Grant Number:	1R01CA303339-01A1 Interpret this number
Primary Investigator:	Eary, Rebecca
Organization:	Ut Southwestern Medical Center
Project Title:	Novel Linkages and Navigation to Improve Childhood and Adolescent Cancer Survivors’ Care Transitions: a Pilot Randomized Controlled Trial Across Three Health Care Systems
Fiscal Year:	2026

PROJECT SUMMARY/ABSTRACT Although childhood and adolescent cancer survivors (CCS) need lifelong, guideline-based survivorship care to manage heightened risks of secondary primary cancers and long-term effects from treatment, most CCS do not receive this as adults. As new adults balancing other life stressors, CCS have difficulty transitioning to adult survivorship care. Thus, successfully navigating the transition from pediatric to adult care demands collaboration between health systems, alongside dedicated support for both patients and clinical teams. Because the timing of transition, reasons for needing continued care, and life circumstances influence transition, a tailored approach that addresses the impact of non-medical drivers of health is vital for improving receipt of appropriate survivorship care. In Aim 1, we will use geospatial data and novel data linkages to understand how CCS treated for their cancer at Children’s Health used medical care as they aged over the past 30 years, identifying risk factors for loss to follow-up and updating our CCS registry with more accurate address and contact information. In Aim 2, we will identify adult CCS who attended a pediatric survivorship visit at Children’s Health, but who have not had a known adult survivorship visit in the past three years. We will conduct qualitative interviews with these unengaged CCS to help understand facilitators and barriers to care in each step of the transition pathway from childhood to adult survivorship care. Finally, the study aims to pilot test a small, randomized control trial aimed at improving transitions from an established pediatric survivorship program to an adult onco-primary care clinic (which provides primary and survivorship care) in either a safety net or academic health care system (Aim 3). The pilot will test whether enhanced support and patient education from a nurse navigator will improve attendance of an adult survivorship clinic visit, compared to the standard referral pathway (usual care). The standard referral pathway uses usual clinical care, which includes an electronic referral to the adult onco-primary clinic. The enhanced pathway adds a nurse navigator who will provide education, assistance in transitioning to adult care, and logistic support during survivorship care. Primary outcome measures will focus on follow-up visits, while secondary outcomes will assess patients' perceived readiness for transitioning care. The goal of the pilot is to inform magnitude, variability, and acceptability for a fully powered trial to be completed later. Our strong multidisciplinary team and established pediatric and adult survivorship programs uniquely positions us to successfully pilot an intervention to improve CCS transitions to adult follow-up care. Additionally, we will improve understanding of the place and time CCS disconnect, thus identifying potential targets for intervention among CCS already lost to follow-up. Our findings will allow for a scale up to a full- scale trial to reduce disparities in transitions of care for all vulnerable CCS across all stages of transition





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