|Measure ||Desired Direction ||As of this Report |
|Percentage of breast cancer patients receiving guideline- recommended mammogram tests in first, second and third follow-up year || || |
|Percentage of colorectal cancer patients receiving guideline- recommended surveillance colonoscopy in first follow-up year || || |
|Percentage of breast and colorectal cancer survivors who continue to be followed at a regional cancer centre with at least 1 screen for symptom severity in the first, second and third follow-up year || || |
| See Methodology and Approach to find out how the ratings are calculated. |
Seventy-eight percent (78%) of breast cancer patients had a guideline-recommended mammogram in the first follow-up year, and 79% of colorectal cancer patients had a surveillance colonoscopy within 18 months of surgery.
Approximately 67% of breast and 74% of colorectal cancer survivors who continue to be followed at a regional cancer centre are screened for symptom severity at least once in the first year of follow-up. Rates decline slightly in the second and third year of follow-up; however it is hoped that patients’ symptom screening rates will remain stable year-over-year.
While there is variation in the proportion of follow-up visits with specialists across regional cancer centres within the first follow-up year (13–24 months from diagnosis), results indicate that proportions of follow-up visits with specialists appear to decrease in each subsequent follow-up year.
What is survivorship?
- As many cancer treatments improve and survival rates increase, the number of those living beyond cancer will continue to grow.
- Some patients experience late side effects of treatment, cancer recurrences and secondary primary cancers following treatment. These events need to be addressed and appropriate care provided for all survivors of cancer.
- Care guidelines are evidence-based statements about the best practice for treating different types of cancer. They also provide guidance for care during the survivorship phase for patients who have completed their cancer treatment.
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In my words
I am not convinced that one ever fully recovers from a cancer experience. Cancer changed my life and continues to have an impact on the way I live my life-- both physically and emotionally. Also the fear of recurrence never leaves you.
- As the number of people living longer with cancer increases, providing high-quality follow-up care for these survivors is a priority.
- The transition from active treatment to post-treatment care is important to long-term health. If care is not planned and coordinated, cancer survivors are left without knowledge of their heightened risks or a follow-up plan of action1.
What is breast cancer follow-up care?
- Despite the evidence for optimal follow-up care for patients with breast cancer, significant variation still exists in the way follow-up care is provided in Ontario. For example, one half of breast cancer survivors have more surveillance imaging studies for metastatic disease than recommended and one quarter have fewer2.
- Cancer Care Ontario endorsed the consensus document developed by the Canadian Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer3.
- Breast cancer survivors who are thought to be at high risk should be referred to Cancer Care Ontario’s Ontario Breast Screening Program (OBSP) High Risk Screening Program to be assessed for potential participation4.
- For more information on survivorship for breast cancer patients, visit the Breast Well Follow-up Pathway Map.
What is colorectal cancer follow-up care?
What is symptom assessment?
- Identifying and measuring the severity of a patient’s symptoms is critical to managing those symptoms.
- Symptom assessment is the identification and triage of patient symptoms.
- The Edmonton Symptom Assessment System (ESAS) is a symptom screening tool that asks patients to rate the severity of 9 symptoms commonly experienced by cancer patients. ESAS includes physical symptoms (such as pain, shortness of breath, appetite and fatigue) and emotional symptoms (such as depression and anxiety). It also assesses a patient’s overall well-being.
- An indicator to measure the use of the tool shows how many patients have completed the assessment at least once in the first and second follow-up year after diagnosis.
- More information is available on the Symptom Assessment and Management page.
What do the results show?
Seventy-eight percent (78%) of breast cancer patients received 1 or more mammograms in the first year of follow-up (Figure 1).
- Seventy-eight percent (78%) of breast cancer patients received 1 or more mammograms 25 to 36 months after diagnosis. These rates are similar to the second (79%) and third year (76%) of follow-up, indicating that surveillance imaging appears to continue at a stable rate.
- There is some regional variation, but regions seem consistent in their follow-up practices in each follow-up year.
- We can compare these rates to the approximately 1.3 million Ontario women from ages 50 to 74 who were screened for breast cancer with a mammogram. This represents a participation rate of 65%.
The majority of colorectal cancer patients received a surveillance colonoscopy within 18 months of surgery (Figure 2).
- Of colorectal cancer patients diagnosed in 2012, 79% received a surveillance colonoscopy within 18 months of surgery.
- There is some regional variation, but there were no significant differences for age groups or geography (data not shown).
Approximately 65% of breast cancer survivors and 70% of colorectal cancer survivors who visited regional cancer centres were screened for symptoms at least once within their first, second and third follow-up year (Figures 3 and 4).
- Sixty-seven percent (67%) of breast cancer survivors visited regional cancer centers and were screened for symptoms at least once within their first follow-up year, 67% in their second follow-up year and 62% in their third follow-up year (Figure 3).
- Large variation is noted across regional cancer centres in all 3 follow-up years for breast cancer survivors. The variation ranges from 8% to 98% in the first year, 42% to 98% in the second year and 49% to 97% in the third year.
- Seventy-four percent (74%) of colorectal cancer survivors visited regional cancer centres and were screened for symptoms at least once within their first follow-up year, 73% in their second follow-up year and 68% in their third follow-up year (Figure 4).
- Large variation also is noted for colorectal cancer survivors across regional cancer centres in all 3 follow-up years. The range of variation in the first year is from 38% to 100%; it is from 45% to 100% for the second year, and from 51% to 100% for the third year.
- It is hoped that the percentage of survivors screened for symptom severity using ESAS will become stable year-over-year. The target for ESAS screening is 70%.
- This analysis was also completed for cervical patients to align with the CSQI 2016 Special Focus story on cervical cancer. More information about survivorship for cervical cancer patients is available on the Survivorship page.
While there is greater variation in the range of follow-up visits with specialists in regional cancer centres within the first follow-up year (13–24 months from diagnosis), results indicate that the rate of follow-up visits with specialists appears to decrease in each subsequent follow-up year (Figures 5 and 6).
- Eight-six (86%) of breast cancer patients attended at least 1 follow-up visit with a specialist in the regional cancer centre in their second follow-up year, and 74% attended at least 1 follow-up visit with the specialist in their third follow-up year. The data does not capture follow-up appointments with specialists that occur outside of regional cancer centres and other hospitals, which may account for the regional variation (Figure 5).
- For colorectal cancer patients, the numbers were 83% in their second follow-up year and 73% in their third follow-up year (Figure 6)
- There is regional variation for routine visits to specialists by breast cancer patients that ranges from 68% to 97% in the second follow-up year. Among colorectal cancer patients, the variation is 57% to 100% for the second follow-up year.
Why is this important to patient care?
The right surveillance
- Over the past 3 decades, there has been great progress in the early diagnosis and treatment of cancers. This, in turn, has led to better survival.
- Surveillance strategies involve detecting disease recurrence as early as possible5, but not all tests have the ability to do this. Tests also vary depending on the type of cancer.
- It is important to monitor using the appropriate surveillance because we do not want to put people through tests needlessly with no overall impact.
Integration of primary care providers and specialists improves patient care.
- Many breast cancer survivors in Canada have regular well follow-up visits with oncologists for many years after treatment is completed3. Evidence shows, however, that a portion of these patients do not require this level of follow-up specialist care6,7.
- In 2012, Cancer Care Ontario provided one-time catalyst funding for a Well Follow-up Care Program for breast and colorectal cancer patients in certain regional cancer centres.
- The evidence suggests that for breast cancer patients, higher patient satisfaction and lower costs are associated with family physician-led care (compared with specialist-coordinated models of care located within institutions)8.
- Other research suggests that having follow-up care with both primary care providers and oncologists improves the likelihood that patients will receive necessary care for other chronic medical conditions9.
Many cancer survivors have ongoing symptoms.
- Longitudinal research has identified that cancer survivors can experience symptoms 10 years following treatment. The most common symptoms are depression, pain and fatigue for the 4 most common types of cancer (breast, gynecological, prostate and colorectal)10.
- Another study of patients in the first follow-up year found that 92% reported symptoms related to their cancer or its treatment, and more than 25% had high symptom burden in the first follow-up year, despite ending treatment11.
- Screening for symptom severity in follow-up care helps providers have a better understanding of patient needs related to quality of life. It also allows them to offer support and intervene when necessary.
Find out more
More information about Cancer Care Ontario’s Breast Cancer Pathway is available on their website.
For more information, see the guideline Models of Care for Cancer Survivorship, developed by the Program in Evidence-based Care at Cancer Care Ontario.
- Hewitt M, Greenfield S, Stovall E, editors. From cancer patient to cancer survivor: lost in transition. Washington (D.C): The National Academies Press; 2005.
- Grunfeld E, Hodgson D, del Guidice M, et al. Population-based longitudinal study of follow-up care for breast cancer survivors. J Oncol Practice. 2010; 6(4):174–181.
- Steering Committee on Clinical Practice Guidelines for the Care Treatment of Breast Cancer. Clinical practice guidelines for the care treatment of breast cancer. Follow-up for treatment for breast cancer. CMAJ. 1998; 158:S65–S70.
- Cancer Care Ontario [Internet]. Toronto: Cancer Care Ontario; 2011 Jun. Ontario Breast Screening Program (OBSP): women at high risk for breast cancer; [cited 2014 Mar 4]. Available from: https://cancercare.on.ca/common/pages/UserFile.aspx?fileId=99488.
- Earle C, Annis R, Sussman J, Haynes AE, Vafaei A. A quality initiative of the program in evidence-based care (PEBC): Cancer Care Ontario follow-up care, surveillance protocol, and secondary prevention measures for survivors of colorectal cancer 2012 [Internet]. Toronto: Cancer Care Ontario; 2012 [cited 2014 Mar 4]. Available from: https://cancercare.on.ca/common/pages/UserFile.aspx?fileId=124839.
- Grunfeld E, Levine M, Coyle D, et al. Randomized trial of long-term follow-up for early-stage breast cancer: a comparison of family physician versus specialist care. J Clin Oncol. 2006; 24(6):848–855.
- Grunfeld E, Mant D, Yudkin P, et al. Routine follow-up of breast cancer in primary care: randomised trial. BMJ. 1996; 313:665–669.
- Grunfeld E, Fitzpatrick R, Mant D, Yudkin P, Adewuyi-Dalton R, Stewart J, et al. Comparison of breast cancer patient satisfaction with follow-up in primary care versus specialist care: results from a randomized controlled trial. Br J Gen Prac. 1999; 49(446):705–10.
- Earle CC, Neville BA. Under use of necessary care among cancer survivors. Cancer. 2004; 101:1712–1719.
- Harrington CB, Hansen JA, Moskowitz M, Todd BL, Feuerstein M. It’s not over when it’s over: long-term symptoms in cancer survivors: a systemic review. Int J Psychiatry Med. 2010; 40(2):163–81.
- Shi Q, Smith TG, Michonski JD, Stein K, Kaw C, Cleeland C. Symptom burden in cancer survivors 1 year after diagnosis. Cancer. 2011; 117:2779–90.