Canadian Context

In view of the high rates of survival from cancer, many survivors are likely to experience late effects and substantial, debilitating and life threatening consequences of the disease. “…cancer survivorship has become a strategic policy focus of cancer control organizations and cancer care programs across the country.”[1] Healthcare centres are beginning to offer care for cancer survivors after they finish treatment; however, not all have universal and comprehensive coverage.

The Ontario Auditor General’s 2017 Report states that: “Psychosocial cancer services are insufficient and inconsistent. According to the Canadian Association of Psychosocial Oncology, as many as 40% of cancer patients require help from specialized professionals in addition to their medical treatment. However, we noted that in 2016/17, only 5.8% of patients received consultations with dietitians, and only 6.6% with social workers. More than half of the 14 regional cancer centres did not have a dedicated psychiatrist, occupational therapist, psychologist, or physiotherapist on site.”[2]

Cancer Care Ontario monitors and measures the performance of the cancer system in the province and oversees a funding and governance model that ties funding to performance, making healthcare providers more accountable and ensuring value for investments in the system. In 2015, the Program in Evidence Based Care at McMaster University, in partnership with Cancer Care Ontario, released the Exercise for People with Cancer clinical practice guideline, providing guidance for clinicians with respect to exercise for patients living with cancer.

Exercise benefits people living with cancer of all types, and can help before, during and after treatment. It helps manage treatment side effects, including fatigue, may enhance tolerance to cancer treatments, and improves physical functioning. It can even improve survival outcomes in some populations. Exercise is generally safe, but needs to be guided by properly-trained professionals who screen and monitor program participants.

Statistics indicate that the number of people living with cancer will increase by about 70% in the next two decades due to better treatments and early diagnosis. Dr. Jennifer M. Jones, PhD, senior Scientist and Director, Cancer Rehabilitation & Survivorship Program at the Princess Margaret Cancer Centre in Toronto, argues that from a public health perspective, disability is now considered as important as mortality, and while advances in cancer detection and treatments have reduced mortality, persistent and late effects of cancer and its treatments need to be identified and managed lifelong.[3]

 

Cancer treatment can affect almost all body systems and result in long-term and post-treatment late effects. Cardiac and respiratory dysfunction, cognitive impairments, pain, neuropathy, fatigue, sleep disturbances, functional limitations, deconditioning, sexual dysfunction, and infertility are some side effects of cancer and its treatment. Patients and their families also face significant psychosocial and economic consequences. Fear of cancer recurrence, uncertainty, anger, anxiety, emotional vulnerability, issues related to sexual dysfunction and altered body image are often common as well as changes in social outcomes such as relationships, communication, or community involvement. Moreover, there are practical concerns in relation to returning to work, employment and insurance discrimination, health and life insurance implications, all of which can lead to significant employment and financial issues.

The fundamental question for living beyond cancer is how the optimal care should be delivered, by whom, in what setting, to what guidelines and best practices.

Currently, there are a number of different models of cancer survivorship care which have been categorized using different characteristics, including:

  • Setting (community-based and integrated setting within oncology hospital).
  • Patient population (disease specific and general cancer).
  • Provider (oncologist, nurse, primary care, shared care).
  • Purpose (transition, rehabilitation).

Further, they can be:

  • Consultative (consultation among different specialties involved in care)
  • Integrated ( Disease centered care)
  • Longitudinal (long-term follow-up)

These models are not mutually exclusive and vary depending on the institution or setting in which they are offered. With the growing number of cancer survivors along and the recognition of risk-stratified levels of need, there has been increased interest in a multidisciplinary cancer rehabilitation approach.[4]

[1] http://www.ccra-acrc.ca/index.php/publications-en/strategy-related-publications/item/pan-canadian-framework-for-cancer-survivorship-research

[2] Auditor General of Ontario 2017 Annual Report Chapter 3.02, Cancer Treatment Service. http://www.auditor.on.ca/en/content/annualreports/arreports/en17/2017AR_v1_en_web.pdf

[3] Jones, Jennifer M. PhD, The Role of Tertiary Care in Cancer Survivorship: Rehabilitation and Risk-based Models of Care. Presented at the All Parties Cancer Caucus Meeting, March 21st, 2018.

[4] Jennifer M. Jones, PhD. “Ontario All-parties Cancer Caucus.” March 21st, 2018.