Life after cancer: Transforming the post-treatment experience

Forging stronger connections between the cancer care and primary care systems

After finishing cancer treatment and returning to primary or community care, many people still need ongoing support for:

  • symptom management
  • psychosocial needs
  • lifestyle adjustments
  • functional challenges

If not addressed, these concerns can have a major impact on a person’s quality of life — so it’s important that primary care providers know how to provide appropriate support. However, many do not have access to relevant information about the cancer treatments people under their care received or insights into cancer-related challenges in general.

Delivering optimal care during and beyond the care transition requires improved communication between healthcare providers and individuals receiving care, plus better coordination between the cancer care and primary care systems. The Partnership has supported initiatives across Canada to achieve those goals, helping primary care providers be better prepared to address the needs of people living with cancer.

How Cancer Care Alberta is helping to support better follow-up care

Primary care providers too often rely on patients to communicate the details of their cancer treatments. To increase communication and coordination across the cancer care and primary care systems, Cancer Care Alberta developed 14 sets of “transfer of care” letters — covering several cancer types and treatment discharge outcomes — that cancer care teams can send directly to both primary care providers and individuals receiving care. These letters outline the steps for follow-up care to be done by the primary care provider and include a list of potential symptoms and signs of recurrence.

With support from the Partnership, Cancer Care Alberta was able to:

  • expand the reach and uptake of the letters through a change management campaign; and
  • create a new website specifically for community and primary care providers.

The website now offers a single source of reliable information across all stages of the cancer journey, with the after-treatment surveillance pages providing links to content from the letters along with easy-to-navigate guidelines for follow-up care. Use of the letters by primary care providers has doubled due to the change management campaign.

Learn why cancer care transitions can be challenging from the perspective of Heather, a primary care provider.

Other initiatives supported by the Partnership

Reviewing the barriers and solutions for improving care transitions
With Partnership contributions, researchers at the McMaster Health Forum conducted two evidence reviews to better understand the transition from cancer care into primary or community care. The first looked at the barriers to optimizing the transition for people living with cancer and their families, and presented three elements in a comprehensive approach for addressing them. The second reviewed the key features of shared-care models designed to enhance coordination between primary care and cancer care, and whether they have an impact on an individual’s experiences and outcomes.

Connecting with adolescents and young adults living with cancer
Primary care providers may not see adolescents and young adults (AYAs) living with cancer often, but this video can help them be ready for when they do. Developed by the Partnership, Talk about it – Connect! gives primary care providers insights into the unique post-treatment needs of AYAs living with cancer

  1. Canadian Partnership Against Cancer. Living with cancer: A report on the cancer experience [Internet]. The Partnership; 2018 [cited 2024 Jan 25]. Available from: