Moving forward after cancer: successful implementation of a colorectal cancer patient–centered transitions program

  • Benjamin A. GoldenbergEmail author
  • Tara Carpenter-Kellett
  • Joel R. Gingerich
  • Zoann Nugent
  • Jeffrey J. Sisler



Cancer survivors transitioning between academic comprehensive cancer systems and community general practice settings are vulnerable to discontinuity, inconsistency and variation in care, inappropriate surveillance testing, and a sense of isolation and loss. Though these issues have been well recognized for over a decade and a half in the survivorship, oncologic, and health services literature, there remains a dearth of positive examples of models that have been well received by both the transitioned patient and the providers on either side of the handoff. We herein describe a sustained positive example of a transitions program. This program centers on standardized and personalized survivorship care plans (SCP) to guide follow-up care and recovery.


Following the province-wide introduction of a transitions program for treated stages II and III colorectal cancer (CRC) patients, a post-implementation survey was mailed to transitioned patients with the primary outcome evaluated the patients’ perception of improved continuity of care and the main instrument used the Patient Continuity of Care Questionnaire. This was compared against a previously published pre-implementation historical control.


The data presented comparing pre- and post-implementation patient cohorts reflect significantly improved patient-reported perceptions regarding the enhanced continuity and coordination of their follow-up and survivorship care after the province-wide introduction of a formal transitions process. This SCP intervention has been sustained post implementation.


Using, as a starting-point, a standardized electronically SCP, CancerCare Manitoba has successfully facilitated a jurisdiction-wide implementation of a scalable, reproducible, and adaptable transitions program.

Implications for Cancer Survivors

This intervention at the time of transition back to the community has enhanced CRC survivor perception of continuity and coordination of follow-up care.


Delivery of health care Continuity of care Patient-centered care primary care Patient handoff colorectal neoplasms 


Author contribution

All authors contributed to the study conception, design, data collection, analysis and drafting and revision of the final manuscript.

Compliance with ethical standards

Conflict of interest

All authors declare they have no financial conflict of interest related to this work; however, they all are or have been employees or contracted consultants of the comprehensive Cancer Agency where this work was undertaken.


  1. 1.
    Institute of Medicine and National Research Council. From cancer patient to cancer survivor: lost in transition: an American Society of Clinical Oncology and Institute of Medicine Symposium. Washington, DC: The National Academies Press; 2006.Google Scholar
  2. 2.
    Kline RM, Arora NK, Bradley CJ, Brauer ER, Graves DL, Lunsford NB, et al. Long-term survivorship care after cancer treatment - summary of a 2017 National Cancer Policy Forum Workshop. JNCI J Natl Cancer Inst. 2018;110(12):1300–10.CrossRefGoogle Scholar
  3. 3.
    Howell D, Hack TF, Oliver TK, et al. Models of care for post-treatment follow-up of adult cancer survivors: a systematic review and quality appraisal of the evidence. J Cancer Surviv. 2012;6:359–71.CrossRefGoogle Scholar
  4. 4.
    Mayer DK, Gerstel A, Walton A, Triglianos T, Sadiq TE, Hawkins NA, et al. Implementing survivorship care plans (SCP) for colon cancer survivors in a comprehensive cancer center. Oncol Nurs Forum. 2014;41:266–73.CrossRefGoogle Scholar
  5. 5.
    Mayer DK, Birken SA, Check DK, Chen RC. Summing it up: an integrative review of studies of cancer survivorship care plans (2006-2013). Cancer. 2015 Apr 1;121(7):978–96.CrossRefGoogle Scholar
  6. 6.
    Sisler J, Taylor-Brown J, Nugent Z, et al. Continuity of care of colorectal cancer survivors at the end of treatment: the oncology-primary care interface. J Cancer Surviv. 2012;6:468–75.CrossRefGoogle Scholar
  7. 7.
    Hadjistavropoulos H, Biem H, Sharpe D. Patient perceptions of hospital discharge: reliability and validity of a Patient Continuity of Care Questionnaire. Int J Qual Health Care. October 2008;20(5):314–23.CrossRefGoogle Scholar
  8. 8.
    Follow up care. CancerCare Manitoba. Accessed July 15, 2019.
  9. 9.
    Mittman N, Beglaryan H, Liu N, et al. Examination of Health System Resources and Costs Associated With Transitioning Cancer Survivors to Primary Care: A Propensity-Score–Matched Cohort Study. Journal of Oncology Practice 14, no. 11 (epub November 1 2018) e653-e664.CrossRefGoogle Scholar
  10. 10.
    Del Giudice EM, Grunfeld E, Harvey BJ, et al. Primary Care Physicians’ Views of Routine Follow-Up Care of Cancer Survivors. Journal of Clinical Oncology 27, no. 20 (July 10 2009) 3338-3345.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Medical Oncology and Hematology CancerCare ManitobaWinnipegCanada
  2. 2.Community Oncology ProgramCancerCare ManitobaWinnipegCanada
  3. 3.Department of Medical Oncology and Hematology and Community Oncology ProgramCancerCare ManitobaWinnipegCanada
  4. 4.Department of Epidemiology and Cancer RegistryCancerCare ManitobaWinnipegCanada
  5. 5.Department of Family MedicineUniversity of ManitobaWinnipegCanada

Personalised recommendations