Improving cancer care in BC: Shared Care-funded projects

As the number of cancer diagnoses in Canada continues to rise, the Shared Care Committee committed to funding up to 15 projects in 2024 that address various priorities within cancer care. These priorities were agreed to in partnership with the BC Cancer, the Provincial Health Services Authority and the Ministry of Health. 

Through an Expression of Interest process from November 2024 to October 2025, 14 project teams engaged in quality improvement work, refined their scope, and built a detailed, costed project plan. They also engaged with regional health authorities and partners to ensure sustainability and explore opportunities for scale and spread. 

In addition to the 14 new projects, a new EOI to advance workforce planning and medical staff retention was introduced in November 2025. 

This cumulative total of 15 projects aims to bolster cancer care in BC and improve the experience for physicians, medical staff, and patients alike. 

The cohort of projects advances work across all five aspects of the IHI Quintuple Aim. 

Recruitment and retention

Achieving better health outcomes in cancer care largely depends on timely services, such as diagnostics, imaging, and pathology. Streamlining how physicians and care teams work can significantly enhance the timeliness and, consequently, the quality of care delivered. 

Advancing diagnostic cancer care and specialist workforce planning 

BC Cancer physicians are working to standardize diagnostic workflows and resource requirements to reduce wait times between diagnostic services, to improve both the quality of care and staff retention. 

Using breast cancer as a proof of concept, one of the project teams determined that BC data shows a median of six weeks from referral to pathological diagnosis, double the Health Canada benchmark target of 21 days. 

Through sustainable workforce planning for diagnostic specialists, the project will support timely shared multidisciplinary care and coordination among specialists, reducing burnout, and improving retention.  

Through this project, they aim to reduce the provincial median six-week wait time by at least 20% benefiting both patient and physicians. 

Pain and symptom management

Supporting patients in overcoming cancer is only part of the picture. Managing pain and symptoms effectively is crucial for the patient's quality of life during and after successful cancer treatment. 

Supporting breast cancer patients on endocrine therapy 

Two-thirds of people diagnosed with breast cancer in BC are prescribed endocrine therapy (ET), lasting five years. But side effects like arthralgia, weight gain, sleep disturbances, bone loss, and induced menopause mean nearly half the people on this treatment stop well before the five-year mark. 

As a result, these patients often experience higher rates of recurrence, many of which are severe and incurable. 

BE-FIT is a research-tested self-management program supporting people in managing the side effects of endocrine therapy. The project aims to increase referrals from family physicians and improve support and symptom management for patients with ET side effects.  

Together with InspireHealth, a project team began delivering BE-FIT on September 1, 2025. Physicians hope this will lead to a 25% increase in enrollment among patients with breast cancer.  

Ultimately, they would like to see BE-FIT implemented and for family physicians to have the knowledge to refer patients to the program. 

Optimizing remote symptom and patient monitoring in Richmond 

Richmond Hospital is adapting its Remote Symptom and Patient Monitoring System (RESPONSe) program to monitor patients on immunotherapy regimens, aiming to reduce emergency department visits by cancer patients. 

The RESPONSe program proactively monitors chemotherapy patients through digital symptom tracking and nurse triage, improving early detection of symptoms, providing timely management, and reducing avoidable acute care. 

But nearly 30% of patients now receive immunotherapy regimens, which differ from chemotherapy in onset, severity, and required management.  

By developing immunotherapy-specific monitoring care plans, providing patient education, and streamlining workup and treatment pathways, the project team aims to enroll 75% of newly eligible patients receiving immunotherapy regimens within six months of launching the tailored care plans. 

Symptom management for post-treatment patients with gynecological cancer in Kelowna 

Surviving gynecological cancer doesn't necessarily mark the end of the care journey. 

Despite potentially life-altering symptoms that can affect patients after treatment, many patients don't want to discuss these impacts. This can lead to patients suffering in silence from sexual and mental health issues. 

This Shared Care project provides proactive support and follow-up services to patients with gynecological cancer who have undergone surgery and pelvic radiotherapy. 

With support from BC Cancer Agency’s leadership in Kelowna, the project team is starting a clinic for survivors, aiming to deliver care to 50% of gynecologic cancer patients who complete curative treatment at BC Cancer-Kelowna.  

Patients will be able to receive interdisciplinary care for their physical health and rehabilitation, mental health, sexual health, and endocrine health, including bone health and hormone replacement.  

Improving access to pain management for patients with spine metastases in Vancouver 

Greater capacity in spine Stereotactic Ablative Radiotherapy (SABR) delivery can provide better pain control to cancer patients. 

Spine SABR is a precise radiotherapy technique that effectively relieves the pain caused by spinal metastases. Only a small group of radiation oncologists provide spine SABR across BC Cancer sites, which means a high demand at sites that offer the treatment.  

This can cause treatment delays, increase patient travel time, and suboptimal or delayed pain control. One patient from Prince George had to wait four weeks for their treatment and had to travel to Vancouver to receive care. During their wait, their pain increased, and they developed numbness in their legs from the growing tumour. 

The project team will provide education and mentorship for medical staff to encourage availability in other sites, and in turn help attract and retain medical staff interested in using these advanced radiotherapy techniques. 

Increasing access to evidence-based group psychotherapy for BC Cancer patients 

Cognitive Behavioural Therapy (CBT) may be just what the doctor ordered for cancer patients with mild-to-moderate depression and anxiety. 

While most people are familiar with physical cancer treatments, such as radiotherapy and chemotherapy, the psychological toll on patients dealing with cancer is often overlooked.  

BC Cancer physicians, along with Mind Space, are hoping to treat mild to moderate depression by expanding access to MSP-funded CBT psychotherapy groups for BC Cancer patients. 

Following the EOI phase, the data reflected a referral rate of roughly 5% for eligible patients seen by psychiatry. The team aims to quadruple that to 20% by October 2026 through educating colleagues and patients, working with Mind Space to address barriers to access, and tailoring content for cancer patients and survivors. 

Improving diagnostic pathways

Clear and up-to-date diagnostic pathways can help physicians confidently support their patients through their cancer journey and improve the overall patient experience. 

Reducing time to lung cancer diagnosis in the South Okanagan 

A small amount of time can make a significant difference when it comes to diagnosing lung cancer, which accounts for roughly 25% of cancer-related deaths. 

A Shared Care project aims to reduce lung-cancer-related deaths by addressing the gaps in care and referral pathways used in stage-three lung cancer diagnoses.  

Following research undertaken during the EOI phase of their project, the project team identified specific steps to improve care, including implementing a flagging system for CT scans at Penticton Regional Hospital and increasing access to advanced bronchoscopy techniques.  

Reducing cardiovascular risk in prostate cancer patients in Victoria 

People diagnosed with localized and regional prostate cancer can have a positive survival outlook. But for patients also at high risk of cardiovascular (CV) disease, the odds may not be as good. 

The CV-Prostate project is creating a nurse-practitioner-led initiative to identify CV risk factors early. Nurse practitioners can then customize care for patients referred to BC Cancer-Victoria who require treatment with androgen deprivation therapy for six months or longer. 

Currently, fewer than 10% of patients at BC Cancer have had their cardiac risk factors assessed. The team hopes that, through education and implementation, this process can become standard and that by November 2026, 100% of patients evaluated will be assessed for cardiac risk factors. 

Improving communication between radiologists and radiation oncologists for timely referrals in the Interior 

Spinal-cord-compression cases are often complex and can get bogged down by disagreements, uncertainties, and a lack of efficient and effective communication between care team members. This can delay patients' treatment and result in paralysis, sensory loss, and bladder or bowel dysfunction. 

Through standardized communication protocols, the project aims to reduce delays, improve patient outcomes, enhance team collaboration, and improve care for both attached and unattached patients presenting with spinal cord compression. 

The project team aims to reduce the wait time from diagnosis to treatment by 50% for patients with spinal-cord compression at BC Cancer-Kelowna. 

Reducing wait times for tissue diagnosis in incidentally detected liver cancers in Victoria 

While developments in breast and lung cancer pathways have significantly reduced wait times for care, Dr Vamshi Kotha says there’s still many cancers that remain discovered by chance. 

In partnership with the BC Cancer Agency, Victoria Division of Family Practice, the Patient Voices Network, and local administration, Dr Kotha and the project team will explore referral and diagnostic pathways for South Island patients with newly diagnosed liver tumours. 

Through a quality-improvement approach and streamlining pathways across the patient journey, Dr Kotha aims to reduce diagnostic wait times for patients in the South Island region with incidentally detected liver tumours by 50% within two years. 

Expediting suspected lung-cancer diagnosis in the Fraser region 

It can take up to 80 days for the initial signs of lung cancer to lead to a definitive diagnosis, but a Shared Care project hopes to reduce that to less than two weeks. 

A team of oncologists, surgeons, radiologists, and other health care professionals in the Fraser region is working to develop a clear diagnostic pathway for lung cancer, with the goal of decreasing the time from initial signs to definitive diagnosis and treatment referral to less than 14 days. 

Transitions in care

Patients receiving cancer care often have a broad care team, from family physicians to radiation oncologists and everything in between. To ensure patients receive the care they need when they need it, the care team must communicate and facilitate transitions, removing any possible barriers. 

Equity model of cancer care for the Downtown East Side (DTES) 

A Shared Care project is offering hope to cancer patients living in Vancouver's Downtown East Side neighbourhood by bringing equitable cancer care to its residents. 

People living with health and social inequities are significantly more likely to be diagnosed with preventable cancers and late-stage disease for screening-detectable cancers. They are also less likely to receive cancer treatment, more likely to have poor pain and symptom management, and to die from cancers that are generally curable. 

Through provider equity training and mentorship, the project team will focus on developing a team-based model that offers a more flexible approach to care and enhances patient navigation. 

The team aims to improve care coordination between oncology and primary care for adult cancer patients connected to DTES primary clinics and who are receiving care at BC Cancer-Vancouver by December 2026. Specifically, they hope to see a 30% increase in patient-reported care experience measures and treatment completion, as well as 50% increases in care coordination and documentation between oncology and primary care teams. They also hope for a 30% decrease in missed appointments. 

Rural cancer-care network in East Kootenay region brings treatment closer to home 

A project is underway in East Kootenay to develop supports for rural patients who must travel to receive care. 

Oncology patients currently visit one of two care locations during diagnosis and treatment—either a CON clinic or a regional cancer centre. However, the distance a patient must travel for care can directly affect the time to an initial diagnosis and the course of treatment. 

The Cancer Care Network project aims to place a physician with enhanced oncology training in rural communities in the East Kootenay region to support Community Oncology Network (CON) clinics. 

The project team is adapting the model of a clinic in Golden, which they hope will improve comprehensive patient communication, pain and symptom management, palliative care, and post-treatment follow-ups in the East Kootenay region. The increased support is also expected to reduce the East Kootenay Regional Hospital CON clinic's workload, expedite diagnoses, and provide care closer to home. 

Vancouver Island project looks to increase Community Oncology Network capacity through alternative care 

Vancouver Island Community Oncology Network (CON) sites are exploring ways to increase capacity while ensuring that cancer patients receive the care they need. For some patients receiving low-risk oral treatment, it’s possible to ensure quality care with fewer appointments.  

By reducing the need for physician appointments to once a year for prostate cancer patients and twice a year for lymphoma patients, the team believes they can avoid booking as many as 1,200 unnecessary physician appointments per year, opening up significant capacity for more complex cases. 

The first clinic will be led by a team of nurses and will focus on prostate cancer patients on oral therapies. The second clinic, led by pharmacists, will support patients with lymphoma on oral therapies.  

Building seamless cancer-care transitions in Greater Victoria 

The Collaborative Pathways for Seamless Care Transitions project in Greater Victoria aims to provide long-term care planning and support for unattached cancer patients. The project will ensure proper hospital discharge protocols for cancer patients without follow-up care. 

Patients will get a clear follow-up care plan, with improved communication, care coordination, and continuity between hospital clinicians, oncology, and community physicians in Greater Victoria.  

The project team will gather data from patients and physicians across specialties, including oncology, family medicine, emergency care, and palliative care, to identify challenges and implement improvements. 

Improving pediatric chemotherapy options in BC 

Currently, patients with osteosarcoma are admitted for six cycles of methotrexate, which equals 50 inpatient days. An outpatient can get the same treatment in six four-hour visits. 

To reduce the time pediatric patients spend in-hospital and hospital admissions, an outpatient chemotherapy program aims to improve mental health through social connections, foster greater independence, and achieve cost savings, thereby enhancing patient recovery. The project may also support other chemotherapy options in an outpatient setting. 

Based on the IHI Model for Improvement, the project team will pilot and evaluate a small number of changes before broader implementation.