Background: Generalist involvement in cancer survivorship care is becoming a global trend, however, significant barriers exist. As a major cancer center in Taiwan, KF-SYSCC is implementing an academic institution-based comprehensive survivorship program, a PCP-coordinated care delivery model. Our goal is to promote health, manage chronic diseases, attend to psychosocial needs, and optimize health care resources without compromising cancer-related clinical outcome or patient satisfaction. Methods: We designed a randomized study with staggered transition of stage 0-3 breast cancer patients from oncologist care to the PCP-coordinated program at one or two years after cancer surgery. The outcomes for comparing the two care models include late effects of breast cancer treatment, anxiety and depression, health-related quality of life, recurrence-related clinical outcome, preventive care, chronic disease management, patient satisfaction, and health services utilization. Questionnaires were given every 6 months from 6 to 30 months after surgery. Results: Within six months, 270 eligible individuals were approached with an enrollment rate of 58% (target sample 1,200). The barriers for non-enrollment include: having established relationship with oncologist, transfer time too soon, lack of trust for non-oncologist, unwilling to change care provider, treatment not yet completed. The 113 non-participants did not differ from the 157 participants in age or cancer characteristics. Between the 1-year and 2-year transfer groups, there were no significant differences in demographics, tumor characteristics and treatment modalities. The initial BCPT and SF-36 questionnaires showed poorer performance in the areas of hot flashes, pain, cognition, weight, role physical, energy, and health perception, as compared with areas of bladder, vaginal, arm problems, physical and social functioning, mental health, and role emotional. Conclusions: We have started a randomized study to evaluate a generalist care model to survivorship care. Baseline patient characteristics were defined. Several barriers to the transition of the new care delivery model were identified.