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Nurse practitioner Gail Larocque (right) follows cancer survivors who have finished active treatment, as part of the Wellness Beyond Cancer Program at The Ottawa Hospital.

Carolyn Shelley has survived breast cancer, but where should she receive follow-up care?

Cancer is now considered a chronic disease, with an increasing number of people surviving, so The Ottawa Hospital developed the Wellness Beyond Cancer Program. Although still in early stages, it’s receiving enthusiastic support from patients.

“It’s helpful to see there are other people in the same boat, that you don’t feel alone,” said Shelley.

Traditionally, patients were followed for many years at the hospital after active cancer treatment had ended, for various reasons but mostly because of concerns that patients could not otherwise return quickly if the cancer recurred.

“We felt there had to be better options to meet patients’ needs,  provide follow-up care closer to home, and help them transition into wellness,” said Dr. Roanne Segal, Medical Oncologist.

The steadily growing program began with colorectal cancer and expanded to breast cancer one year later. Well patients who have completed active treatment are referred for follow-up care by their family doctor or, for those with complex treatment side effects or risks, by the nurse practitioner, before discharge to their family doctor.

Program highlights include:

• An education session called “Living well and managing your health after cancer,” which teaches patients about common survivorship concerns, late and long-term treatment effects, and reducing risk through healthy lifestyle.
• A personal survivorship care plan and review, which outlines their treatment, follow-up tests and outstanding self-identified needs.
• Rapid re-entry for patients back to the Cancer Program for reassessment at any time.

After attending the education session, Shelley recently met with RN Carrie Liska to review her care plan, which summarizes her entire cancer journey from diagnosis in 2004 through chemotherapy, surgery, radiation and brachytherapy, and the recommended tests for her follow-up care.

“My family doctor gets the exact same care plan, in case there are any questions later on,” Shelley said. “It recommends I have a mammogram every year for the rest of my life.”

The program also allays her biggest worry, which is what to do if cancer recurs.

“If there is cancer that comes back, you don’t have to start from the beginning again – you can get in there quickly,” she said. “There’s a number for the family doctor to call. They don’t drop you. It gives you some reassurance.”

Family doctors like knowing they can get their patients back into the Cancer Program quickly if needed. “It gives them the tools and the safety net that we all need to ensure best outcomes for our patients,” said Dr. Segal.

Shelley would definitely recommend the program to fellow cancer survivors.

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