Skip to main content

Main menu

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums

User menu

  • My alerts

Search

  • Advanced search
The College of Family Physicians of Canada
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums
  • My alerts
The College of Family Physicians of Canada

Advanced Search

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • RSS feeds
  • Follow cfp Template on Twitter
Article CommentaryCommentary

It takes a team

CanIMPACT: Canadian Team to Improve Community-Based Cancer Care along the Continuum

Eva Grunfeld
Canadian Family Physician October 2016, 62 (10) 781-782;
Eva Grunfeld
Giblon Professor and Vice-Chair of Research in the Department of Family and Community Medicine at the University of Toronto in Ontario and Director of Knowledge Translation Research in the Health Services Research Program at the Ontario Institute for Cancer Research.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: eva.grunfeld@utoronto.ca
  • Article
  • eLetters
  • Info & Metrics
  • PDF
Loading

In the 1990s pioneers in family medicine research in Canada such as Ian McWhinney and Martin Bass1,2 lamented, in the pages of Canadian Family Physician (CFP), the separation between FPs and their cancer patients. The prevailing metaphor at that time was that after a cancer diagnosis patients went into the “black box” of the cancer centre. Those FP researchers, however, challenged that metaphor and through chart reviews3 and surveys4,5 showed that FPs were not only willing to play a greater role, they were in fact already playing an active role in the follow-up care of their patients with breast cancer, and likely other cancers as well. Despite this early work, however, the metaphor of the black box persists and, despite the many changes in primary care systems, cancer care systems, and communication systems, I still hear it often: plus ça change, plus c’est la même chose.

Advances in care

The early 1990s also saw landmark parliamentary hearings that highlighted the need for greater consistency in breast cancer services and delivery, identifying communication problems, variations, and fragmentation of care.6 It will not be lost on the readers of CFP that most of the studies I cite here are about breast cancer. In many ways this is a direct result of the parliamentary hearings and ensuing report7 that drew attention and resources to breast cancer. Indeed, over the past 20 years there have been tremendous advances in breast cancer diagnosis and treatment: identification of BRCA1 and BRCA2 mutations and introduction of screening programs for high-risk patients; better imaging techniques for early diagnosis; advances in adjuvant radiotherapy; advances in adjuvant systemic therapy both in terms of hormonal therapy and targeted therapies; and recognition of the benefits of exercise both for quality of life and improved outcomes.

It was during that time that I completed my FP residency and was working at a cancer centre. Those articles and reports made a big impression on me and were consistent with my own clinical experience. The number of breast cancer patients seen for well follow-up at the cancer centre was large, and I often asked those patients about the ongoing involvement of their own FPs. I also questioned whether continued long-term follow-up at the cancer centre was necessary, as the clinical skills and knowledge required are well within the purview of family practice. Surely, I hypothesized, it would be better for patients and for the use of resources if long-term follow-up was centred in primary care. This observation and hypothesis set the direction of my career. While many things have changed since the 1990s, the lament about the black box and the fragmentation of care persists: plus ça change, plus c’est la même chose.

What has changed

What has changed, however, is that, based on evidence from randomized controlled trials,8–11 it is now widely accepted that well follow-up centred in primary care is a safe and acceptable alternative to cancer centre follow-up. Clinical practice guidelines endorse12,13 and cancer programs encourage14 transfer to primary care for routine follow-up. Moreover, we now have rigorous population-based studies that show frequent ongoing active involvement of FPs,15,16 even during chemotherapy,17 confirming the earlier studies. Many studies, commentaries, conferences, and continuing professional development events now focus on the role of FPs in the care of cancer patients.

What has also changed is that we no longer focus solely on cancer-specific issues. The discourse has widened to consider the holistic needs of those who are living beyond a cancer diagnosis. This holistic perspective is captured in the concept of survivorship.18 The impetus for this change is improvements in cancer survival whereby now, for the high-prevalence adult cancers (breast, colorectal, and prostate), most patients will be long-term survivors.19 Optimum care goes well beyond cancer treatment and cancer management to include management of cancer treatment’s late and long-term effects. Moreover, as most cancer patients are elderly and have multiple chronic conditions, the management of those comorbid conditions and psychosocial sequelae, as well as general medical and preventive care, are equally important.18 The recent breast cancer survivorship guidelines specifically designed for primary care reflect this holistic approach.20 This is truly a paradigm shift. However, serious problems of fragmentation persist21: plus ça change, plus c’est la même chose.

Fragmentation of care

The latest Canadian cancer statistics project a 40% increase in cancer incidence by 2030.19 The implications of this increase will reverberate throughout the cancer system and the broader health care system. It will be crucial that primary care plays a pivotal role from diagnosis through to end-of-life care. In recognition of this, Lancet Oncology commissioned a comprehensive report to examine the role of primary care along the cancer control continuum.22 Part 7 of the report focuses on integration of care between primary care and cancer specialist care, and an accompanying editorial identifies integration as one of the key challenges.23

To better understand the issues underlying this fragmentation of care, a multidisciplinary pan-Canadian group of primary care physicians, nurses, oncology specialist physicians, researchers, knowledge users, and patients coalesced to form a team: the Canadian Team to Improve Community-Based Cancer Care along the Continuum (CanIMPACT).24 The vision of CanIMPACT is “improving cancer care together.” The overarching objective is to enhance the capacity of primary care to provide care to cancer patients and improve integration between primary care and cancer specialist care along the cancer care continuum. CanIMPACT has taken a multimethod approach, and the activities of the team are divided into 2 phases. Phase 1 represents the foundational research using population-based administrative health databases; qualitative methods involving primary care practitioners, cancer specialists, and patients; an environmental scan and systematic review of existing initiatives to improve integration of care; and—a unique element—the exploration of issues related to personalized medicine. Phase 1 culminated in a consultative workshop with key stakeholders from across Canada and abroad.

Through a deliberative process, ideas were generated and prioritized that give direction to CanIMPACT for its second phase. Phase 2 will test an intervention developed in phase 1 to improve the integration of cancer care.

In this issue of CFP, findings from the first phase of CanIMPACT are presented,25–30 along with some practical reviews for FPs on care of patients with and at risk of breast cancer.31,32 The importance of primary care and the ongoing commitment of FPs to their cancer patients has not changed: c’est la même chose. However, the problems of communication, coordination, and integration of care persist. Plus ça change, plus c’est la même chose? Let’s put that tired truism to rest!

Footnotes

  • Cet article se trouve aussi en français à la page 789.

  • Competing interests

    None declared

  • The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.

  • Copyright© the College of Family Physicians of Canada

References

  1. 1.↵
    1. McWhinney IR,
    2. Hoddinott SN,
    3. Bass MJ,
    4. Gay K,
    5. Shearer R
    . Role of the family physician in the care of cancer patients. Can Fam Physician 1990;36:2183-6.
    OpenUrlPubMed
  2. 2.↵
    1. McWhinney IR
    . Caring for patients with cancer. Family physicians’ role. Can Fam Physician 1994;40:16-7. (Eng), 18–9 (Fr).
    OpenUrlPubMed
  3. 3.↵
    1. Worster A,
    2. Wood ML,
    3. McWhinney IR,
    4. Bass MJ
    . Who provides follow-up care for patients with early breast cancer? Can Fam Physician 1995;41:1314-20.
    OpenUrlPubMed
  4. 4.↵
    1. Worster A,
    2. Bass MJ,
    3. Wood ML
    . Willingness to follow breast cancer. Survey of family physicians. Can Fam Physician 1996;42:263-8.
    OpenUrlPubMed
  5. 5.↵
    1. Dworkind M,
    2. Shvartzman P,
    3. Adler PSJ,
    4. Franco ED
    . Urban family physicians and the care of cancer patients. Can Fam Physician 1994;40:47-50.
    OpenUrlPubMed
  6. 6.↵
    1. Greene B
    . Breast cancer: unanswered questions. Ottawa, ON: House of Commons Standing Committee on Health and Welfare, Social Affairs, Seniors and the Status of Women; 1992.
  7. 7.↵
    1. Health Canada
    . Report on the National Forum on Breast Cancer. Ottawa, ON: Health Canada; 1994.
  8. 8.↵
    1. Grunfeld E,
    2. Mant D,
    3. Yudkin P,
    4. Adewuyi-Dalton R,
    5. Cole D,
    6. Stewart J,
    7. et al
    . Routine follow up of breast cancer in primary care: randomised trial. BMJ 1996;313(7058):665-9.
    OpenUrlAbstract/FREE Full Text
  9. 9.
    1. Grunfeld E,
    2. Levine MN,
    3. Julian JA,
    4. Coyle D,
    5. Szechtman B,
    6. Mirsky D,
    7. 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):848-55. Epub 2006 Jan 17.
    OpenUrlAbstract/FREE Full Text
  10. 10.
    1. Grunfeld E,
    2. Julian JA,
    3. Pond G,
    4. Maunsell E,
    5. Coyle D,
    6. Folkes A,
    7. et al
    . Evaluating survivorship care plans: results of a randomized, clinical trial of patients with breast cancer. J Clin Oncol 2011;29(36):4755-62. Epub 2011 Oct 31.
    OpenUrlAbstract/FREE Full Text
  11. 11.↵
    1. Wattchow DA,
    2. Weller DP,
    3. Esterman A,
    4. Pilotto LS,
    5. McGorm K,
    6. Hammett Z,
    7. et al
    . General practice vs surgical-based follow-up for patients with colon cancer: randomised controlled trial. Br J Cancer 2006;94(8):1116-21.
    OpenUrlCrossRefPubMed
  12. 12.↵
    1. Khatcheressian JL,
    2. Wolff AC,
    3. Smith TJ,
    4. Grunfeld E,
    5. Muss HB,
    6. Vogel VG,
    7. et al
    . American Society of Clinical Oncology 2006 update of the breast cancer follow-up and management guidelines in the adjuvant setting. J Clin Oncol 2006;24(31):5091-7. Epub 2006 Oct 10.
    OpenUrlAbstract/FREE Full Text
  13. 13.↵
    1. Grunfeld E,
    2. Dhesy-Thind S,
    3. Levine M,
    4. Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer
    . Clinical practice guidelines for the care and treatment of breast cancer: follow-up after treatment for breast cancer (summary of the 2005 update). CMAJ 2005;172(10):1319-20.
    OpenUrlFREE Full Text
  14. 14.↵
    1. Grant M,
    2. De Rossi S,
    3. Sussman J
    . Supporting models to transition breast cancer survivors to primary care: formative evaluation of a Cancer Care Ontario initiative. J Oncol Pract 2015;11(3):e288-95. Epub 2015 Apr 7.
    OpenUrlAbstract/FREE Full Text
  15. 15.↵
    1. Grunfeld E,
    2. Hodgson DC,
    3. Del Giudice ME,
    4. Moineddin R
    . Population-based longitudinal study of follow-up care for breast cancer survivors. J Oncol Pract 2010;6(4):174-81.
    OpenUrlAbstract/FREE Full Text
  16. 16.↵
    1. Hodgson DC,
    2. Grunfeld E,
    3. Gunraj N,
    4. Del Giudice L
    . A population-based study of follow-up care for Hodgkin lymphoma survivors: opportunities to improve surveillance for relapse and late effects. Cancer 2010;116(14):3417-25.
    OpenUrlCrossRefPubMed
  17. 17.↵
    1. Bastedo SJ
    . A population based assessment of primary care physician visits and acute care utilization among women receiving adjuvant chemotherapy for breast cancer. Toronto, ON: University of Toronto; 2014. [master’s thesis].
  18. 18.↵
    1. Hewitt M,
    2. Greenfield S,
    3. Stovall E
    . From cancer patient to cancer survivor. Lost in transition. Washington, DC: The National Academies Press; 2006.
  19. 19.↵
    1. Canadian Cancer Society Advisory Committee on Cancer Statistics
    . Canadian cancer statistics 2015. Toronto, ON: Canadian Cancer Society; 2015.
  20. 20.↵
    1. Runowicz CD,
    2. Leach CR,
    3. Henry NL,
    4. Henry KS,
    5. Mackey HT,
    6. Cowens-Alvarado RL,
    7. et al
    . American Cancer Society/American Society of Clinical Oncology breast cancer survivorship care guideline. J Clin Oncol 2016;34(6):611-35. Epub 2015 Dec 7.
    OpenUrlAbstract/FREE Full Text
  21. 21.↵
    1. Levit LA,
    2. Balogh EP,
    3. Nass SJ,
    4. Ganz PA
    , editors. Delivering high-quality cancer care. Charting a new course for a system in crisis. Washington, DC: The National Academies Press; 2013.
  22. 22.↵
    1. Rubin G,
    2. Berendsen A,
    3. Crawford SM,
    4. Dommett R,
    5. Earle C,
    6. Emery J,
    7. et al
    . The expanding role of primary care in cancer control. Lancet Oncol 2015;16(12):1231-72.
    OpenUrlCrossRefPubMed
  23. 23.↵
    1. Coburn C,
    2. Collingridge D
    . Primary care and cancer: integration is key. Lancet Oncol 2015;16(12):1225.
    OpenUrlPubMed
  24. 24.↵
    1. Grunfeld E
    . Canadian team to improve community-based cancer care along the continuum (CanIMPACT). Ottawa, ON: Canadian Institutes of Health Research; 2014. principal investigator. Grant no. 128272. Available from: www.cihr-irsc.gc.ca/e/47154.html. Accessed 2016 Aug 29.
  25. 25.↵
    1. Easley J,
    2. Miedema B,
    3. Carroll JC,
    4. O’Brien MA,
    5. Manca D,
    6. Grunfeld E
    . Patients’ experiences with continuity of cancer care in Canada. Results from the CanIMPACT study. Can Fam Physician 2016;62:821-7.
    OpenUrlAbstract/FREE Full Text
  26. 26.
    1. Jiang L,
    2. Lofters A,
    3. Moineddin R,
    4. Decker K,
    5. Groome P,
    6. Kendell C,
    7. et al
    . Primary care physician use across the breast cancer care continuum. CanIMPACT study using Canadian administrative data. Can Fam Physician 2016;62:e589-98.
    OpenUrlAbstract/FREE Full Text
  27. 27.
    1. Easley J,
    2. Miedema B,
    3. Carroll JC,
    4. Manca D,
    5. O’Brien MA,
    6. Webster F,
    7. et al
    . Coordination of cancer care between family physicians and cancer specialists. Importance of communication. Can Fam Physician 2016;62:e608-15.
    OpenUrlAbstract/FREE Full Text
  28. 28.
    1. Barisic A,
    2. Kish M,
    3. Gilbert J,
    4. Mittmann N,
    5. Moineddin R,
    6. Sisler J,
    7. et al
    . Family physician access to and wait times for cancer diagnostic investigations. Regional differences among 3 provinces. Can Fam Physician 2016;62:e599-607.
    OpenUrlAbstract/FREE Full Text
  29. 29.
    1. Carroll JC,
    2. Makuwaza T,
    3. Manca D,
    4. Sopcak N,
    5. Permaul J,
    6. O’Brien MA,
    7. et al
    . Primary care providers’ experiences with and perceptions of personalized genomic medicine. Can Fam Physician 2016;62:e626-35.
    OpenUrlAbstract/FREE Full Text
  30. 30.↵
    1. Brouwers M,
    2. Vukmirovic M,
    3. Tomasone J,
    4. Grunfeld E,
    5. Urquhart R,
    6. O’Brien MA,
    7. et al
    . Documenting coordination of cancer care between primary care providers and oncology specialists in Canada. Can Fam Physician 2016;62:e616-25.
    OpenUrlAbstract/FREE Full Text
  31. 31.↵
    1. Heisey R,
    2. Carroll JC
    . Identification and management of women with a family history of breast cancer. Practical guide for clinicians. Can Fam Physician 2016;62:799-803. (Eng), e572–7 (Fr).
    OpenUrlAbstract/FREE Full Text
  32. 32.↵
    1. Sisler J,
    2. Chaput G,
    3. Sussman J,
    4. Ozokwelu E
    . Follow-up after treatment for breast cancer. Practical guide to survivorship care for family physicians. Can Fam Physician 2016;62:805-11. (Eng), e578–85 (Fr).
    OpenUrlAbstract/FREE Full Text
PreviousNext
Back to top

In this issue

Canadian Family Physician: 62 (10)
Canadian Family Physician
Vol. 62, Issue 10
1 Oct 2016
  • Table of Contents
  • About the Cover
  • Index by author
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on The College of Family Physicians of Canada.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
It takes a team
(Your Name) has sent you a message from The College of Family Physicians of Canada
(Your Name) thought you would like to see the The College of Family Physicians of Canada web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
It takes a team
Eva Grunfeld
Canadian Family Physician Oct 2016, 62 (10) 781-782;

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Respond to this article
Share
It takes a team
Eva Grunfeld
Canadian Family Physician Oct 2016, 62 (10) 781-782;
del.icio.us logo Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Advances in care
    • What has changed
    • Fragmentation of care
    • Footnotes
    • References
  • Info & Metrics
  • eLetters
  • PDF

Related Articles

  • Ça prend une équipe
  • PubMed
  • Google Scholar

Cited By...

  • The effect of comorbidity on primary care use during breast cancer chemotherapy: a population-based retrospective cohort study using CanIMPACT data
  • Google Scholar

More in this TOC Section

  • Mitigating COVID-19’s impact on missed and delayed cancer diagnoses
  • Kintsugi mind
  • Collaboration is key to concussion management in family medicine
Show more Commentary

Similar Articles

Navigate

  • Home
  • Current Issue
  • Archive
  • Collections - English
  • Collections - Française

For Authors

  • Authors and Reviewers
  • Submit a Manuscript
  • Permissions
  • Terms of Use

General Information

  • About CFP
  • About the CFPC
  • Advertisers
  • Careers & Locums
  • Editorial Advisory Board
  • Subscribers

Journal Services

  • Email Alerts
  • Twitter
  • RSS Feeds

Copyright © 2022 by The College of Family Physicians of Canada

Powered by HighWire