If you or a loved one has ever come out the other side of cancer into post-treatment, you know that one chapter of the cancer journey may have ended, but another has begun.
That’s where the Transitions of Care program comes in. Established in 2014 by CancerControl Alberta with nearly $1 million in funding from the Alberta Cancer Foundation, the program seeks to ensure that cancer patients and their family doctors receive the information they need about recommended follow-up care and transitioning into a new normal once treatment has ended.
Integrating these new transition resources into clinical practice is currently underway across the province on a site by site basis. Each set of resources was informed by a team of physicians and other health-care professionals, including registered nurses, psychosocial oncology specialists and radiation therapists that specialize in the management of particular types of cancer.
Among this team is Calgary-based Dr. Linda Watson, provincial lead for Person Centred Care Integration. Watson says that, to build the Transitions resources, the team started by identifying three priority areas that would address the issues most in need of attention. The first was developing established provincial recommendations for follow-up care for each cancer type. The second was creating patient and primary care provider resources that mirrored and delivered those recommendations in ways that empowered patients and their family health care providers to partner more effectively in the recovery process. The third was working in tandem with community partners, such as the Wellspring cancer support network, to ensure an integrated approach supporting patients in the post-treatment phase of the their journey.
After gradually establishing provincial consensus on follow-up care recommendations for the seven cancers with the largest population of survivors (guidelines for hematology, for example, were only finalized this past May), and developing the different resources, the current work revolves around ensuring the correct transition information is shared with the patient and their family health provider at the right time.
When the Transitions resources are integrated into clinical practice, patients and doctors will receive information in the form of workshops and classes as well as letters and booklets — put together by Watson’s team in collaboration with expert provincial oncologist and clinical teams and provincial patient education teams — outlining things like recommended follow-up, signs of recurrence, where to get psychological and emotional support, and how to deal with long-term effects of their treatment. All information is tailored to the particular types of cancer populations. For instance, head and neck cancer patients receive information regarding the effects of radiation on their oral and dental health, and breast cancer patients are given information on rediscovering intimacy with their partners after a mastectomy.
Informing the creation of these educational aids are patient advisors — people who have experienced their own cancer journey and who share patient and family perspectives on the health care system. One such advisor, Bill Richardson, has dealt with both prostate and head and neck cancer and actively provides feedback on Transitions. He believes having a centralized resource like Transitions of Care that provides targeted information based on individual patient needs and situations will improve quality of life for cancer survivors and their families. “It helps to ensure that the province will have some information to help [cancer survivors and their families], and then gives them ideas of places where they can go depending on the type of cancer they have, where they live in the province and other factors,” he says.
Currently, the implementation of the Transitions resources has begun in a staggered fashion, starting with gynecological and genitourinary tumour groups at the Tom Baker Cancer Centre in Calgary and Lethbridge’s Jack Ady Cancer Centre, but Watson hopes it will be integrated widely across tumour teams and cancer care facilities soon.
“The reality is, improving transitions in care post-treatment is a huge issue across Canada and internationally, and this is a home-grown solution,” says Watson. “Part of the solution is
increasing awareness and plugging away with the work of creating these resources, and then following through and getting our clinical teams to utilize these Transition resources with their patients on a regular basis. We’re on the right path, it’s just not moving as fast as we would like because it’s such a huge gap.”