ONE TEAM Study: Onco-Primary Care Networking to Support TEAM-based Care

Care providers representing one team

Involving the primary care provider as an integral member of the cancer team during cancer treatment will allow for improved efficiency in the treatment-to-survivorship transition.

  • Principal Investigator: Kevin Oeffinger, MD
  • Co-Principal Investigator: Leah Zullig, Ph.D., MPH

The Problem

Despite advances in understanding and preventing healthcare problems faced by cancer survivors, little has changed in the delivery of survivorship care. With the lack of a planned and formal transition of the cancer survivor from cancer care to the primary care team, non-cancer-related comorbidities are poorly managed. The ONE TEAM study aims to use a multi-level intervention including patient and Primary Care Provider (PCP) strategies to optimize the management of cardiovascular disease (CVD) comorbidities during and after cancer therapy.

Our Solution

We will determine the effectiveness of the multi-level iGuide intervention and the up-titrated iGuide2 intervention compared with usual care on the primary outcomes. The theory-driven, self-guided iGuide intervention consists of patient-level components (video vignettes, patient-facing webinars) and PCP-level components (electronic health record [EHR] automated cancer specialist-PCP letter, tele-education series, and automated reminders). The up-titrated iGuide2 intervention consists of tailored patient-level video vignettes and targeted EHR specialist-PCP communication.

The Goal

The primary outcomes of the ONE TEAM SMART-design study are (1) Healthcare Effectiveness Data and Information Set quality measures of management of the three CVD comorbidities (hypertension, type 2 diabetes mellitus, hypercholesterolemia) based upon laboratory and clinical measurement; (2) medication adherence assessed pharmacy refill data using Proportion of Days Covered; and (3) patient-provider communication (Patient-Centered Communication in Cancer Care). Secondary aims include exploring moderating and mediating factors in each level of the intervention, support of patient-centered outcomes, health care use, measures of provider activation, and costs of care resulting from the multi-level intervention.

The overarching goal of this proposed project is to optimize the management and outcomes of individuals with cancer, both during and after treatment, and to develop a ‘low-touch’ multi-level intervention that can be generalized, adapted and scaled in other health care systems.

The proposed ONE TEAM study brings together a multi-disciplinary research team with the necessary expertise and experience in survivorship research, population and behavioral science, primary care, oncology, and biostatistics. Results from this intervention will have important implications in the advancement of healthcare delivery for cancer survivors.


  • Zullig LL, Sung AD, Khouri MG, Jazowski S, Shah NP, Sitlinger A, Blalock DV, Whitney C, Kikuchi R, Bosworth HB, Crowley MJ, Goldstein KM, Klem I, Oeffinger KC, Dent S. Cardiometabolic Comorbidities in Cancer Survivors: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol. 2022 Jun 21;4(2):149-165. doi: 10.1016/j.jaccao.2022.03.005. PMID: 35818559; PMCID: PMC9270612.
  • Zullig LL, Drake C, Shahsahebi M, Avecilla RAV, Whitney C, Mills C, Oeffinger KC. Adherence to cardiovascular disease risk factor medications among patients with cancer: a systematic review. J Cancer Surviv. 2022 May 17. doi: 10.1007/s11764-022-01212-0. Epub ahead of print. PMID: 35578150.
  • Tonorezos ES, Cohn RJ, Glaser AW, Lewin J, Poon E, Wakefield CE, Oeffinger KC. Long-term care for people treated for cancer during childhood and adolescence. Lancet. 2022 Apr 16;399(10334):1561-1572. doi: 10.1016/S0140-6736(22)00460-3. PMID: 35430023; PMCID: PMC9082556.
  • Zullig LL, Shahsahebi M, Neely B, Hyslop T, Avecilla RAV, Griffin BM, Clayton-Stiglbauer K, Coles T, Owen L, Reeve BB, Shah K, Shelby RA, Sutton L, Dinan MA, Zafar SY, Shah NP, Dent S, Oeffinger KC. Low-touch, team-based care for co-morbidity management in cancer patients: the ONE TEAM randomized controlled trial. BMC Fam Pract. 2021 Nov 18;22(1):234. doi: 10.1186/s12875-021-01569-8. PMID: 34794388; PMCID: PMC8600877.


  • Zullig, LL. Oral: “The ONE TEAM Study.” Annual Breast Oncology Program Research Retreat, Duke Breast Oncology Group. Raleigh, NC; May 27, 2022
  • Zullig, LL. Oral: “ONE TEAM Onco-Primary Care Networking to Support TEAM-based Care: Study Design.” Duke Department of Population Health Sciences Research Seminar. Durham, NC; September 24, 2020.
  • Zullig, LL. Oral: “The ONE TEAM Study: Integrating implementation science principles to support TEAM-based onco-primary care.” Kansas University Medical Center Implementation Impact Research Collaborative Special Seminar. Kansas City, KS. April 21, 2022.
This page was reviewed on 02/14/2024