Life after cancer: Transforming the post-treatment experience
Forging stronger connections between the cancer care and primary care systems
After finishing cancer treatment and returning to primary or community care, many people still need ongoing support for:
- symptom management
- psychosocial needs
- lifestyle adjustments
- functional challenges
If not addressed, these concerns can have a major impact on a person’s quality of life — so it’s important that primary care providers know how to provide appropriate support. However, many do not have access to relevant information about the cancer treatments people under their care received or insights into cancer-related challenges in general.
Delivering optimal care during and beyond the care transition requires improved communication between healthcare providers and individuals receiving care, plus better coordination between the cancer care and primary care systems. The Partnership has supported initiatives across Canada to achieve those goals, helping primary care providers be better prepared to address the needs of people living with cancer.
How Cancer Care Alberta is helping to support better follow-up care
Primary care providers too often rely on patients to communicate the details of their cancer treatments. To increase communication and coordination across the cancer care and primary care systems, Cancer Care Alberta developed 14 sets of “transfer of care” letters — covering several cancer types and treatment discharge outcomes — that cancer care teams can send directly to both primary care providers and individuals receiving care. These letters outline the steps for follow-up care to be done by the primary care provider and include a list of potential symptoms and signs of recurrence.
With support from the Partnership, Cancer Care Alberta was able to:
- expand the reach and uptake of the letters through a change management campaign; and
- create a new website specifically for community and primary care providers.
The website now offers a single source of reliable information across all stages of the cancer journey, with the after-treatment surveillance pages providing links to content from the letters along with easy-to-navigate guidelines for follow-up care. Use of the letters by primary care providers has doubled due to the change management campaign.
How Quebec’s integrated health and social services centres are improving the survivorship experience
To help individuals in Quebec make the transition to life after cancer treatment, the Programme québécois de cancérologie (PQC) worked with cancer care teams from three health and social services centres (CISSS de Laval, CIUSSS de la Capitale-Nationale and CIUSSS du Nord-de-l’Île-de-Montréal) to develop a toolkit of French-language resources and strategies that cancer teams and front-line professionals can use to improve the experience for people after treatment.
The toolkit was developed with input from:
- physicians
- specialty cancer and front-line pharmacists
- researchers
- people living with cancer
- representatives from community organizations
It features several clinical and educational tools, including:
- a video to help healthcare professionals understand survivorship from the perspective of the individual receiving care;
- an end-of-treatment preparation tool (for the individual receiving care);
- a risk stratification tool to personalize and organize follow-up by the cancer professional;
- a support guide, developed by patient partners; and
- a medical transfer plan, written by a cancer professional for the primary care provider.
The toolkit also meets Accreditation Canada’s standards for information transfer during care transitions, which will enable it to be used across Canada.
The Partnership’s funding made it possible to free up professionals to reflect on and propose new ways of improving the transition after cancer. The various teams in Quebec who carried out the surveys and clinical tools were able to do so without fear that the project would be halted for lack of resources. They knew they were working as part of a good team, supported by a credible pan-Canadian organization.
-CISSS de Laval
Learn why cancer care transitions can be challenging from the perspective of Heather, a primary care provider.
Other initiatives supported by the Partnership
Reviewing the barriers and solutions for improving care transitions
With Partnership contributions, researchers at the McMaster Health Forum conducted two evidence reviews to better understand the transition from cancer care into primary or community care. The first looked at the barriers to optimizing the transition for people living with cancer and their families, and presented three elements in a comprehensive approach for addressing them. The second reviewed the key features of shared-care models designed to enhance coordination between primary care and cancer care, and whether they have an impact on an individual’s experiences and outcomes.
Connecting with adolescents and young adults living with cancer
Primary care providers may not see adolescents and young adults (AYAs) living with cancer often, but this video can help them be ready for when they do. Developed by the Partnership, Talk about it – Connect! gives primary care providers insights into the unique post-treatment needs of AYAs living with cancer
- Canadian Partnership Against Cancer. Living with cancer: A report on the cancer experience [Internet]. The Partnership; 2018 [cited 2024 Jan 25]. Available from: https://www.partnershipagainstcancer.ca/topics/living-with-cancer-report-patient-experience.