Comprehensive virtual survivorship care: TN Oncology and OncoveryCare Survivorship Program.

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Background: In 2022, there were an estimated 18.1 million cancer survivors in the United States. Cancer survivors face a wide range of ongoing challenges and often encounter barriers to accessing comprehensive survivorship care. To address these gaps, OncoveryCare, a survivorship care organization, partnered with Tennessee Oncology to expand survivorship services with a virtual, multidisciplinary care model. We report descriptive data from the implementation of a survivorship needs assessment and comprehensive care model in breast cancer survivors at Tennessee Oncology. Methods: The cancer survivorship program was launched with a team including nurse practitioners, licensed clinical social workers, peer survivors and a supervising physician. Patients were eligible for the survivorship program if they had a diagnosis of stage I-III breast cancer, completed active treatment within the prior 12 months and were patients of a selected group of oncologists. Those oncologists were also able to directly refer patients based on their clinical needs. Eligible patients were enrolled through direct outreach. Patients were asked to complete a custom survivorship needs assessment upon enrollment. Survivorship visits were performed by the clinical team virtually using a HIPAA compliant video platform. Results: Between January and May 2025, 213 eligible patients were invited to participate in the survivorship program. 176 (82%) patients completed an intake visit with the nurse practitioner and among this group 132 (75%) completed the needs assessment. 12 patients (6.8%) completed the needs assessment but did not have an intake visit, and their data were included in the sample. Among patients who completed the needs assessment, the average age was 59 years old (range 31- 84). The average number of unique clinical needs per patient was 7 and a substantial number of needs were classified as unmet prior to the survivorship intake. The top five needs among cancer survivors included: 1) Hot flashes or night sweats (n = 86 or 60%), 2) fear of cancer recurrence (n = 82, 57%), 3) muscle or joint stiffness (n = 80, 56%), 4) difficulty sleeping (n = 74, 51%), and 5) fatigue interfering with daily activities (n = 72, 50%). Among patients who completed a nurse practitioner intake, 38% had referrals placed, including those to cancer rehabilitation and behavioral health. Over 75% of patients have completed or scheduled follow up visits with the survivorship nurse practitioner or survivorship behavioral health team at the time of data analysis. Conclusions: The Tennessee Oncology Survivorship Program, in partnership with OncoveryCare, identified a substantial number of survivorship-related care needs among this patient cohort. These findings underscore the importance of investing in comprehensive, multidisciplinary and scalable survivorship programs and the feasibility of virtual survivorship care models.