Improving Cancer Post-Treatment Transitions of Care

Dr. Linda Watson, RN, PhD, CON(C)

Scientific Director

Applied Research and Patient Experience

Elysa Meek, RN, BA, BN

Patient Education Specialist

CancerControl Alberta

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Faculty/Presenter Disclosure

Dr. Linda Watson

Relationships with commercial interests:

• Grants/Research Support: Alberta Cancer Foundation, Canadian Partnership Against Cancer

• Speakers Bureau/Honoraria: None

• Consulting Fees: None

• Other: Employee of CancerControl Alberta, AHS, President of the Canadian Association of Nurses in Oncology

• This Program is funded through

AHS Operational Funding.

• This Program has not received

financial support.

• This Program has not received

in-kind support.

• Dr. Linda Watson is presenting

at this Program on a voluntary

basis.

• Potential for conflict(s) of

interest: None

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Faculty/Presenter Disclosure

Elysa Meek

Relationships with

commercial interests:

• Grants/Research Support:

None

• Speakers Bureau/Honoraria:

None

• Consulting Fees: None

• Other: Employee of

CancerControl Alberta, AHS

• This Program is funded through

AHS Operational Funding.

• This Program has not received

financial support.

• This Program has not received

in-kind support.

• Elysa Meek is presenting at this

Program on a voluntary basis.

• Potential for conflict(s) of

interest: None

4

Objectives

• Define and explore survivorship trends

• Explore the issues that make survivorship care

challenging for primary care physicians

• Identify resources available to support patients at end of

treatment

• Discuss strategies for improved collaboration between

CancerControl Alberta and Primary Care

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Cancer Continuum of Care

Prevention screening Diagnosis Treatment

Survivorship

Cancer Survivorship is the period of well follow up care and

rehabilitation following cancer treatment; it addresses a comprehensive

range of survivorship issues for the duration of the survivor’s life

End of Life

Primary Care Primary CareCancer Care

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Alberta Health Services, 2019

Cancer

in

Alberta

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Alberta Health Services, 2019

Cancer in Alberta

8Stats Canada, 2014

Cancer Survivorship Picture (Canadian data)

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Impact on the Health System

Increasing Incidence

• Need capacity in the cancer system to get new patients in for consult and treatment quickly

Increasing survival

• Growing population requiring ongoing screening for recurrence, second primary, and late and long term effects

Growing prevalence

• Increasing burden of cancer in the general population

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Reality in CancerControl Alberta

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Primary Care Reality

Breast Cancer

Colorectal cancer

Prostate

Lung

Specialist

system

Generalist

system

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Common Survivorship Issues in

Primary Care

1. A history of cancer may actually divert medical attention

from other health issues unrelated to cancer

2. Most cancer survivors are 65 years and older and typically

have a number of comorbidities

3. Survivors face a spectrum of health concerns that are

different than those they faced prior to diagnosis that can

significantly impact quality of life

4. Survivors are at increased risk for secondary cancers

5. Specialized knowledge base is evolving quickly

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The survivor and their family often feel that they are

the ones that have to connect the systems and often

are not sure which system they need, for what problem

Patient Reality

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• Cancer survivors face short and

long term consequences as a

result of having been treated for

cancer and often require

rehabilitation, and supportive care

services

• Nothing prepares the patient or

family for the anxiety that follows

the completion of acute therapy

Patient Reality

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Post Treatment phase

…the most inconsistent phase of the cancer journey

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1. Consequences of cancer and its therapies have

been poorly understood

2. Medical school curricula and residency training

programs have emphasized the screening,

diagnosis, and treatment of cancer without focusing

on late effects of the cancer experience on survivors

3. Little research into effective models of survivorship

care and few implemented programs

4. Ineffective communication mechanisms between

Cancer care and primary care

Why?

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Provision of long-term survivorship care

A Collaborative Effort

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Overarching Goal

To guide system evolution and

integration so that Albertans finishing

cancer treatment receive excellent

post treatment follow-up care in the

survivorship phase of the cancer

journey regardless of where that

follow-up care is provided

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Improving Transitions Post Treatment in Alberta

Engage/

Understand

Design/

Develop

Implement/

Evaluate

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Engagement/Understanding

Literature

Research

Best Practices

across Canada

AHS

CCA

PCNs

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Primary Care

Engage and Understand

CCA Patients and Families

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Key Learnings: This is an Important Issue

Cancer TX Follow upDischarge from CCA

CCA

PC PC

Perspective of what is needed to improve transitions post Tx differed based

on which stakeholder group or motivator

Patients

Patients Patients

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Key Learnings

• Improving transitions must start

with provincial consensus on

follow up recommendations

• Follow up guidelines must meet

the needs of end users

(patient/families and primary

care providers)

• Consistent communication of

key elements to end users

must be simple

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Key Learnings (Patients)

CCA

Patients

PC

-Patients need more

information about follow up

care requirements to be

partners

in their post-treatment

follow up care

-the patients role in each

system is different

The patients don’t know what

they will need to know before

it happens

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Key Learning: Primary Care

• Consistent content areas

regardless of cancer type

• Include recommended follow up,

late and long term effects, signs

of recurrence, supports available

and other screening

recommendations

• Ensure easy route for PC to ask

questions of CCA and/or to return

patient to CCA if recurrence

identified

Surveillance:

Who is doing what

Consistent info

Easy access to answers/return

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Project Components

Guideline LettersAfter Treatment

Patient Resources

Finishing cancer

treatment?

NFR

Patient end of TX letter

Primary care End of

Tx letter

Patient transfer of care letter

Primary care

transfer of care letter

Primary care

transfer of care

Patient transfer of care letter

CCA will do surveillance

for recurrence

PC will do other CA

screening & symptom manage-

ment

NFR

CCA follow up / Shared Care

Give After Treatment

Book & Book into

Class

Invite patient to a

class and LYBL Event

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Guidelines

• Being developed by

Tumour Teams as

capacity allows

• Available on the

AHS external web –

accessible

anywhere:

www.ahs.ca/guru

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Tumour Type

Early Stage

Breast

Prostate (post

RT)

Testicular

Endometrial

Cervical

Hodgkin’s

B Cell

Lymphoma

Additional info for

Patient and Family

doctor:

• Signs and

Symptoms of

Recurrence

• Late and long term

effects of treatment

• Supportive care

services available

• Wellness and other

screening

recommendations

Disease Specific Letters

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Shared Care

Primary Care

Disease Specific Letters

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Provide information on:• Follow up appointments and tests

• Reminder to continue to see primary care provider

• Managing side effects

• Specific signs and symptoms of recurrence to watch for

• Disease specific follow-up (e.g. hormone therapy for prostate patients)

• Support and general recommendations

• Healthy lifestyle recommendations

• Disease specific areas of concern (e.g. Sexual health)

Disease Specific Letters

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Book and Class

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HealthChange® Methodology

HealthChange Methodology

Health service delivery methodology

• Evidence-informed suite of tools developed by clinicians

• Person-centred system for understanding and working with patients and families

• Promotes health-literacy, shared and full decision making

• Self-management focus

Developed in Australia, adopted by AHS

www.healthchange.com

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Personal

Self-Management

Plan

HealthChange® Methodology

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• 3 sections

• Friendly, accessible

narrative and

navigation

The Book

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Narrative & Navigation

i. Welcome & Purpose

ii. How to use the book

iii. Menu of Options

One thing at a time, one step at a time,

adding up over time.

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Greater focus on self-management

•HealthChange Methodology

•Concrete steps to Take Action

• Icons to set off actions to try

The Book

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The Class

Learning launch

• Interactive, workshop style

• Education focused but supports connection and

sharing within the scope of the material

• We explore ‘After Treatment’ as a condition

• Conversation based

• Make a ‘plan’ in the class – almost everyone leaves

with one

Current Availability

• Jack Ady Cancer Centre

• Tom Baker Cancer Centre (online registration)

https://app.bookking.ca/ahs_cancerpatienteducatio

npub/index.asp

• Cross Cancer Institute – AYA focus starting;

regular class offering being prepared

• Grande Prairie Cancer Centre (preparing to start)

• Any site can offer the class if they are ready

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Who is this for and where do I get it?

Who should have

this resource?

All patients finishing treatment except active end of

life palliative patients

Where can

I get the

book from?

• Online

• In print from DATA Group

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CancerControl Alberta Website

www.cancercontrolalberta.ca

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www.cancercontrolalberta.ca

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Thank You!

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Primary Care Educational Resources

https://www.cpd-

umanitoba.com/lessons/unit-1-the-

survivorship-phase-of-cancer/