Survivorship Care in Manitoba: Transition Appointments and Follow-up Care Plans

Get Permission

Tara Carpenter-Kellett, HSM, HRM

We’ve rolled out transition visits and developed standardized care plans and guidelines for breast, colorectal, lymphoma, and ovarian cancers, and we have others that will be launched in 2016.

—Tara Carpenter-Kellett, HSM, HRM

Working with specialized oncology teams, a provincial agency in Manitoba, Canada, has developed standardized care plans and guidelines for cancer survivors that are implemented in a transition appointment.1 This appointment, which follows the end of active treatment, marks the transfer of medical responsibility to the primary care provider and includes screening for distress, appropriate referrals, and provision of a personalized treatment summary and survivorship care plan.

“We’ve rolled out transition visits and developed standardized care plans and guidelines for breast, colorectal, lymphoma, and ovarian cancers, and we have others that will be launched in 2016,” said Tara Carpenter-Kellett, HSM, HRM, of CancerCare Manitoba. “We’re hoping that all diseases will have these transition phases eventually.”

As Ms. Carpenter-Kellett reported at the 2016 Cancer Survivorship Symposium, a growing body of research has focused attention on transitions in cancer care from treatment to follow-up, demonstrating deficiencies in the quality of survivorship care, including necessary surveillance testing.

Set of Materials

CancerCare Manitoba’s initiative to improve cancer system–primary care coordination and enhance survivorship care planning began in 2010 with a grant from the Canadian Partnership Against Cancer. Ms. Carpenter-Kellett and colleagues developed the following set of materials with the input from specialists and subject-matter experts as well as patients and their families:

Part 1—Information provided to the patient and primary care provider: letter to the primary care provider outlining responsibilities for the oncology primary care teams for different aspects of care; personalized patient cancer summary with treatment history; standardized follow-up care plan for the primary care provider

Part 2—For patients only: information on the cancer-specific follow-up care, side effects after treatment, post-treatment programs and resources

Part 3—For patients only: information on general wellness and health promotion, reducing future risk, and resources and supports available in Manitoba after being treated for cancer.

Transparency, Standardization

For Ms. Carpenter-Kellett, the most important contribution of this initiative has been transparent communication. “The care plan that the patient gets is the exact same piece of paper that the family doctor receives,” she explained. “There’s no longer confusion about what’s been said or what’s been recommended.”

“The plan has also been standardized,” she added, “so no matter which doctor is visited or which patient visits, they are going to get the same follow-up. There is a provincial standard of care established through this initiative.”

By implementing these care plans, Ms. Carpenter-Kellett also hopes to see increased rates of surveillance. Previous studies conducted in Manitoba indicated that screening recommendations for patients with colorectal cancer were followed less than 40% of the time in 2004.2

“That’s been part of the impetus for establishing this program—We’re hoping to bolster adherence to screening,” she said. “In the future, when we have a bit of funding, we’re going to determine if surveillance rates are going up and whether patients have better access when sent for testing.”

Surveillance aside, preliminary research has found enthusiasm from primary care providers regarding care plans. “Feedback has all been very positive so far,” Ms. Carpenter-Kellett concluded. ■

Disclosure: Ms. Carpenter-Kellett reported no potential conflicts of interest.


1. Carpenter-Kellett T, Sisler JJ: Moving forward after cancer: Implementation of transition appointments and follow-up care plans in Manitoba. 2016 Cancer Survivorship Symposium. Abstract 50. Presented January 15, 2016.

2. Mysliwiec PA, Brown ML, Klabunde CN, et al: Are physicians doing too much colonoscopy? A national survey of colorectal surveillance after polypectomy. Ann Intern Med 141:264-271, 2004.