Highlights
1. The CHIIP randomized trial found that a specialized survivorship care plan (SCP) intervention did not significantly reduce the undertreatment of hypertension, dyslipidemia, or glucose intolerance compared to a control group receiving basic risk assessments.
2. Despite the lack of primary endpoint significance, the intervention group showed a significant 14.8% improvement in primary care physician (PCC) documentation of cardiovascular risks compared to only 0.9% in the control group.
3. High levels of participant engagement were strongly associated with better outcomes, suggesting that the effectiveness of survivorship interventions depends heavily on patient activation and adherence.
4. The study highlights a critical ‘implementation gap’ in survivorship care, where providing information to patients and providers is necessary but often insufficient to change clinical management outcomes.
The Evolving Challenge of Cardiovascular Health in Cancer Survivorship
As pediatric oncology treatments have advanced, the population of childhood cancer survivors has grown substantially. However, this success comes with a price: the long-term ‘late effects’ of cardiotoxic therapies. Survivors exposed to anthracyclines or chest radiation are at a significantly higher risk for premature cardiovascular disease (CVD), including heart failure, myocardial infarction, and stroke. In fact, these survivors face a risk of chronic health conditions that is nearly six times higher than that of their siblings by age 45.
Despite these well-documented risks, a significant portion of this population remains undertreated for modifiable risk factors like hypertension, dyslipidemia, and diabetes. The transition from pediatric oncology to adult primary care is often fraught with fragmented communication. Many primary care physicians (PCCs) are unfamiliar with the specific screening guidelines for cancer survivors, and many survivors are unaware of their elevated risk profile. The Communicating Health Information and Improving Coordination With Primary Care (CHIIP) Study was designed to address this gap by evaluating whether a structured, counseling-based intervention could bridge the divide between knowledge and clinical action.
Methodology of the CHIIP Randomized Clinical Trial
The CHIIP study was a multi-center randomized clinical trial that recruited participants from the Childhood Cancer Survivor Study (CCSS) cohort across nine U.S. metropolitan areas. The study targeted adult survivors of childhood cancer who had been exposed to cardiotoxic therapies and had at least one undertreated CVD risk factor.
Participant Selection and Baseline Assessment
Of the 1,840 survivors initially approached, 347 met the strict eligibility criteria and were randomized. Eligibility required the presence of undertreated hypertension, dyslipidemia, or glucose intolerance, defined according to standard clinical guidelines (e.g., JNC or AHA/ACC for blood pressure). A unique feature of this study was the use of a trained home examiner to collect baseline and one-year follow-up data, including blood pressure measurements, lipid profiles, and hemoglobin A1c levels, ensuring high-quality, standardized data collection.
The Intervention vs. Enhanced Care
Participants were randomized into two groups:
1. The Intervention Group: Received a single remote counseling session focused on a personalized Survivorship Care Plan (SCP). This session reviewed the survivor’s specific cancer history, treatment-related risks, and current lab results. A follow-up ‘booster’ session was conducted four months later to review progress and troubleshoot barriers to care.
2. The Enhanced Care Control Group: Received their laboratory and measurement results with clear notations of abnormal findings. They also received written encouragement to follow up with their PCC. This is considered ‘enhanced’ because simply providing lab results is already a step above standard care for many survivors.
In both arms, the participants’ PCCs were sent the same materials provided to the survivors, ensuring that the clinicians were informed of the patient’s risk status and the recommended screening guidelines.
Key Results: Comparing SCP-Based Counseling to Enhanced Care
The primary outcome was the change in the status of undertreated CVD risk factors after one year. The results, published in JAMA Network Open, provided a sobering look at the challenges of behavioral and clinical change in this population.
Primary Outcome: Undertreatment Status
At the start of the study, approximately 53% of participants had undertreated hypertension, 51.9% had undertreated dyslipidemia, and 49% had undertreated glucose intolerance. After one year, 26.0% of the intervention group showed an improvement in their undertreatment status (meaning they were now receiving appropriate care), compared to 30.2% of the control group. Statistically, the intervention did not provide a significant benefit over the control (Odds Ratio [OR], 1.31; 95% CI, 0.84-2.05).
The Power of Engagement
While the ‘intent-to-treat’ analysis was negative, a secondary analysis revealed a significant ‘dose-response’ relationship. Participants in the intervention group who were more highly engaged—measured by their participation in the counseling sessions and adherence to the plan—were significantly more likely to have improved their risk factor control (OR, 0.31; 95% CI, 0.18-0.72). This suggests that the intervention works for those who use it, but engaging a broad, high-risk population remains a formidable hurdle.
Physician Documentation and Awareness
One of the most notable successes of the study was the impact on primary care documentation. The intervention group saw a 14.8% improvement in the documentation of cancer-related CVD risks in their medical records, compared to a negligible 0.9% improvement in the control group (P = .002). This indicates that the SCP-based counseling was effective at prompting survivors to discuss their history with their doctors, even if it did not immediately translate into changes in medication or physiological outcomes.
Critical Analysis: Why the Intervention Fell Short of Primary Endpoints
Several factors may explain why the counseling intervention did not outperform the provision of simple lab results. First, the ‘Enhanced Care’ control group was quite robust. In many real-world settings, patients do not receive clear, written interpretations of their lab results along with specific provider-facing guidelines. By providing this information to the control group, the researchers may have closed the ‘knowledge gap’ enough that the additional counseling provided little marginal benefit.
The Implementation Gap
The study highlights the distinction between ‘education’ and ‘implementation.’ Knowing that one has high blood pressure is step one; scheduling an appointment, receiving a prescription, and adhering to that prescription are steps two, three, and four. The CHIIP intervention focused heavily on education and planning, but it may not have addressed the systemic barriers to care, such as cost, time, or the clinical inertia of providers who may be hesitant to start new medications in relatively young patients.
Clinical Inertia and Risk Perception
The mean age of participants was 40.5 years. At this age, both patients and physicians may perceive cardiovascular risk as a ‘future problem’ rather than an ‘urgent problem.’ This bias can lead to a ‘wait and see’ approach, even when clinical guidelines suggest immediate intervention for survivors of cardiotoxic treatments.
Clinical Interpretation and Expert Commentary
Experts in the field of cardio-oncology suggest that the CHIIP study should not be viewed as a failure of survivorship care plans, but rather as a refinement of how they should be used. The significant improvement in PCC documentation is a crucial ‘process measure.’ Documentation is the first step toward long-term surveillance. However, to move the needle on physiological outcomes like blood pressure and cholesterol, we may need more ‘active’ interventions.
Potential future strategies could include:
1. Collaborative Care Models: Integrating pharmacists or specialized nurses who can titrate medications under a collaborative practice agreement, bypassing some of the barriers found in traditional primary care visits.
2. Direct-to-Provider Alerts: Using Electronic Health Record (EHR) prompts that trigger when a patient with a history of childhood cancer presents with a CVD risk factor.
3. Telehealth Monitoring: Using home-based blood pressure and glucose monitoring that feeds directly into the clinical workflow, providing real-time data to both the survivor and the clinician.
Conclusion: Moving from Education to Action
The CHIIP trial demonstrates that for long-term childhood cancer survivors, simply ‘knowing’ about risk is not enough to change the trajectory of cardiovascular health. While Survivorship Care Plans are excellent tools for improving physician awareness and documentation, they must be paired with more intensive implementation strategies to effectively manage hypertension, dyslipidemia, and diabetes. As we look to the future, the focus must shift from merely providing information to creating seamless, automated pathways that ensure high-risk survivors receive the evidence-based care they need to survive and thrive long after their cancer diagnosis.
Trial Registration and References
ClinicalTrials.gov Identifier: NCT03104543
Reference: Chow EJ, Chen Y, Yasui Y, et al. Counseling and Cardiovascular Disease Risk Factor Control in Long-Term Cancer Survivors: A Randomized Clinical Trial. JAMA Netw Open. 2026;9(2):e2555863. doi:10.1001/jamanetworkopen.2025.55863.
