In Primary Care–Oncology Collaboration, the Baton Goes Both Ways

In a relay race, the baton is passed in a single direction from one runner to the next, but in oncology care, the passing of the baton must go both ways between primary care and oncology—and in both situations, a disruption in the handoff can be disqualifying. Those were among the takeaways from the panel “Passing the Baton: Building Relationships With Primary Care” during the Patient-Centered Oncology Care® 2025 conference.

“We all know how important this relationship is,” said panel moderator Mark Fendrick, MD, director of the Center for Value-Based Insurance Design at the University of Michigan and co–editor in chief of The American Journal of Managed Care^®. “Maybe one small ray of hope is to talk about how we can do a better job of communicating between primary care providers and oncologists.”

Bringing their perspectives and solutions were panelists Kathryn Paliotta, RN, vice president of patient communication, New York Cancer and Blood Specialists; Yale Podnos, MD, MPH, FACS, chief medical officer, The Oncology Institute of Hope & Innovation; and Jonathan Tinker, MBA, MHA, vice president of oncology services, HCA Healthcare Sarah Cannon Cancer Network. Despite their varying roles, they each described their view of the primary care–oncology handoff as one where relationships are key.

Successful Handoffs at the Time of Cancer Diagnosis

While conference panels often point out where gaps and pitfalls exist in current workflows, Fendrick asked the participants to highlight the elements that make a handoff go well. Paliotta discussed the importance of identifying key stakeholders, who are often the “behind the scenes” administrative staff like patient coordinators who can help obtain a patient’s medical records and make the appointments. Podnos agreed that the office managers in the respective practices need to know who to call if information is missing. On a larger scale, Tinker said, networks like HCA are investing in screening centers where notification of the original physician is automatic if a screening leads to a diagnosis.

The panelists all agreed that navigators are indispensable, even though their services are not specifically reimbursed. “We look at it from an efficiency and productivity perspective, and that’s really where the value is,” Podnos said. “One other thing we can’t put a price on is the care and comfort that they provide the patients themselves.”

Ensuring Collaborative Cancer Screening Amid Clinical, Policy Changes

Even before the moment of diagnosis, primary care and oncology are both involved in screening for cancer, and this overlap means that screening is a group effort, according to Paliotta: “We have plenty of referrals that come out of the primary care world, and then we’re also doing our own screenings within the clinic to capture patients who are eligible. I think it’s important to note that it’s not solely relying on primary care, that there’s onus on our side as well.”

Awareness of this shared responsibility is even more important with the advent of multicancer early detection (MCED) tests, which are raising questions around access as the target of new legislation that could mandate their coverage if they are approved by the FDA.¹ Tinker noted his organization is aiming to make the MCED process easier on primary care, including through partnerships with virtual navigators who can notify the primary care office of a positive signal. “Based on whichever trigger it is, the physicians for those disease groups have identified the clinical pathway to finish the diagnostic workup, and so we have a hands-on navigator helping that patient and primary care doctor complete the diagnosis and if it actually is positive introduce them at an upcoming multidisciplinary tumor board for next steps,” he explained.

The panelists also agreed on ways that technology leveraging artificial intelligence can help smooth the primary care–oncology workflow, whether it be generating after-visit summaries in preferred languages, optimizing nurse scheduling through predictive modeling, or aiding diagnostics by recognizing lung nodules.²

Patient Preferences for Site of Care

Audience member Brian Koffman, MDCM, DCFP, FCFP, DABFP, MSEd, a retired primary care physician and now the executive vice president and chief medical officer of the CLL Society, pitched an intriguing example of how to better integrate the fields of primary care and oncology. In Canada, primary care physicians can seek extra accreditation in oncology, which lets them follow patients’ cancer journeys even though they don’t make the oncologic treatment decisions. This not only saves money, because the family practice setting is always cheaper than specialty, but also lets the patient stay with a provider they already are familiar and comfortable with.

The panelists agreed that the patient has to be in the middle of all treatment communications and decisions between primary care and oncology. “Something that I’ve seen in my time in the chronic care management department is that patients who are most successful are those who are advocates and active participants in their care,” Paliotta said. “When we see these patients who are willing to participate and talk to us about their medication changes and their symptoms and their recent hospitalizations so that we can communicate that information back, it just makes a world of difference.”

References

1. Nancy Gardner Sewell Medicare Multi-Cancer Early Detection Screening Coverage Act, HR 842, 119th Cong (2025). Accessed September 25, 2025. https://www.congress.gov/bill/119th-congress/house-bill/842

2. Cheo HM, Ong CYG, Ting Y. A systematic review of AI performance in lung cancer detection on CT thorax. Healthcare (Basel). 2025;13(13):1510. doi:10.3390/healthcare13131510