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Shared cancer follow-up and survivorship care


Follow-up care is essential following completion of active treatment for cancer to check whether the cancer has returned, discuss physical and emotional health, and monitor and manage any risk factors and side effects of treatment. Shared cancer follow-up care involves the joint participation of specialists and GPs in the planned delivery of follow-up and survivorship care for patients.

As the number of people diagnosed with and surviving cancer increases, progressively more people will require follow-up care, placing an increased demand on Australia’s health system and resources. Shared care leverages the skills and expertise of the specialist and primary care workforce to support the delivery of high quality, safe and sustainable follow-up and survivorship care.

COVID-19 and cancer follow-up care

During the COVID-19 pandemic it is important that patients continue with their post-treatment cancer follow-up care. Patients may be unable to or may be concerned to visit the cancer service for their follow-up appointments during the pandemic. Cancer specialists may be able to arrange to share the follow-up care of cancer patients with the patient’s GP, particularly where there is evidence for the safety and effectiveness of shared follow-up care, for example for early breast cancer.

To ensure best practice follow-up care, it is essential that the roles and responsibilities of each member of the shared follow-up and survivorship care team are discussed and agreed prior to commencing shared follow-up care. The timely communication of information about the patient’s cancer diagnosis and treatment is also very important.

During the COVID-19 pandemic, Telehealth may provide an opportunity to facilitate agreement of the shared arrangement between specialist, GP and the patient without the need for a face-to-face consult. Patients can choose to have face-to-face follow-up appointments with their GP or through telehealth, however there are times when a face-to-face consultation is required to enable the GP to conduct a clinical examination. Resources are available for shared cancer follow-up and survivorship care for early breast cancer and low-risk endometrial cancer.