The ACTT at Women’s College Hospital

Now that his treatment is complete, Jim is relieved to be cancer-free – but he’s still anxious about a future that could include long-term side-effects or even a small risk of recurrence. Women’s College Hospital is here to ensure that his post-cancer care includes care for treatment side-effects, surveillance for recurrence and emotional support.

The transition from cancer patient to cancer survivor is one that many find difficult to navigate.

The After Cancer Treatment Transition (ACTT) program is leading the way. An innovative partnership between Women’s College and Princess Margaret Hospital, the ACTT program is the first of its kind in Canada and one of only a few such programs in the world.

Patients are referred to ACTT at Women’s College Hospital after they have completed cancer treatment at Princess Margaret, and are disease-free with low to moderate risk of cancer recurrence. ACTT’s novel approach to care as these patients transition back to the community includes:

• a comprehensive clinical assessment, by a team led by an advanced practice nurse and physician, which includes an assessment for mental health conditions like depression and anxiety

• plan for transition back to the family physician, when appropriate, with a clear plan for post-treatment care

• reassessment if abnormalities arise and rapid access to Princess Margaret should the cancer recur

Patients are provided with a post-treatment summary that includes a review of their cancer treatment, information about long-term side-effects and symptoms of recurrence, and links to information about healthy lifestyles. ACTT encourages cancer survivors to take charge of their own health by being active participants in their own followup care, such as sharing their treatment information with their primary care provider, and establishing a plan to ensure monitoring for long-term treatment effects, cancer recurrence and recommended screening for other cancers.

“We give them a passport for the future,” says Shari Moura, clinical nurse specialist at Women’s College Hospital.

More than 1,200 survivors of testicular, breast and gynecological cancers have already benefited from the ACTT program. By evaluating the model, Women’s College Hospital is establishing a standard of care and a model for delivering high quality, safe and integrated post-cancer care throughout the health-care system.

The need for ACTT is clear: thousands of new cancer cases are diagnosed in Ontario every year, and the numbers are only increasing due to a growing and aging population. The good news is that advances in treatment mean that more and more people are surviving cancer. That creates a growing need for post-cancer followup care. It’s a need that Women’s College Hospital is filling with another pioneering partnership.

Shari Moura
Clinical Nurse Specialist
Women’s College Hospital


Ontario’s Action Plan for Health Care, Ministry of Health and Long-Term Care

“Helping people stay healthy must be our primary goal and it requires partnership.”