Through implementation of a quality improvement initiative, the number of referrals to a cancer rehabilitation program at an academic cancer center increased significantly for patients with gastrointestinal (GI) cancers, according to a report published in JCO Oncology Practice.

Comprehensive cancer rehabilitation programs are designed to be embedded within cancer care to optimize the functional status and quality of life of patients with cancer.  Specifically, these programs facilitate the prevention and treatment of adverse sequelae of cancer and cancer treatment from treatment initiation through long-term cancer survivorship.

Following recognition of a low referral rate for patients with GI cancers to its established, outpatient cancer rehabilitation and survivorship program (CRS), a team at The Princess Margaret Cancer Centre in Toronto, Canada, sought to identify barriers to its use by these patients. The investigators then developed a quality improvement initiative to increase the number of patients with GI cancer participating in the CRS program.

Continue Reading

For this study, they completed a literature review and conducted informal interviews using a validated questionnaire with 7 clinicians who specialized in the care of patients with GI cancers — including physicians in surgical, radiological, and medical oncology; nurses; and trainees — to identify impediments to CRS program referral for patients with GI cancers.

Lack of clinician awareness/knowledge of the CRS program and the referral process were key barriers to CRS program participation. In addition, time constraints interfered with patient assessment and referral to the program.

In an attempt to increase CRS program referrals for this subgroup of patients, the quality improvement CRS team at the facility implemented the following Plan-Do-Study-Act (PDSA) cycle every 2 months from January to December 2019:

  • Place posters with descriptions of referral criteria, as well as referral forms, within GI clinics
  • Offer presentations to increase awareness about the CRS program among oncology fellows and members of the GI multidisciplinary team
  • Host a luncheon with informal discussions and question-and-answer sessions regarding the CRS program for GI nurses
  • Place posters designed to educate patients about the CRS program in the GI clinics
  • Send emails thanking clinicians who referred patients with GI cancers to the CRS program to all GI staff

The initiative produced a 100% relative increase in the number of referrals to the CRS program for patients with GI cancers in 2019 compared with the previous year. Supportive care clinicians made 49% of patient referrals to the CRS in 2018; this decreased to 25% in 2019. In addition, the percentage of referrals from oncologists, who often oversee earlier-stage treatment relative to supportive/palliative care clinicians, increased from 51% in 2018 to 75% in 2019.

“Future work will be dedicated to sustainability of our success,” commented the investigators.


Nadler MB, Rose AAN, Prince R, et al. Increasing referrals of patients with gastrointestinal cancer to a cancer rehabilitation program: a quality improvement initiative.JCO Oncol Pract. Published online December 8, 2020. doi:10.1200/OP.20.00432

This article originally appeared on Oncology Nurse Advisor