Community and Academic Synergy for Cancer Survivorship Care Delivery Enhancement (Project CASCADE): a study protocol for a pragmatic, stepped-wedge, cluster-randomized trial in Texas primary care community health centers

In the United States, over 18 million individuals are living with cancer. The majority of these cancer survivors also manage other chronic conditions and receive care from multiple specialists, including oncology, cardiology, and primary care clinicians. However, it remains unclear who holds primarily responsibility for coordinating their care across specialties. Because of its generalist nature, primary care is uniquely suited to deliver whole-person and coordinated care for all conditions for cancer survivors. However, primary care teams experience many challenges delivering high-quality survivorship care. While integrating care for all conditions including cancer is a core principle of high-quality primary care, few survivorship care delivery interventions have been developed and tested among patients with a history of cancer in primary care panels of community health centers (CHCs). These under- and uninsured cancer survivors experience disproportionately worse health outcomes and often rely solely on CHCs for consistent health care. Community and Academic Synergy for Cancer Survivorship Care Delivery Enhancement (Project CASCADE) is a theory-driven pragmatic hybrid trial testing implementation and effectiveness of a multi-component primary care-based survivorship care delivery intervention among 8 Texas CHC sites. The specific aims are: Aim 1: Implement a system-level cancer survivorship care delivery intervention in partnership with CHC clinicians, patients, and community representatives, which includes: (1) primary care clinician training in cancer survivorship care through provider-to-provider tele-mentoring, (2) identification and tracking of survivors by modifying existing clinic workflows, and (3) coordinating survivors’ care by designating a care coordinator champion. Practice facilitation and stakeholder engagement strategies will support intervention implementation; Aim 2: Test the effectiveness of the intervention on patient (screening for second primary cancers) and clinician outcomes (clinician knowledge of and confidence in survivorship care) using a stepped-wedge clinic-randomized design; and Aim 3: Evaluate implementation using a mixed-methods approach guided by the Practice Change Model. We will utilize electronic health record (EHR), survey, interview, and observation data to assess effectiveness and implementation outcomes. Findings will inform a scalable, generalist primary care-based survivorship care model to enhance care delivery and outcomes in CHCs serving vulnerable populations. This study represents a critical step toward addressing gaps in cancer survivorship research and achieving equitable care for all survivors. This study is registered under clinical trial registration number NCT06883838; 2025–03-12.