Transforming Cancer Survivorship in Community Health Centers
Summary
- Sylvester Comprehensive Cancer Center is leading a groundbreaking initiative designed to transform survivorship care in community health centers across South Florida.
- Sylvester launched a five-year study of an evidence-based survivorship care education and training program for primary care clinicians and comprehensive survivorship care for their patients.
- U.S. cancer survivor population is estimated to surge to 26 million people by 2040.
As the U.S. cancer survivor population surges to an estimated 26 million by 2040, health care systems face a critical challenge. How do they provide comprehensive and coordinated care that meets survivors’ long-term needs?
Sylvester Comprehensive Cancer Center, part of UHealth — the University of Miami Health System, is meeting that challenge with a groundbreaking initiative designed to transform survivorship care in community health centers across South Florida.
Fueled by a $4 million grant from the National Cancer Institute (NCI), Sylvester launched a five-year study of an evidence-based survivorship care education and training program for primary care clinicians and comprehensive survivorship care for their patients. Provider training begins this summer.
“We’re bringing Sylvester’s expertise directly into federally qualified community clinics, where the gaps — and the potential impact — are paramount,” said Frank Penedo, Ph.D., associate director for population sciences and director of cancer survivorship and supportive care at Sylvester, South Florida’s only NCI-designated cancer center, and principal investigator for the study.
“By empowering community providers, we’re closing a critical gap in survivorship care and ensuring cancer patients receive the long-term support they need and deserve,” added Jessica MacIntyre, D.N.P., M.B.A., APRN, assistant vice president of advanced practice providers at Sylvester, and study co-investigator.
Bridging a Critical Gap in Cancer Survivor Care
Primary care clinicians are essential to the long-term health of cancer survivors. But many lack the necessary training and skills needed to support survivors’ unique physical, emotional and psychosocial needs. These needs can persist or even intensify long after primary treatment ends.
Sylvester’s study addresses this gap. The initiative provides frontline clinicians with best-practice guidelines, care coordination tools and strategies for managing the full spectrum of survivor needs, from physical health to emotional wellness and recurrence monitoring.
This is the first large-scale initiative to assess the effectiveness of an integrated primary care survivorship training and care program in reducing morbidity, mortality and the overall burden of cancer in community health centers.
“We’re not just teaching survivorship care. We’re rebuilding it from the ground up,” said MacIntyre. “This is about early assessment and intervention, whole-person care and creating a system that supports survivors for life.”
Elements of Cancer Survivorship Support Training
Developed through collaboration between Sylvester experts, primary care clinicians and community oncologists, the training includes:
• 21 self-paced modules on prevention, surveillance, assessment, symptom management and care coordination
• AI-narrated lessons for optimized engagement that assess knowledge uptake
• Continuing medical education credits through UM to incentivize providers
“This training program was designed with frontline community providers in mind,” said Dr. Penedo, endowed chair in cancer survivorship and professor of psychology and medicine at the University of Miami. “It is practical, sustainable and designed for implementation in busy community clinics.”
Smarter Technology, Seamless Care
At the core of the initiative is its powerful technology integration. The training platform and survivorship care modules that will be provided to patients integrate with Epic systems, the electronic health record (EHR) system used by all participating FQHCs in the Health Choice Network. A secure, third-party application connects patient data to Sylvester’s assessments, patient survivorship modules and care guidelines, enabling real-time, automated communication.
We’re giving survivors a personalized roadmap, because navigating life after cancer can be overwhelming. This program helps them take control of their future.
Jessica Macintyre
When a patient screens high for fatigue or depression, or reports other concerns, the system generates immediate alerts, recommends next steps and helps coordinate referrals, all within the EHR. It also generates personalized care plans, including treatment summaries and long-term follow-up recommendations.
“This training and care coordination program creates a clinical ecosystem that provides comprehensive survivorship care,” said Dr. Penedo. “With our Health Choice Network partners, we’re closing the loop between oncology and primary care to deliver faster, precise, more effective care in our communities.”
Shaping the Future of Survivorship Care
In early 2026, the initiative will launch in 14 FQHC clinics through a randomized rollout. Half will implement the full survivorship program. The other half will continue with standard care. Researchers will track health outcomes, health care utilization and overall quality of life to assess the program’s effectiveness and scalability.
Cancer survivors will have access to SmartManage, a digital platform developed at Sylvester providing evidence-based assessment, intervention and wellness tools. Curated local resources will be tailored to the survivors’ cancer type and needs.
“We’re giving survivors a personalized roadmap, because navigating life after cancer can be overwhelming,” said MacIntyre. “This program helps them take control of their future.”
Sylvester’s research provides strong evidence that unmet care needs are linked to poorer health outcomes and increased use of health care. That translates to higher costs, especially in vulnerable populations.
Using real-time data from a unified EHR platform, researchers will track whether patients adopt recommended care, experience psychosocial and lifestyle changes, adhere to follow-up screenings and engage with survivorship services.
“We’re leveraging data science, cutting-edge technology and clinical education to deliver expert care where it’s needed most,” said Dr. Penedo. “We’re not just supporting survivors. We’re transforming the future of their health care in primary care settings.”
Tags: cancer research, Cancer Support Services, cancer survivorship, community health, Dr. Frank Penedo, Jessica MacIntyre, Sylvester Comprehensive Cancer Center