Peter Jones, Smriti Shakdher, Prateeksha Singh
Clinical Synthesis Map: Cancer Care Pathways in Canadian Healthcare
Jones PH, Shakdher S and Singh P. Systemic visual knowledge translation for breast and colorectal cancer research. Current Oncology 2017 (in press).
The Clinical Map visually represents breast and colorectal cancer processes across Canadian provincial and territorial systems. A roadmap metaphor illustrates a system-wide view of patient flow across the stages of cancer care. Green “road signs” identify clinical cancer stages across the roadmap: Pre-Diagnosis, Peri-Diagnosis, Diagnostic Interval, Diagnosis, Treatment, Rehabilitation, After Care, and Survivorship (with Palliative Care expressed as an end point). The visual metaphor of seasonal trees visually connects these stages to the patient’s cancer journey from pre-diagnosis (summer) through treatment (winter), followed by new growth (spring) in survivorship.
The levels of primary, secondary and tertiary care guide the vertical dimension. Information and communications technology reaches across levels and stages, but is shown disconnected from primary care. The road-like pathways are colour-coded where experts differentiated care pathways between breast cancer (pink) and colorectal (blue). Where not distinguished (white), the pathways indicate current practices shared across the cancer journeys.
Yellow navigation signs indicate cancer events across primary care pathways. Starting with Prevention and ending with Long-term Care, these events show points for primary care continuity during cancer treatment. A parallel path below the stages indicates where some patients may also employ complementary or alternative therapies.
Significant areas of complexity generalized across cancer care are revealed in peri-diagnosis and the diagnostic interval pathways. A patient can be screen-detected (and then present to a family physician, shown in the breast cancer pathway) or may be initially diagnosed in primary care (white pathway). The circular pathways in the diagnostic cycle suggest multiple possible tests within primary care. With a primary care diagnosis, patients are referred and flow to secondary/tertiary cancer care. The stages of intake, biopsy, pathology, and confirmed diagnosis are shown, and the complex pathways of cancer treatment, shown on the map in a typical (not definitive) order of surgery, radiation/chemotherapy, and continuing treatment through assessment of outcome.
1. PREVENTIVE
SCREENING
INITIAL FP CONCERN/
EXAM/PRESENTATION
CONTINUITY
WITH FP
CANCER
DIAGNOSIS BY FP TRANSITIONPREVENTION
TRANSFER TO
PRIMARY CARE
LONG-TERM
CARE
CONFIRMED
SPECIALIST DIAGNOSIS
GENETICS CENTRE
EMERGENCY
ACUTE CARE
EMR
LABS
INTERNAL NETWORKSINTERNET TELEHEALTH
PATHOLOGY LAB
CANCER REGISTRY
INTERNAL MEDICINE
EMERGENCY
Practice EMR
Diagnostic Cycle
Medical
Test Results
Referral
LABLAB
RxRx
Referral
RxRx
Diagnosis
DxRx
Remission/
Good outcomeBiopsy
Investigations
Remission/
Good outcome
Problematic
outcome
Progression/
Recurrence
Partial
Remission
Discharge Cycle
End of Life/Hospice/
Home based Care
Skilled Nursing Home/
HOSPITAL EMR
INCIDENT OR
SYMPTOM
Rural patients rely
heavily on Primary
Care for access to all
applicable care needs.
PATIENT PORTAL
NP/Nurse
RN/RPN/LPN
Family
Physician
Oncology NurseGPO
Oncology
Specialist
Surgical
Oncologist
Oncology Nurse Nutritionist
GPO
Surgical
Oncologist
Palliative
Therapist
Patient
Navigator
Palliative
Therapist
Radiation
Oncologist
Occupational
Therapist
Medication
Advisor
Oncology
Specialist
Family
Physician
Medical
Oncologist
TREATMENT
AFTER
CARE
REHAB
PRIMARY
CARE PRACTICE
PERI
DIAGNOSIS
DIAGNOSTIC
INTERVAL
DIAGNOSIS SURVIVORSHIP
PRIMARY CARE TEAM
PALLIATIVE CARE
CANCER CARE SPECIALIST TEAM
MULTIDISCIPLINARY CANCER CARE TEAM
Community Clinic
Ambulatory Care
Genetics Centre
Investigations
Pharmacy
Family Practice
SECONDARY
CARE PRACTICE
Radiology
Surgery
General Practice Oncology
Oncology Practice
Investigations
TERTIARY
CARE
INFO TECH &
COMMUNICATION
Cancer Surgery
Cancer Pain Clinic
Radiotherapy
Oncology
Labs & Imaging Mgt
Clinical Decision Support Tools
Hospital Websites
Patient Portal
EMR/EHR/PHR
COMPLEMENTARY
& ALTERNATIVE
THERAPIES
Homeopathy
Naturopathy
Ancient Healing Systems
Testing for Hereditary
& Familial Cancers
50% Breast Cancer cases
are screen detected and
50% through Primary Care
Breast Cancer
patients adhere to
Hormonal Treatment
for 5-10 years.
About 20% Colorectal
Cancer patients
present symptoms
first in Emergency.
Lab Tests/Radiology/
Mammogram or
other diagnostic tests
43% visit ER due
to adverse chemo
reactions.
Care Planning
5% Breast
Cancer patients get
Neoadjuvant therapy.
Continuity
of Care Plan
Surgery
Radiation
Hormone Treatment
Clinical Trials
Surveillance
Chemo
Psychosocial
Supportive Care
Complementary
Psychosocial Support
Support Groups/
Religious Organizations
Psychosocial
Supportive Care
Surveillance
Patient Population -
Colorectal/Breast
Initial
Investigation
Burden on
Patient
Reinforcing
Behaviour
Symptoms
True
Diagnosis
Inconclusive
+ -
+
+-
-
Treatment
Effectiveness
End of
Life Care
Reinforcing Limiting
Reinforcing
Reinforcing
Survivorship
Chronic
Population
Primary
Care
Family
Physicians
More
Primary
care
Increased
Patient
Load
More
Primary
care
+
+
+
+
+
+
+
+
-
Increasing the effectiveness
of Cancer treatment, grows
the population of survivors,
who live longer with
manageable (but expensive)
chronic illnesses.
Uncertainty in diagnostic
interval can erode FP
relationship with
potential for adverse
effect on survivorship.
Care
Assistance
& Managing
Comorbidities
The Clinical Map is a synthesis of findings across the modes of CanIMPACT
research. It visually models the complex systems of care for breast and
colorectal cancers, portraying the general processes of Canadian cancer
care. The system map reveals salient clinical issues while aiming to
express a sense of the system’s actual complexity.
The Mission: Enhance the capacity
of community based primary
healthcare clinicians to provide
care to cancer patients and to
improve the links between primary
care and specialty providers.
35%
Patients
require
Psychosocial
Support
10-12%
On-going
psychosocial
care
UNDER
CONSTRUCTION
Telehealth could be a
solution to preventing
unnecessary travel for
medical consultations
with Physicians
PRE
DIAGNOSIS
Psychosocial
Support
CANCER CARE PATHWAYS
IN CANADIAN HEALTHCARE
CANCER CARE PATHWAYS
IN CANADIAN HEALTHCARE
®
RESEARCH SYNTHESIS MAP
CANCER CARE PATHWAYS
IN CANADIAN HEALTHCARE
Nurse/Patient
Navigator
TREATMENT CONTINUITY
STRATEGIES
Interoperable
Electronic
Communication
& Information
Systems EMR
LABS HOSPITAL EMR
Multidisciplinary
Care Teams
(Integrated
Practice Units)
Psychosocial
Support
PREVENTION AND
DIAGNOSIS STRATEGIES
Health
System
Integration
EMR
LABS HOSPITAL EMR
Patient
Activation
Health
Promotion
SURVIVORSHIP
STRATEGIES
Multicomponent initiatives
Interoperable
Electronic
Communication
& Information
Systems EMR
LABS HOSPITAL EMR
Nurse/Patient
Navigator &
Education
Physician
Education
Survivorship & Primary
Care support to
“unattached patients”
New Colorectal Cancer cases
by provinces (2015)
25.1 K
New Breast Cancer cases
by provinces (2015)
25.2 K
Lifetime probablity
of Colorectal Cancer
M: 1 in 14
F: 1 in 16
Colorectal Cancer
Breast Cancer
9200
9800
Lifetime probablity
of Breast Cancer
High continuity more
likely to be screen-detected
High comorbidity less
likely to be screen-detected
F: 1 in 9
25% (MB)
28% (AB)
25% (MB)
28% (AB)
Rural ON & MB more likely to
be screen-detected than urban.
to
25% (MB)
28% (AB)
7-13%7-13%7-13%
Screen Detected
28 days28 days
screen-detected
symptom-detected
28 days
34 days34 days34 days
Median Diagnostic Interval
ONONON
ON immigrants
less likely to be
screen-detected
Ontario Breast
Screening Program
Diagnostic
Assessment Program
Colorectal Cancer
Breast Cancer
970
860
MBMBMB
Colorectal Cancer
Breast Cancer
920
780
NSNSNS Nova Scotia Breast
Screening Program
LEAN on cME
19 days19 days
screen-detected
symptom-detected
19 days
21 days21 days21 days
Median Diagnostic Interval
ABABAB
Comprehensive
Breast Care Program
Clinical Breast
Health Program
eReferral
Colorectal Cancer
Breast Cancer
3150
3400
7-13%7-13%7-13% 30 days30 days
screen-detected
symptom-detected
30 days
30 days30 days30 days
Median Diagnostic Interval
BC immigrants
less likely to be
screen-detected
BCBCBC
Colorectal Cancer
Breast Cancer
6600
6100
CANADACANADACANADA
Colorectal Cancer
Breast Cancer
2160
2300
QCQCQC
Colorectal Cancer
Breast Cancer
120
110
PEIPEIPEI
Colorectal Cancer
Breast Cancer
560
360
NLNLNL
Colorectal Cancer
Breast Cancer
770
710
SKSKSK
Cancer
Related
Agencies
& NGOs
Canadian Partnership
Against Cancer
Canadian Cancer Society
Canadian Breast Cancer
Foundation
Clinical
Colleges
Colleges of Physicians,
Surgeons, Nursing
Canadian College of
Family Physicians
Licensing Bodies, Professional
Standards & Certifiers
Communities Faith Communities &
Congregations
Community groups
Voluntary Sector
Foundations
Support Groups
Individuals
& Families
Persons as Patients
Family Members
Friends & Social Circle
National
Policy &
Governance
Canadian Task Force on
Preventive Health Care
Federal Ministry of Health
Canadian Institutes of
Health Research (CIHR)
Provincial
& Territorial
Ministries of Health
Provincial Cancer
Agencies
Provincial Health
Regions or Districts
Regional Cancer Programs
Ontario Institute for
Cancer Research
STAKEHOLDERS
CanIMPACT Research Team
Contributors
to the map
Eva Grunfeld, Univ of Toronto
Geoff Porter, Dalhousie
Jonathan Sussman, McMaster
Julie Easley, Dalhousie
June Carroll, Univ of Toronto
Patti Groome, Queen’s
Bo Miedema, Dalhousie
Sharon Matthias, Edmonton
Mary Ann O’Brien, U of Toronto
Marg Fitch, Univ of Toronto
Patient
Advisory
Committee
Marg Fitch, Co Chair
Sharon Matthias, Co Chair
Dawn Powell
Julie Easley
Nancy Schneider
Margaret Tompson
Catarina Versaevel
Bonnie Vick
Richard Wassersug
OCADU
sLab Team
Peter Jones
Prateeksha Singh
Smriti Shakdher
Legend
Type of Care
Clinical Role in Journey
Clinical Process/Workflow
Primary Care Stages
Colorectal Cancer Patient Flow
Breast Cancer Patient Flow
Typical Cancer Patient Flow
Info Tech & Communication
Secondary Care Practice
Primary Care Practice
Tertiary Care
Recommendation
Cancer Clinical Flow
Cancer Stages
Other Flows
Facts & Statistics
Qualitative Research
Information
Copyright (c) 2016 Strategic Innovation Lab, OCAD University