Our aim is to improve coordination of care to improve the quality of care provided to cancer survivors.

Cancer survival has improved dramatically and the prevalence of cancer survivors is increasing. It is estimated that 3% of the population are cancer survivors, translating to approximately 800,000 Canadians. The survivorship phase represents a major point of care transition from specialist care to primary care.

Healthcare systems are challenged on a number of fronts to provide the most appropriate care to cancer survivors, including coordination among providers for:

  • cancer follow-up care including¬†surveillance for recurrence, late effects and second cancers
  • rehabilitation and management of pre-existing chronic health conditions
  • general preventive care.

Moreover, the volume of cancer patients has caused cancer centres to re-examine priorities in terms of workload. Although primary care providers have repeatedly shown willingness to assume responsibility for cancer follow-up care, these circumstances require enhanced communication and knowledge transfer between cancer care providers and primary care, together with clear identification as to role responsibility. In short, optimum survivor care requires long-term coordination among inter-professional teams that includes oncology care, but with primary care as a key locus of care.

We are studying variations and gaps in the quality of survivorship care in order to:

  1. Identify clinical and sociodemographic determinants of later morbidity and need for higher levels of care in order to stratify subgroups of survivors according to level of risk of morbidity and need for follow-up care.
  2. Examine care patterns and relationships between oncologist and primary care providers.
  3. Determine gaps in adherence to guideline recommended follow-up care.

Patient groups at risk for sub-optimal care will be identified with a focus on our specified vulnerable populations (the elderly, new immigrants, those living in rural/remote regions). The role of comorbidities in cancer survivorship care will be considered. We will identify variation and gaps in quality survivorship care considering cancer-specific follow-up care, comorbidity-related general medical care, and age-appropriate general preventive care.