Structured Transition for Childhood Cancer Survivors

(BRIDGES-YAS! Trial)

Although 95% of young adult childhood cancer survivors (YA CCS) will develop chronic health conditions, suboptimal transition to adult-oriented care leads to \<20% receiving recommended lifelong survivorship care. YA CCS survivorship follow-up care at the pediatric cancer treatment center is limited by organization- and patient-level barriers. This study overcomes these barriers by transitioning survivors to community adult primary care providers (PCPs) after orienting PCPs to survivors' individual survivorship care needs and educating YA CCS regarding health self-management/advocacy. This study includes a remote transition approach for YA survivorship care that leverages community PCPs, telehealth, and nurse navigators (NNs). BRIDGES-YAS! will investigate a novel, remote, multi-level intervention to transition YA CCS to community adult PCPs for a survivorship visit versus usual cancer treatment center (CTC) based follow-up care (plus educational handout about transition). The 1-year intervention includes: 1) tailored telehealth CCS education and resource navigation with self-management and self-advocacy skills training by a CTC NN, 2) brief, structured, interactive phone handoff by CTC NN to the community PCP conveying the CCS's individualized survivorship care needs, 3) secure electronic storage on CCS' smartphone (or other device) of Survivorship Care Plan and established health education materials, and 4) ongoing NN support and communication between CCS, CTC, and PCP. If successful, this intervention strategy could readily be deployed in cancer treatment centers to improve adult survivor access to quality, community-based survivorship care.