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Restructuring!Cancer!Services!for!Survivorship!Care:!The$Ontario$Experience

Dr. Carol Sawka MD, FRCPC VP, Clinical Programs and Quality Initiatives

Cancer Care Ontario Professor of Medicine, University of Toronto

August 30, 2012

UICC World Cancer Congress

Setting the context for healthcare in Canada Canada:!

•  >"33"million"people,"9.9"million"sq."km"•  10"provinces,"3"territories"•  Healthcare:"na;onal"strategy,"provincial"plans/

implementa;on"•  Cancer"services"uniquely"organized"in"most"

provinces""

"Ontario:!!•  >"13"million"people,"1.1"million"sq."km."•  Est."72,300"incident"cases"in"2012"•  Colorectal,"Lung,"Breast"and"Ovarian""

have"high"rela;ve"rates"of"survival""interna;onally"

2!

About Cancer Care Ontario

Mandate!•  Provincial"government"agency"

responsible"for"con;nually"improving"cancer"services"

"

Mission!•  Improving"the"performance"of"the"

cancer"system"by"driving"quality,"accountability"and"innova;on"

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In Ontario, cancer incidence is increasing….

4 Ontario Cancer Plan III 2011-2015

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…. as are 5 year Cancer Survival Rate for those living with cancer

… leading to a 40% increase in the number of Ontarian’s living with cancer

Ontario Cancer Registry 6

406,000"

Ontarians"will"be"living"with"cancer"by"2017.!

Inconsistency in follow-up visits with Specialists* for Breast Cancer Patients

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Figure!1:!%!Breast!Cancer!Survivors!with!at!least!one!followBup!visit!by!specialists*!in!Regional!Cancer!Centre!!12B24!months!aHer!their!diagnosis!in!2009.!

67"

35"40"

71"79" 80"

59"67"

88"95"

81" 85"93" 93"

0"10"20"30"40"50"60"70"80"90"

100"

A" B" C" D" E" F" G" H" I" J" K" L" M" N"

%"Pa;ents"Followed["Up" """"""Provincial"Average"*"Specialists"include"Medical,"Radia;on"and"Surgical"Oncologists"in"Regional"Cancer"Centres"in"Ontario""""Source:"Ontario"Cancer"Registry,"Ac;vity"Level"Repor;ng,"Discharge"Abstract"Database"and"Na;onal"Ambulatory"Care"Repor;ng"System""

High-variability in follow-up testing and care FollowBup!PracLce!PaMerns!Cohort!Studies!–!Grunfeld!et$al.1"•  Examined"follow[up"prac;ces"for"Breast"Cancer,"Hodgkin’s"Lymphoma,"Endometrial"

Cancer"and"Colorectal"Cancer"pa;ent"cohorts"in"Ontario"

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•  Number!of!followBup!visits!within!cohorts!highly!variable!–  Some"cohorts">50%"pa;ents"had"more"(or"fewer)"than"guideline"recommended"

visits"–  Pa;ents"frequently"seeing"mul;ple"providers"

•  FollowBup!imaging!within!cohorts!variable!–  Many"pa;ents"had"too"frequent"imaging"

•  Screening!for!relevant!secondary!cancers!within!cohorts!variable!–  Higher"than"expected"numbers"of"unscreened"pa;ents"in"some"cohorts"

1.  Kron et al. Obstetrics and Gynecology (2009), and Grunfeld submitted and unpublished data

Patients are not Satisfied

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Our Vision for Survivorship

Goals:!1.  To"enable"cancer"survivors"to"receive"the"right"care"in"the"right"place.""2.  To"ac;vely"empower"cancer"survivors"with"pa;ent[centred"informa;on"and"

tools."3.  To"develop"the"evidence"base,"informa;on"and"tools"for"oncologists"and"

primary"care"providers."4.  To"enable"improved"coordina;on"and"integra;on"of"survivorship"care"into"

planning"and"prac;ce."10

Survivors!of!cancer!have!access!to!the!right!care!and!informaLon!to!achieve!a!

posiLve!health!status!

Our Approach •  Con;nue"to"build"evidence"base"

."

•  Facilitate"and"evaluate"new"models"of"care"that"deliberately"extend"scope"of"prac;ce"of"nursing"and""allied"health"professionals"and""include"strong"primary"care""follow[up"."

•  Understand"tools"and"training""requirements"to"drive"change"Improve"pa;ent"experiences"and""ac;vely"empower"cancer"survivors""with"tools,"informa;on"and""support"when"needed"

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Progress to Date

•  Maximize"opportuni;es"to"transi;on"care"from"Cancer"Centres"to"Primary"Care"Providers:"•  Colorectal"Demonstra;on"projects"–"3"sites"•  Breast"Cancer"Models"–"all"Regions"(14"sites)"

To"enable"survivors"to"

receive"the"right"care"in"the"right"

place"

•  Literature"review"and"scan"in"progress"

•  Plan"to"follow"

To"ac;vely"empower"

survivors"with"pa;ent[centred"informa;on"and"

tools"

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Goals!

AcLviLes!

Progress to Date

• Evidence[based"guidelines"""""""""""Completed:""Colorectal"Cancer"""""""""""In"progress:""Models"of"Care""

"""""""""""""""""""""Breast"" """""Lung"Cancer""" """""Prostate"Cancer"

""""""""""Planned:""""""Gynecological"Cancer"" """""Head"and"Neck"Cancers"

To"develop"the"evidence"base,"informa;on"and"tools"for"providers"

• Engaging"Primary"Care"to"implement"guidelines"

• Planned"integra;on"of"guidelines""into"electronic"medical"records"

•  Iden;fica;on"of"key"performance"indicators"ongoing"

Improved"coordina;on"and"integra;on"of"care"

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Goals!

AcLviLes!

Survivorship Models of Care for Colorectal and Breast Cancer

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!

Examples!of!Key!Elements!within!Models:!!•  Increased"scope"of"prac;ce""

•  i.e."Nurse"Prac;;oner[led"clinics"and"maximizing"use"of"Primary"Care"Providers"

•  Crea;on"of"care"plan"with"pa;ents"•  Psychosocial"support"and"link"to"community"resources"•  Educa;on"sessions"in"group"format"•  Tools"for"clinicians"and"pa;ents"•  Rapid"re[entry"referral"to"specialists""•  Pa;ent"and"provider"experience"measures"

"

!!!!Key!Enablers:!•  Electronic"Medical"Record"with"embedded"Guidelines"for"cancer"follow[up"•  Electronic"Care"Plans"for"providers"and"pa;ents"

Champlain Regional Cancer Program

15 Colorectal Cancer Follow-Up

Questions?

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