TBM ORIGINAL RESEARCH

Process of diffusing cancer survivorship careinto oncology practice

Irene Tessaro, DrPH,1 Marci K Campbell, PhD,2 Shannon Golden, MA,3 Mindy Gellin, RN, BSN,2

Mary McCabe, RN, MA,4 Karen Syrjala, PhD,5 Patricia A Ganz, MD,6 Linda Jacobs, RN, PhD,7

Scott Baker, MD,5 Kenneth D Miller, MD,8 Donald L Rosenstein, MD2

ABSTRACTThe LIVESTRONG Centers of Excellence were funded toincrease the effectiveness of survivorship care inoncology practice. This study describes the ongoingprocess of adopting and implementing survivorship careusing the framework of the diffusion of innovation theoryof change. Primary data collection included telephoneinterviews with 39 members from the eight centers andsite visits. Organizational characteristics, overallprogress, and challenges for implementation werecollected from proposals and annual reports. Creating anawareness of cancer survivorship care was a majoraccomplishment (relative advantage). Adoptiondepended on the fit within the cancer center(compatibility), and changed over time based on trial anderror (trialability). Implementing survivorship care withinthe existing culture of oncology and breaking downresistance to change was a lengthy process (complexity).Survivorship care became sustainable as it becamereimbursed, and more new patients were seen(observability). Innovators and early adopters were crucialto success. Diffusion of innovation theory can provide astrategy to evaluate adoption and implementation ofcancer survivorship programs into clinical practice.

KEYWORDS

Cancer, Survivorship care, Diffusion of innovation,Implementation

BACKGROUNDAn aging population and the earlier detection ofcancer through screening have increased the numberof cancer patients, and more effective therapies haveenabled people to live longer with cancer [1]. Addedto this is the prediction that there will be insufficientnumbers of oncologists available to meet the needs ofcancer patients as well as survivors in the future [2].Cancer survivors are not only at increased risk fordeveloping a second cancer but also, as they age, forchronic illnesses that can affect survival [3]. Thus,there is an increasing need for posttreatment survi-vorship care to promote healthy lifestyle behaviors,such as smoking cessation, physical activity, nutrition,and a healthy weight; surveillance for new andrecurring cancer and late effects of treatment; inter-

ventions for the consequences of cancer and itstreatment; and care coordination [3].Between 2004 and 2008, a number of National

Cancer Institute-designated comprehensive cancercenters were invited to respond to an invitationfrom the Lance Armstrong Foundation (LAF) toapply for grant funding that would provide theLIVESTRONG Survivorship Center of Excellence(COE) Network designation and infrastructuresupport for program development. Eight centerssuccessfully competed for funding to join thenetwork, and each program identified three com-munity affiliates as partners. The goals of theLIVESTRONG Network are to (1) increase thequality of life for cancer survivors, (2) transformhow survivors are treated and served, (3) contributeto the collective body of knowledge on survivor-ship, (4) increase the accessibility and quality ofservices for survivors, and (5) explore reimburse-ment issues and develop financial strategies to coverthe cost of survivor care [2]. Network goals areaccomplished by the COEs working collaborativelywith one another and their community affiliates toidentify best practices and develop models of carethat will provide cancer survivors with comprehen-

12009 Pershing Street, Durham,NC 27705, USA2Lineberger Comprehensive CancerCenter,University of North Carolina,Chapel Hill, NC 27599, USA3Goldsmith Research Group,Winston-Salem, NC, USA4Memorial Sloan-Kettering CancerCenter, New York, NY 10021, USA5Fred Hutchinson Cancer ResearchCenter, Seattle, WA 98109, USA6Jonsson Comprehensive CancerCenter, Los Angeles, CA 90095-6900, USA7Abramson Cancer Center,University of Pennsylvania,Philadelphia, PA 19104, USA8Sinai Hospital Medical Oncology,Baltimore, MD 21215, USACorrespondence to: I Tessaroirenetessaro@yahoo.com

Cite this as: TBM 2013;3:142–148doi: 10.1007/s13142-012-0145-4

Marci K Campbell is deceased.

ImplicationsPractice:Recognizing barriers and facilitators forchange when introducing a new practice (cancersurvivorship) into oncology services is essentialfor program success.

Policy:Adequate and continuing resources along withorganizational commitment and support are essen-tial for adoption and implementation of cancersurvivorship care into clinical care.

Research:Research to identify what does and does not work inthe process of adopting and implementing survivor-ship programs in a clinical setting should occur fromthe beginning to make sure programs continue.

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sive medical follow-up for recurrence and lateeffects, screening for second cancers, developingongoing wellness initiatives as well as buildingsupport services for survivors, education for healthproviders and survivors, and building communityinitiatives and partnerships [2]. Collaborative re-search is also an overarching goal of the network,and there have been and continue to be a number ofresearch projects conducted across the network.In 2008, the LAF funded a study to examine the

clinical survivorship care and organizational charac-teristics of the eight COEs and provide key recom-mendations for future efforts. Using bothquantitative and qualitative data, findings from thestudy offered support for several domains of thechronic care model (CCM) which emphasizes theimportance of six elements essential to improvechronic illness care: health system organization,delivery design, clinical information systems, self-management care, decisional support, and commu-nity linkages [4]. A major issue that emerged fromthe qualitative data was the experience of the COEsin adopting and implementing the survivorship careprograms into the oncology practices of theirinstitutions. The current manuscript presents find-ings related to this process using the framework ofdiffusion of innovation theory.

Diffusion of innovations theoryDiffusion of innovations is a theory of social andcultural change developed over 50 years ago byEverett Rogers [5]. As defined by Rogers, diffusionof innovations is a process, not a discrete event,through which an innovation, defined as a new idea,practice, or object, unfolds over time through thecommunications networks of members of a system[5]. According to Rogers, there are five elementsthat make an innovation more likely to be adoptedover time: (1) there is a relative advantage over what iscurrently being done; (2) it is compatible or fits withorganizational or professional culture and values,norms, perceived needs, and ways of working withlittle disruption; (3) it is not difficult to understandand there are few barriers to overcome (complexity);(4) it can be tried on a limited basis (trialability); and(5) the benefits are visible to others (observability). Ifpotential adopters can adapt, refine, or otherwisemodify the innovation to the local context, it willalso be adopted more easily [5]. New conceptsusually come from outside the current system, butfor change to occur, processes need to come locallyfrom inside the system [6]. Individuals or organiza-tions adopt innovations at varying rates. Innovatorscan imagine the possibilities and are eager to try itout; early adopters learn about the advantages frominnovators and make a connection between the newpractice and the needs; others (early majority adopters,late majority adopters) follow as they see the advan-tages, and laggards are the last to adopt, if at all [5].

A great deal of research in a variety of academicdisciplines has been conducted on the diffusion ofinnovations since the development of the theory. Themajority of diffusion studies rely on quantitative data,usually via surveys, and study the rate of adoption of asingle innovation at a single point in time afterwidespread diffusion has already taken place [7]. Theinnovation is most often a simple, product-basedinnovation, for which the unit of adoption is theindividual and diffusion occurs by means of simpleimitation [5]. When the unit of adoption is a complexorganization, the aforementioned “standard” charac-teristics of an innovation are necessary but notsufficient to explain or guarantee the adoption andimplementation of complex innovations in organiza-tions [8]. The rate of adoption depends on theinteraction among a particular innovation, theintended adopter and the situational context [8].The adoption of a new clinical practice is not a linear

process; and scientific evidence, although useful, is notsufficient in itself for diffusion of a new practice orbehavior [9, 10]. In practice, medical behavior isshaped as much by experience and peer comparisonas by scientific evidence from randomized clinicaltrials or other high-quality studies [9]. Decisions aboutimplementing best evidence practices are driven bythe interplay between the interests of the patient, theclinician, and the healthcare system [11]. We need tounderstand more about the adoption and implemen-tation process if we want to accelerate incorporation ofevidence-based programs into practice to improvehealth care quality. Although much attention iscurrently focused on dissemination and implementa-tion research, relatively few theories and models havebeen applied to studying this in the context ofincorporating cancer-related interventions into healthsystems [12, 13].

METHODSData collectionStudy data collected from the eight participatingCOEs is listed in Table 1. Three primary sources ofqualitative data were collected: program data,telephone interviews, and site visits. Program datawere collected from the eight proposals and 22annual reports available for analysis at the time ofthe study. The reports covered the first and secondyears of progress in all COEs and for years 3 and 4in the five earliest-funded centers. Program dataanalyzed for this manuscript included organizationalissues concerning cancer survivorship, models ofcare, change over time, prior survivorship initia-tives, and processes and lessons learned duringCOE development. Telephone interviews were com-pleted with 39 COE members during May and June2009 (Table 2). With permission, interviews wereaudio-taped and transcribed verbatim. An open-ended interview script utilized the framework of theCCM [4, 14] and added questions about thestrengths and weaknesses of the COE, challenges

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(lessons learned) for program development, impor-tant accomplishments of the COE, changes overtime, and the value of survivorship care to oncologypractice. Site visits were conducted in May 2009 withthree of the earliest-funded COEs. Each site visitlasted 1 day and was led by a two-person staff andresearch assistant team. Individual and group meet-ings were held with COE staff and affiliates, andobservation of facilities was conducted. Field noteswere taken during the visit. Site visits providedobservational data related to operations and facili-ties, as well as situational background that provideda more in-depth understanding of issues, institution-al context, and challenges faced in program devel-opment. Study protocols and materials wereapproved by the Institutional Review Board of theUniversity of North Carolina at Chapel Hill.

AnalysisProgram data (annual reports), transcribed tele-phone interviews, and site visit field notes wereimported into a qualitative data management soft-ware program (ATLAS.ti 5.0). Data were reviewedseveral times, and a codebook, developed. Contentwas coded using the initial framework of the CCMand additional questions about the COE providing apreliminary list of codes (deductive), which weresupplemented with emergent codes (inductive) asanalysis proceeded [15]. Data were coded and

analyzed by two independent investigators (IT,SG). The unit of analysis was the site (COE). Theinvestigators independently coded a sample of fiveinterview transcripts, reaching agreement on codedefinitions and decision rules and checking inter-coder reliability until the kappa statistic reached0.70–0.80. Analysis revealed themes (patterns) de-termined by the strength, depth and frequency ofconcepts, and consistency between the sites (COE),derived from the coding process.

RESULTSThemes related to the diffusion process are pre-sented below with supporting quotes from theinterviews and site visits. These include the follow-ing: creating awareness (relative advantage); makingthe cultural shift and start where they are (compat-ibility), trial and error (trialability); change is veryhard and very slow (complexity); and the bottomline (observability). These themes are also presentedin Table 3.

Relative advantage

Creating awarenessCreating an awareness of the scope and need forcancer survivorship care, as opposed to traditional

Table 1 | Data collected from each of the eight cancer centers involved in the study

Cancer center Year COEstarted

Annual reportsa

(n=22)Telephone interviews(n=39)

Dana-Farber Cancer Institute,Harvard University

2004 4 4

Memorial Sloane-Kettering Cancer Center 2005 3 5Fred Hutchinson Cancer Research Center /Seattle Cancer Care Alliance

2006 3 5

Jonsson Comprehensive Cancer Center,University of California Los Angeles

2006 3 5

University of Colorado Cancer Center 2006 3 3Ohio State University ComprehensiveCancer Center

2007 2 5

Abramson Cancer Center, Universityof Pennsylvania

2007 2 6

Lineberger Comprehensive CancerCenter, University of North Carolinaat Chapel Hill

2008 2 6

a Indicates number of years a COE at the time of the study (2009)

Table 2 | Characteristics of interviewees from the eight COEs

Position n %

Center director or co-director 12 31Clinical personnel 10 25Administrators/coordinators 12 31Other affiliated personnel 5 13Time with COELess than 2 years 11 282 years or more 19 49Since beginning of COE 9 23

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posttreatment care, was considered by many as themajor accomplishment of the COEs. As one re-spondent said “we're putting survivorship on themap.” Raising awareness was accomplished throughvarious educational venues, such as integrating withthe standing lecture series at the cancer center,adding survivorship-focused talks to preexistingannual disease-specific patient conferences, onlineand in-house continuing medical and nursing edu-cation courses, presentations for oncology andprimary care practices, grand rounds presentations,survivorship conferences for health care professio-nals, and educational events for providers andsurvivors in the community.

“The most important accomplishment for theCenter of Excellence, to look at it from theclinical side, is that it has brought into awarenessin a new way for the treating physicians and forthe cancer center, some of the concerns ofpatients after treatment. That's a culture changethat has definitely begun.” (clinical coordinator)

Compatibility/fit

Making the cultural shiftCreating the awareness that survivorship is somethingseparate and different from traditional oncology carewas a challenge. Oncologists typically focus on treat-ing and curing active disease and tend to providefollow-up care and surveillance even when patients areyears posttreatment. As one clinician commented onshifting this traditional paradigm, “it's moving a freighttrain in a slightly different direction.”

“We probably have similar experience to otherpeople in that it's a change in culture. Everythingis so focused on treatment and the immediacy ofthose problems that these patients are the wellestof the well, so to speak, that come here. They arenot dying and they're not in active treatment sothere hasn't been a lot of emphasis on theresources they need.” (COE director)

“[Survivorship care] comes from a very longhistory of a medical model. We are a very high-profile, research-evidence-based center, and a lotof research is geared toward eradicating cancerand that's what the philosophy is.” (clinicalcoordinator)

Resistance to making changes in survivorship caretook several forms: it was already being done;oncologists did not want to “give up” their patients;there was little evidence for the effect of survivorshipinitiatives on outcomes; there was little time to changethe system of services; and there was limited or noreimbursement for the services. Survivors also wereattached to providers and felt comfortable there.While most COEs reported a high level of

commitment from the senior leadership of theirinstitution, this did not necessarily translate intobuy-in among the practitioners and administratorsthroughout the system.

“The leadership of the cancer center is behindsurvivorship at the very top. I think that there aresome challenges in the mid-section, if you will,from both some of the medical leaders being asenthusiastic as the head of the cancer center andthereby helping to facilitate things happening.”(clinical coordinator)

Start where they areAll COEs completed needs assessments to explore(1) what was currently being done for survivorshipcare and education in practices in their institution,(2) what providers and patients needed and wantedregarding survivorship care, and (3) how to adaptsurvivorship care to make it fit with their site's needsand constraints. The needs assessments were admin-istered using a variety of methods (questionnaires,online surveys, key informant interviews, focusgroups).COEs started the process of adopting survivorship

care with those oncology practices and individualoncologist that saw the benefit for their patients.Some of the COEs started with separate survivor-

Table 3 | Diffusion characteristics, study themes and strategies to promote adoption, and implementation of survivorship care

Diffusion characteristic Themes Strategies for change

Relative advantage–perceived asbetter than before

Creating awareness Widespread education

Compatibility/fit – consistent withvalues, habits, experiences ofpotential adopters

Making the culturalshift; start wherethey are

Find the best fit for survivorship care with theinstitution's organizational and professionalculture

Trialability–experiment beforecommitment

Trial and error Flexibility and change in the models of carethat work for the practice and institution

Observability/visibility–tangibleresults

The bottom line Funding, institutional support, andreimbursement

Complexity/ease of use inunderstanding or using innovation

Change is very hardand change is veryslow

Education and training for professional staff toimprove performance

Innovators and early adopters Champions Identify leaders, invest time, and commitment

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ship clinics, relying on individual practice areas torefer their long-term patients. However, the ultimategoal for some COEs was to integrate survivorshipcare into the various oncology practices. In eithercase, the COEs relied on the decision of theindividual oncology practices to see how this was afit for them, both in terms of referrals to a separateclinic or for integration into the practice.

“Selling a package of resources really took sometime, a lot of patience and spending lots and lotsof time with people, particularly the treatingphysicians and the nurses, about what wouldwork in their area and what they thought wasgood for them. There are always champions andthere are always naysayers so I started with thechampions, people who wanted to do it.” (COEdirector)

Trialability

Trial and errorModels of survivorship care and implementationdepended on fit within the cancer center andchanged over time based on trial and error. Virtuallyall COEs started with a different model of care fromtheir current model(s) for survivorship care. Manyused more than one model, depending on thedisease group and setting. All COEs tried out anumber of different models of care before decidingon which model(s) worked for their institution.Some models of care worked in one clinic but notin another. A few COEs were integrating survivor-ship care into oncology practices, but in some cases,logistics of time and space constituted a barrier.Being a part of the LIVESTRONG network ofCOEs was helpful to learn about the experiencesothers had in the process of adoption.

“It's been an evolution. Every clinic that we startup, we've learned new things and we've takenwhat we've learned from the other clinics, bothsuccesses and failures. We've been able toexpand on the program and have used thelessons from the previous clinics to improveupon existing clinics and future clinics.” (Projectadministrator)

Complexity

Change is very hard and change is very slowChanging any system is difficult, especially a healthcare system. The complexity in adding survivorshipcare to the existing practice of oncology, particularly inthese largemedical institutions, was a major challenge.Changing culture and building consensus for change isa lengthy process. This process is multifaceted and a“moving target,” always evolving and requiring con-siderable time, effort, and commitment. Programs,

particularly the establishment of survivorship clinicalprograms, took longer than expected in most COEs.

“There is an honest realization from my part thatintegrating any new service into oncology is along-term proposition, just as palliative care tookyears to reach a state of being recognized, whichit is now. ” (COE director)

Several factors made this a complex endeavor,including resistance to change from oncology prac-tices, piloting numerous models of care, inadequatestaff, and the general logistics of setting up a newprogram. Each COE had its own barriers thatslowed down the process.

“There is constant resistance. Every single initia-tive that I've mentioned has met with resistanceand then eventually it becomes part of theinstitution. I think you have to be persistent,because change doesn't happen overnight.” (COEdirector)

To help reduce the perceived difficulty or com-plexity of the innovation, education and training toraise awareness and to provide an overview of lateeffects of treatment and general guidelines forproviding optimal survivorship care was providedto nurses, nurse practitioners (NPs), and physicians,as well as to social workers, psychologists, and otherhealth professionals.

Observability/visibility

The bottom lineFunds from LIVESTRONG were instrumental ininitiating or enhancing survivorship care. Having theinitial grant funding was considered an importantrecognition for these research-oriented institutions,most of which probably would not have provided theresources needed for a survivorship care program.This funding enabled COEs that had already estab-lished survivorship programs to expand their efforts.

“The funds have been extremely important.Early on they were critical to be able to getthings up and running and show some momen-tum and to demonstrate to the powers that bethat this was something that could and should bedone.” (COE director)

“The fact that this new area had national fundsbehind it and that there was a grant opportunity,got a lot of the academic physicians' attentionbecause that's how they make their careers iswith grants.” (COE director)

A major issue for the COEs was that, for the mostpart, survivorship care does not provide significantreimbursement. Therefore, it was important for thecancer centers to develop sustainability plans for these

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survivorship programs. COEs accomplished this invarious ways. For example, they demonstrated thebenefit for practices of decreasing the number of long-term follow-up patients, thus allowing oncologists tosee more new patients, and/or they establishedmechanisms of reimbursement for theNPs who staffedthe clinics. The NPs at some COEs were supported byinstitutional funds and at others through philanthropy.

“The other big piece of it is in winning overhospital administrators because the bottom lineis they are interested in budget and what bringsmoney in or certainly what's a service that addsvalue in some way. ” (COE director)

Innovators and early adopters

ChampionsProgram leaders, steering committees, leadershipteams, and individual oncology groups were crucialto the success of the COEs. These champions werethe early adopters of this process, helping to breakdown resistance for oncology to make that “culturalshift” to survivorship care as standard practice. Theinput of these groups early on was invaluable toaffect these changes and reach a consensus on howto deliver this kind of care within a particular cancercenter. Getting these opinion leaders involvedhelped obtain institutional commitment, which oftenincluded the resources to help sustain the program.These champions of survivorship care understoodthat the existing model for long-term follow-up carewas not sufficient; those visits were very short andmainly involved evaluation for recurrence. In addi-tion, oncology practitioners were frequently over-whelmed, and there was an institutional push to seenew patients rather than the same long-term patientsyear after year.

“Because of the oncology work force issuesnationally and locally, people are starting torealize that they can't hold on to all these patientsand give them adequate follow-up care. Thereare just too many patients.” (COE director)

DISCUSSIONStudy findings show the experience of the LIVE-STRONG Centers of Excellence in the process ofdiffusing a new practice, survivorship care, into theexisting organizational structure of oncology practice.Groups involved in setting clinical policy are part ofhighly complex networks of social relationships thataffect their practice, and the complexity and variabilityof local contexts ensure that there is no one way tointroduce innovations [9]. While each COE is uniqueand the best model for survivorship care in each isdependent on the context and history of the parentinstitution, there are similar processes in developing

new programs for cancer survivors in an existingsystem. In this study, the characteristics of the diffusionmodel (relative advantage, compatibility, complexity,trialability, and observability) in influencing adoptionand implementation of cancer survivorship programswere evident. Table 3 summarizes these study findingsand the strategies used by the COEs.Different organizations provide widely differing

contexts for innovations, and some features oforganizations, both structural and cultural, influencethe likelihood that an innovation will be successfullyadopted into practice [6, 9]. If the innovation startsout with a budget as well as adequate and continuingresources, there is a flexible organizational structure,and top management supports and advocates for theprocess with continued commitment, then an inno-vation is more likely to be adopted [8, 11]. TheCOEs had a budget from LIVESTRONG to startthe process and raise awareness; however, thisfunding was time-limited. COEs that had strongerinstitutional support and developed reimbursementstrategies for survivorship services were furtheralong in this process. A key determinant of success-ful innovation is whether the new routine associatedwith the innovation aligns rather than conflicts withorganizational and interorganizational routines. Ifpeople are uncomfortable with the status quo anddesire change, a potential innovation is more likelyto be successfully adopted [16]. Alignment withroutines and an understanding of the “culture ofoncology,” as well as flexibility to try an approachand then change to another approach as needed,were important attributes in the diffusion process forthe COEs. Oncologists often had to be persuaded ofthe relative advantage of a survivorship program:they tended to want to follow their own patientsindefinitely, even though patients' needs and oncol-ogists' workloads were issues that needed to beaddressed. To an important extent, timing favoredCOE development, in that workforce limitationswere being recognized and published in the sameperiod as the onset of the survivorship programs.Center administrations were thus primed to value achange in the status quo.The active support and involvement of opinion

leaders was cited repeatedly in the interviews, anddiffusion theory supports the importance of theseprogram champions to enact change and demon-strate new ideas to later adopters. The influence ofopinion leaders and champions is a powerful factorfor making organizational changes in a variety ofsettings [8]. While impersonal channels of commu-nication, such as brochures and publicity about anew program can create awareness of an innovation,interpersonal influence through social networks is adominant mechanism for diffusion [8, 17], particu-larly as programs develop [18]. If respected andinfluential clinicians argue for and demonstrate theapplication of a new procedure or treatment ap-proach, it is likely to have a positive impact uponadoption rates [19].

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In the case of adopting survivorship care intostandard practice, influence needed to occur atmultiple levels, including top-down support fromadministrators and day-to-day buy-in and supportfrom clinicians, nurses, and other key personnel, aswell as patient feedback. In addition to promotingthe relative advantage and benefits of survivorshipcare, these individuals were key for issues such asfinding flexible strategies to promote compatibility,and providing visibility in their care and referralpatterns. Opinion leaders in administration werealso instrumental in providing other features toassure survivorship clinic success. This includedsuch basic resources as space for the clinic, sched-uling, intake procedures, and other basic resourcesrequired for successful patient care.For innovations to spread, it takes time, energy,

and money [6]. Facilitators for change for the COEsincluded the large number of patients and the needto make room for new patients, the funding thatstarted or enhanced efforts, and the early adopterswho helped promote the idea, as well as the timeand energy of those innovators who wrote the grantto begin the process. Much of the success of theCOEs can be attributed to the vision, persistence,and hard work of these leaders who devoted timeand energy to pursuing survivorship as a priority intheir institution. Additionally, LIVESTRONG fund-ing provided the recognition and “branding” tocreate an interest and priority in survivorship andgave a boost to existing survivorship programs.Barriers to change included resistance from oncol-

ogy practices, lack of financial support from the parentinstitution, the logistics of setting up a new program ina large institution, and the slow pace of change.Changing the culture of oncology was considered amajor challenge, particularly changing the awarenessof survivorship care needs and overcoming thereluctance of oncologists to give up a positive aspectof their practice, i.e., the opportunity to see thrivingsurvivors. Commitment from the senior leadership ofthe cancer center for the survivorship programs didnot necessarily translate into buy-in among the practi-tioners and administrators throughout the system, nordid it translate automatically into resources to supportthe change. Organizational commitment from thecancer center at the highest level was necessary forsuccess but was insufficient to ensure that survivorshippriorities were actualized.There are several limitations to this study. The

process of diffusion illustrated here does not necessar-ily apply to all oncology practices. These COEs werein major research and teaching hospitals, all NationalCancer Institute-designated comprehensive cancercenters. Research is a major initiative in these high-profile and high-volume medical centers, and thisoften takes priority and resources. Several of the

cancer centers already had begun initiatives to redirectcare of long-term survivors, both adults and children,and large numbers of oncology patients were long-term survivors in the large-volume practices of thesemedical centers. This may not be true of smallerhospitals or of private practices.

CONCLUSIONDespite any limitations the diffusion of innovationsframework provides insight into the complex processof incorporating a new survivorship paradigm intoclinical care. As more cancer survivorship programsbecome standard care, this studymay offer insight intothe factors important to consider when affectingchange within the institutional setting.

Acknowledgments: This research was supported by funding from theLIVESTRONG Foundation.

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