cancer survivorship care and inform modifications to implementation strategies. Guided by the Normalization Process Theory, we will examine agentic factors (e.g., actions taken/decisions made by the practice) to modify modes of care management and delivery. The RE-AIM evaluation framework will be used to explore potential population-level impact and generalizability of the intervention in real-world clinical settings. The study will be conducted in 16 rural primary care practices in Kansas and was intentionally designed to bring care delivery changes into resource-limited practices and health systems. Results will add new evidence by informing pragmatic strategies to facilitate the adoption and delivery of EBP cancer survivorship in rural primary care.

Inclusion criteria:

1. Rural primary care practice (PCP) located within rural urban continuum codes (RUCC) 4-9 in Kansas
2. PCPs must have multiple providers
3. PCPs must have at least on medical assistant
4. PCPs must have an employed medical scribe or be willing to consider employing a medical scribe using study compensation and practice revenue
5. Cancer survivor data is eligible for extraction if the patient is a breast, prostate, lung, and/or colorectal cancer survivor and considered to have a "reasonable likelihood" of 24-month survival by a practice provider.

Exclusion criteria:

1. PCPs not located within RUCC 4-9 in Kansas
2. PCPs without multiple providers
3. PCPs without a medical assistant
4. PCPs without a medical scribe or unwilling to consider employing one
5. Cancer survivorship data is ineligible for extraction is the patient is <18 years of age or >75 years of age, is currently receiving hospice services, or has a history of cancer other than breast, prostate, lung, or colorectal.

Research resources generated within this project will be explicitly developed in an effort to improve cancer survivorship outcomes in rural primary care practice. We will develop a strategic plan with the KU Cancer Center and NCI to widely disseminate any product, intellectual property, or data to promote scientific activity and health promotion work that will be of assistance to similar patient populations. As such, we will work to fully share these materials and items with qualified individuals across the greater scientific community and with rural practices, providers and community members. All program materials and data generated within the overall study will be shared to the fullest extent possible. De-identified data from this project will be preserved and shared in a public repository to validate and replicate research findings described in the Aims.

Start date: June 2026 End date: June 2029

De-identified study data will be made available as public use data to the research community via Open Science Framework.