The Finding Common Ground team: Back row (left to right): Dr. Susan Still, Francine Lavoie, Michael Shulha, Vinita D'Souza, Dr. Manuel Borod, Dr. Roland Grad. Front row (left to right): Gligorka Raskovic, Rosanna Faria, Dr. Geneviève Chaput. Not pictured: Dr. Joan Zidulka; Dr. Mitali Ruths.
As family doctor Roland Grad glanced at the chart in front of him, it became clear that he didn’t have all the facts. His patient, a breast cancer survivor and recent immigrant, had first come to him many months earlier clutching a pathology report from her home country. Dr. Grad had referred her for cancer treatment. Now she was back in his office for another medical problem and he realized he hadn’t received anything back. “She told me she had seen two oncology specialists, but I had seen nothing.” All these months later, Dr. Grad still had only that same pathology report to guide him in treating his cancer survivor patient.
Fixing these all too common communication breakdowns between oncology and primary care is the focus of the RCN’s Finding Common Ground project. Dr. Grad is one of the participating family doctors and is also the project champion at the JGH.
“The project grew out of a patient satisfaction survey conducted McGill-wide,” explains RCN project manager Dr. Mitali Ruths. “Responses indicated that one of the strongest areas for improvement was communication between cancer care specialists and GPs for survivorship care.”
The RCN project has three main streams to improve long-term care for cancer patients and survivors: first, workshops to educate family physicians about existing guidelines; second, a Standardized Treatment Plan which will provide regular updates to family physicians during a patient's cancer treatment; and third, a Survivorship Care Plan sent to family doctors as a patient transitions from treatment to survivorship.
Give me guidance
Dr Ruth explains that Drs Genevieve Chaput and Desanka Kovacina conducted a survey targeting family physicians at various Montreal sites in order to assess their needs and perceived barriers in caring for cancer survivors. The survey revealed that 46% of doctors who responded weren't familiar with current guidelines on surveillance of cancer survivors. In addition, 48% of family physicians expressed feeling uncertain about their role in caring for survivors. A further 53% said the biggest barrier was lack of communication with specialists.
“Because it is an emerging field, a significantnumber of family physicians simply aren’t aware of what cancer survivorship is,” adds Dr. Gen Chaput, who is leading the stream of the RCN project to educate physicians, along with Dr. Manny Borod, the RCN project champion at the MUHC. Dr. Chaput is a family doctor with a cancer survivorship expertise, and is the leader of the MUHC Cancer Survivorship program.
To address this, starting in January, a MAINPRO-accredited workshop created and delivered by Dr. Chaput has been offered at all RCN sites. The interest from family physicians has been huge. “We anticipated 30 to 40 family physicians,” says Dr. Ruths, “So far 125 have participated in four workshops and another session is planned.”
Dr. Chaput explains that a number of factors have changed the care plan in recent years. “Earlier detection and better treatments mean that cancer survivors are living longer; but this comes at a price: greater disease burden. Cancer survivors have more comorbid conditions compared to the general population.”
In turn, family physicians have a specific list of issues they must screen for in any patient with a cancer history: they must monitor for late effects such as cardiovascular diseases and psychosocial problems.
Dr. Chaput says the main goals of the workshops are to raise awareness and educate family physicians about these specific cancer survivors’ issues and surveillance needs.
Share early, share often
Cancer patients often see their family doctors while they're in treatment for a variety of other medical problems, and each intervention can potentially impact the other. This is the reason for the second stream of Finding Common Ground: the Standardized Treatment Plan.
“There is no standard way for family physicians to be informed about the diagnosis and planned treatment of their patients,” explains Dr. Joan Zidulka, an oncologist leading this stream of the project and also the project champion at SMHC.
The idea is to develop a document that would record pertinent information from diagnosis until the end of treatment. “The document will be sent to physicians before treatment begins and updated to reflect changes in treatment or diagnosis, such as referrals to psychosocial services for anxiety, depression, etc,” explains RCN Project Manager, Gligorka Raskovic.
Family doctors will receive updates if there are changes in treatment; the patient will also get a copy to share during a visit to a walk-in clinic or emergency room. The pilot project will be conducted over the course of a year with the support of family physician Dr. Susan Still at SMHC who is collaborating on developing the prototype, along with RCN site coordinator Francine Lavoie.
“This is about opening lines of communication and forming more of a team,” adds Dr. Zidulka. “We want to ensure that non-oncological issues, like blood pressure, cholesterol and sugar levels, are being appropriately followed by family physicians. Patients assume we are taking care of these things, but we’re not.”
Planning for survivorship
The third stream is the development of a Survivorship Care Plan (SCP), a document meant to succinctly summarize a patient’s cancer treatment and provide guidance on late effects and surveillance.
At the moment, a family doctor can consult the Dossier Santé Quebec (DSQ) software that allows access to test results done in the public system, but the reports are not integrated into a plan and do not include a synopsis or recommendations for care. “We need better information — not too technical, concise, and relevant for decision making with individual patients,” explains Dr. Grad.
Mike Shulha, the lead for this stream of the project, explains that a series of expert panels made up of survivors, family physicians and oncologists from the JGH, SMHC and MUHC as well as the CLSC Côte-des-Neiges will discuss what should be included. Statistical analysis will pare down the items everyone agrees on and the groups will discuss the results to finalize an SCP prototype.
Shulha notes that there are a variety of options for disseminating an SCP but the most common is to give it the patient in a paper format. The next logical phase of work will to be to develop a sustainable strategy for creating and delivering SCPs in electronic formats as well.
One certainty is that SCPs have the potential to fufill important information needs, as Montreal breast cancer survivor Vivianne Korah can attest. Her own transition from cancer care to survivorship hasn't run entirely smoothly. “During treatment, it's terrific,” says Korah, who received her treatments at the MUHC. “There was a pivot nurse who could check with the oncologist if anything came up. Then I was followed in the breast clinic, so there was still someone to respond to my questions. But when treatment finishes, it's very hard not to worry.”
“If I had a care plan it would put my mind at ease. I'd know when I should have my markers drawn or an electrocardiogram or an ultrasound. A care plan would diminish the anxiety of looking for signs and make you feel like you're not neglecting yourself.”
And as Dr. Ruths notes, “Whenever you improve communication, you improve care.”