Don’t miss our upcoming webinars: Subscribe today! The CanRehab Team brings together a large group of patients, researchers, and clinicians at four Canadian centres and includes three concurrent projects focused on improving access to effective, appropriate, and timely cancer rehabilitation (CanRehab Team). The objectives of the presentation are: 1) to provide a background on cancer rehabilitation; 2) to introduce the CanRehab Team projects; and 3) to provide an overview of the team structure including a call for interest to the Patient Advisory Committee. View the YouTube video: https://youtu.be/B2tcIsrw4WE To learn more about CCSN, visit us at survivornet.ca Follow CCSN on social media: Twitter - https://twitter.com/survivornetca Facebook - https://www.facebook.com/CanadianSurvivorNet Instagram: https://www.instagram.com/survivornet_ca/ Pinterest - https://www.pinterest.com/survivornetwork

1. CanRehab Team: Improving the
systematic identification,
management, and treatment of
the adverse effects of cancer.
Jennifer M. Jones, PhD
Director and Senior Scientist, Cancer Rehabilitation & Survivorship
Program Butterfield/Drew Chair in Cancer Survivorship Research
Princess Margaret Cancer Centre, UHN
October 22, 2020 @1PM

2. Cancer Survivorship by numbers
Over 1.5 million people are living with
a personal history of cancer in Canada
Canadian Cancer Statistics 2018

3. L king f a d
• over the next yrs the of person’s aged years will
nearly double in North America to 20% of the population
• doubling of the number of individuals living with a personal
hx of cancer by 2050- 3 million survivors

4. The g d ne
• mortality rates have dropped significantly
• tobacco control, early detection and better treatments
• five-year age-standardized RSR for cancers combined is 63%
when measured from the date of diagnosis
• increases to 81% when measured among those who survived the first year
after a cancer diagnosis.
CancerSurvivorship

6. ‘Disease Free’
Remission
Managed Chronic or
Intermittent Disease
Treatment Failure
Recurrence/ Second
Primary
Treatment with
Intent to Cure
Palliative Care
Diagnosis and
Staging
Death
Survivorship Care
Cancer SurvivorshipCancerSurvivorship

7. S i al b a a c
Treatments
“Unlike other chronic diseases such as diabetes or arthritis where
disability is commonly caused by the disease process itself, short
and long term disability associated with cancer is often caused
more by treatment than the disease itself. Short et al 2008

8. Challenges Facing Cancer Survivors
• all major types of Ca tx can result in side-effects that can impair
well-being, physical and psychosocial functioning and overall
quality of life (acute side effects) and some may last after
treatment ends (persistent treatment effects)
• new side-effects may also develop months or even years after
treatment ends (late treatment effects)
• Survivorship experience is HIGHLY INDIVIDUAL
y

9. Physical Effects
• at risk of local and distant recurrence and second primary cancers
• tx can affect almost all body systems and result in long-term and
late effects
• cardiac and respiratory dysfunction, cognitive impairments,
pain, fatigue, neuropathy, functional limitations, sleep
disturbances, sexual dysfunction, infertility
• symptoms often co-exist and are worsened by comorbidities and
may be exacerbated by age-related processes

10. Health Status and Disability (NHIS Survey)
0%
10%
20%
30%
40%
50%
60%
Fair/Poor health > 1 limitations of
ADL
> 1 functional
limitation
Unable to work
30%
11%
58%
17%
11%
3%
29%
5%
Cancer Hx n=4878
No Cancer Hx n=90,737
Hewitt et al. 2003 J Gerontol A Biol Sci Med Sci (2003) 58 (1): M82-M91
PhysicalEffects

11. Psychosocial Wellbeing
• patients and their families also face significant psychosocial and
economic consequences
• fear of cancer recurrence, uncertainty, anger, anxiety, emotional
vulnerability, issues related to sexual dysfunction and altered
body image are often common.
• changes in social outcomes such as relationships, communication,
or community involvement
• practical concerns in relation to returning to work, employment
and insurance discrimination, health and life insurance
implications, leading to significant employment and financial
issues
• these conditions are underdiagnosed and undertreated, despite
the availability of effective psychosocial and drug interventions

12. Prevalence and severity of physical, emotional and practical concerns
after completing cancer treatment – 2016 reporting year
Data source: Experiences of Cancer Patients in Transition study (2016).

13. Reasons for not seeking help for physical, emotional or practical
concerns after completing treatment — 2016 reporting year
Percentages reflect total number of times a certain response was selected regardless of whether a respondent checked off one or more responses.
Base population excludes respondents who had no concerns and those who sought help for their concerns.
Data source: Experiences of Cancer Patients in Transition study (2016).

14. Canadian Cancer Rehabilitation (CanRehab) Team:
Improving the systematic identification, management,
and treatment of the adverse effects of cancer
Principal Investigators
Jennifer M. Jones (Toronto)
Kristin Campbell (Vancouver)
Jonathan Greenland St. John’s
Anthony Reiman (Saint John)
David Langelier (New Investigator)

15. Overview of team goals,
research projects, and team
structure

16. The Canadian Cancer Rehabilitation Team (CanRehab) brings
together a large group of researchers, clinicians, and cancer
survivors at four cancer centres across Canada (BC, ON, NB,
NFLD) to conduct three linked projects focused on improving the
systematic identification of the adverse effects of cancer and its
treatments, increasing access to cancer rehabilitation using
innovative ehealth solutions, and extending reach to include a
growing population of cancer survivors, including those living
with incurable or metastatic cancer.
For a health care system to achieve optimal patient outcomes, it should aim to
control both the disease (i.e., cancer) as well as consequences of its
treatments and improve functioning for individuals.
Team Goals

17. Project One: Development
and implementation of an
electronic prospective
surveillance (ePSM)
model for cancer
rehabilitation
Project Two: Pragmatic
hybrid type 1
effectiveness-
implementation (E-I)
trial of a virtual cancer
rehabilitation program
Project Three: Phase II
randomized controlled
trial (RCT) of group-based
cancer rehabilitation for
people with metastatic
cancer
The CanRehab projects include breast, colorectal, head and neck, and lymphoma cancers.
Project One will develop and evaluate an online system to screen patients for cancer
related impairments and provide timely access to cancer rehabilitation services.
Project Two will test an 8-week on-line cancer rehabilitation program and examine
implementation factors.
Project Three will develop and assess feasibility of a rehabilitation program for patients
with stable metastatic cancer.

18. IDENTIFICATION
Project 1: Development and implementation
of an electronic prospective surveillance
(ePSM) model for cancer rehabilitation

19. Prospective Surveillance Model (PSM)
Prospective Surveillance Model (PSM) includes routine assessment of
survivors’ needs and functioning post-diagnosis and continuing into post-
treatment survivorship
Rationale:
1. increasing number of cancer survivors who can expect relatively normal
life expectancies, thus failure to treat cancer-related side effects may
adversely affect wellbeing and functionality for decades;
2. treatment related side-effects and impairments are common and often
go unreported and unrecognized
3. many treatment related impairments either can be prevented or effects
meaningfully ameliorated through early education, self-management
and comprehensive rehabilitation
4. evidence suggests few survivors receive such care.

20. Numerous challenges to the implementation of PSM for cancer rehabilitation have been
identified:
• lack of risk-stratification to guide surveillance
• referring all patients to cancer rehabilitation specialists to screen for possible impairment
is “neither patient-centric, cost-sensitive, nor frankly even possible with current
workforce limitations
• Implementing systematic screening within oncology clinics has been proposed as one
solution BUT oncology clinicians are challenged with busy clinics and often lack
knowledge of appropriate referral pathways or available services for a given problem
In order to address this:
• the PSM should include clear pathways to appropriate resources and interventions
• process should be personalized to tailor responses and dose based on the level of risk
and need and avoid a “one-size fits all approach.
• Advances in use of technology provide a potentially cost-effective and patient-centered
solution for implementation of the PSM for cancer rehabilitation by enabling remote
monitoring of cancer survivors and the development of automated and personalized
linked-to-treatment responses but these have yet to be developed or implemented
Prospective Surveillance Model (PSM)

21. Project 1: Development and implementation of an
electronic prospective surveillance (ePSM) model
for cancer rehabilitation
Project One is the development
and implementation of an
electronic prospective
surveillance system for cancer
rehabilitation, including
standardized remote screening of
rehabilitation needs and a risk
stratified automated response
system to deliver support and
connect patients with the level of
rehabilitation services they
require.

22. Project 1: Aims
Aim 1.1 Create a user-centered ePSM for cancer
rehabilitation (months 1-18)
Aim 1.2 Optimize and test the ePSM (months 19-36)
Aim 1.3 Explore implementation and maintenance of
ePSM and develop an observational CanRehab
cohort (months 37-60)

23. ACCESS
Project 2: Pragmatic hybrid type 1
effectiveness-implementation (E-I) trial of
a virtual cancer rehabilitation program

24. ACCESS: Virtual Cancer Rehabilitation
• the evidence on cancer rehabilitation comes largely from trials
utilizing face-to-face delivery in a clinical setting.
• BUT cancer survivors face significant barriers (e.g., remote home
locations, cost, poor health) that can prevent access to cancer
rehabilitation services delivered in medical facilities
• distance-based eHealth interventions that use technologies have
been suggested as one way to reduce some barriers to accessing
and providing rehabilitation
• this approach well established in other chronic disease
populations such as heart disease and diabetes
• eHealth technology presents opportunities to increase access to
cancer rehabilitation in a virtual setting and has shown promise in
increasing physical activity and reducing specific psychosocial and
physical symptoms in cancer survivors.

25. Project 2: Pragmatic hybrid type 1 effectiveness-
implementation (E-I) trial of a virtual cancer
rehabilitation program
Project Two will test the
effectiveness of a virtual
cancer rehabilitation
program for patients with
identified cancer-related
impairments and explore
factors that affect
implementation.

26. Project 2: Aims
Aim 2.1 Effectiveness evaluation of CaRE@Home (months 36-58)
Design: Multi-centre pragmatic RCT to evaluate effectiveness.
Study Arms:
• Care@Home 8-week program comprised of: 1) weekly e-modules
providing interactive education to promote self-management skills;
2) individualized progressive exercise prescription supported with
mobile application (Physitrack); 3) wearable technology (Fitbit) to
track activity & sleep; 4) weekly brief telephone counselling.
• WLC will receive usual care. Following T3 assessment, the WLC group
will be offered the CaRE@Home program.
Aim 2.2 Conduct a descriptive implementation-focused process
evaluation to inform future implementation efforts

27. REACH
Project 3: Phase II randomized controlled trial
(RCT) of group-based cancer rehabilitation for
people with metastatic cancer

28. EXTENDING REACH: Cancer Rehab and Advanced
Cancer
• advances in treatments have led to prolonged survival and a growing
population of individuals who are living with metastatic solid tumour
cancer (advanced cancer)
• these treatments (and the cancer itself) lead to loss of physical function,
deconditioning, fatigue, pain and high levels of psychosocial distress
• improving this loss of functional independence and high symptom burden
is described by individuals with metastatic cancer as one of their highest
medical priorities
• cancer rehab interventions can address common impairments and reduce
the rate of functional decline in patients with advanced cancer.
• However, rehabilitation services and programs are underdeveloped and
underutilized
• = urgent calls for the development and evaluation of proactive
multidimensional interventions to address the needs of this growing
population of cancer survivors who may continue to live years with their
impairments.

29. Project 3: Phase II randomized controlled
trial (RCT) of group-based cancer
rehabilitation for people with metastatic
cancer
Project Three will test the
feasibility of an in-person
cancer rehabilitation program
focused on maximizing
potential for independent
function and QoL for
individuals who are living with
incurable, locally advanced or
metastatic solid tumour
cancer.

30. Project 3: Aims
Aim 3.1 Test the feasibility and safety of CaRE-AC plus standard
best practice cancer care (INT) compared to standard
best practice cancer care alone (CON)
• Design: Phase II feasibility RCT (Vancouver and Toronto).
• Study Arms:
• CaRE-AC program, plus standard best cancer care practice (INT): 8-week
group program; 1 hr exercise and 1 hr self-management education. Each
participant will receive an individualized aerobic and resistance exercise
prescription.
• Standard best cancer care practice (CON): All participants (INT and CON)
will receive usual oncology care by their HCPs.

31. Team Structure

32. Project One Team Project Two Team Project Three Team
CanRehab Streering Committee (SC)
Study PIs, Training Program Lead (David Langelier), CCSN Rep
(Jackie Manthorne), Implementation Science Lead (Sarah Neil-
Sztramko)
Cancer Survivor Advisory Committee
Jackie Manthorne (CCSN)/Jennifer Jones
(Co-Leads)
Operations Committee (SC)
Nominated PI, clinical representative for each site, patient
representative, team coordinator, site coordinators, and IT
representative
CanRehab Trainee Program
External Advisory Committee
Andrea Cheville, Nicole Stout, Catherine Alfano, Ethan Basch,
David Mohr

33. Cancer Survivor
ADVISORY COMMITTEE

34. Overview
The Canadian Cancer Rehabilitation (CanRehab) Cancer Survivor
Advisory Committee will play a key advisory role as an overarching
committee and ensure cancer survivor perspectives remain at the
forefront, influencing the direction of the research and
implementation activities.
MANDATE
To build a sustainable, accessible, and equitable cancer care
system and to improve the care provided to cancer survivors
across Canada, it is essential that patients are integrated into
the research process in a meaningful and substantive manner.

35. CanRehab Cancer Survivor Advisory Committee:
ROLES AND RESPONSIBILITIES
The Cancer Survivor Advisory Committee shall advise the CanRehab team from
cancer survivors and caregivers perspectives throughout the research and
implementation process. This includes:
1. Providing feedback and ideas on CanRehab project methods and
implementation
2. Guiding the research design teams to focus on issues important to cancer
survivors
3. Identifying issues, gaps in service, support and programs
4. Committing to attending the 3 committee meetings per year as an active
member
5. Collaborating with others in a respectful manner to enhance the care model
6. Using personal experiences constructively and providing specific perspectives
that contributes to the diversity of perspectives of committee members
7. Promoting the inclusion of all voices in decision-making

36. Please consider joining us!
•If you are interested in getting involved in the
Cancer Survivor Advisory Committee and helping us
to improve the delivery of cancer rehabilitation in
Canada, please contact:
• Charmaine Silva (team coordinator) at
Charmaine.silva@uhn.ca

37. Thank you!
Questions?
jennifer.jones@uhn.ca
charmaine.silva@uhn.ca (Team Coordinator)