Survivorship Care for Patients Without a Primary Care Physician-Unattached Patients
A key implementation consideration for primary care-led survivorship models of care is a lack of access to primary care physicians (i.e. survivors unattached to a primary care physician). Patients without a primary care physician is problematic for the general population across Canada and may be a barrier to care for survivors who are being transitioned from oncologist specialist-led care. A national survey across Canada in more than 9000 people revealed that more than one in five Canadians (about 6.5 million people) do not have a family physician or nurse practitioner they see regularly (87). Wide variation in access was noted with Ontario showing the lowest rate (13%) compared to British Columbia (27%), Atlantic Canada (31%), and Quebec (31%) that reported not having regular access to a primary care provider. Racialized people (term used in study), those with lower incomes, and those in poor health were among those least likely to report access to a regular primary care provider.
A rapid review that summarized the evidence from 9 systematic reviews and 19 primary studies conducted by McMaster Health in 2023 found limited evidence and few programs designed specifically for unattached patients in the cancer system and were unable to identify programs to accelerate access to a primary care provider for patients with a suspected or diagnosed cancer (88). However, they identified nurse-led navigation models as a promising model of care that could be beneficial to ensure access to primary care as a replacement for PCPs; and particularly for transitioning patients from acute cancer care to PCPs. In this report they highlighted solutions that have been operationalized to address this problem across Canada. For example, NP clinics in some regions of Northern Ontario accept these unattached patients. Oncology nurse navigator roles have been advocated across Canada for the last decade and have been shown to contribute to coordination of care to meet a broad range of cancer patient and survivor needs and improve well-being, quality of care and system efficiencies (89). However, a lack of training, national standards for oncology nurse navigator models, funding, and lack of role clarity remains a barrier to their implementation and scale and spread. The Canadian Association of Nurses in Oncology have developed a position statement on the role of oncology nurse navigators (90).
Chan and colleagues in an umbrella review of 61 systematic reviews examined the evidence for patient navigation across the cancer continuum from early diagnosis to survivorship (2012 to 2022) (91). In this review they showed that patient navigation improves quality of life and patient satisfaction in the survivorship phase of care. While a deeper discussion of the role of navigators is beyond the scope of this guideline, the South Australian Cancer Navigation Framework and Action Plan may be instrumental for guiding the development of navigation programs that was developed by Flinders University and the Government of Australia (https://fac.flinders.edu.au/dspace/api/core/bitstreams/a4e517e7-a17b-4ae7-a35f-0046dc4f041a/content).