Shared care model for early follow-up of breast cancer survivors

Survivors of early breast cancer will take part in a new nationwide study trialing a shared care model between cancer specialists and GPs for the follow-up care when they have completed their initial treatment.

• National clinical trial to implement shared care between cancer specialists and GPs to alleviate pressure on out-patient clinics
• Care model will allow for better care to address physical and psychosocial needs of survivors
• Trained specialist breast care nurses will co-develop a survivorship care plan with patients and coordinate care with the patient’s GP

QUT Professor Ray Chan, from QUT and Metro South Health, who is leading the study, said early breast cancer survivors are typically followed up by cancer specialists at outpatient clinics for three to five years after treatment, and at times longer.

“Offering early breast cancer patients the opportunity for their follow-up care to be shared between cancer specialists and GPs is increasingly recognized as best practice internationally,” Professor Chan said.

“Currently many women travel long distances to a breast cancer specialist clinic. They often see a junior doctor who does not have time or skills to attend to the psychosocial and emotional needs breast cancer survivors report such as anxiety, depression, pain, fear of recurrence.

“The model we are trialing has a unique feature in that specialized breast care nurses from the McGrath Foundation will be the point of contact and coordinator for women who have completed their chemotherapy and/or radiation treatment.

“The nurses’ role is to engage patients, GPs and specialists to take an active part in the patient’s survivorship care and quality of life.

“The nurse will see the patient in a dedicated nurse-led clinic to assess their needs and priorities of care. The nurse will address a range of issues in a tailored way for the patient.

“Together they will develop a Survivorship Care Plan which sets out the patient’s goals for example, getting back to work, exercising or anxiety relief and the tools to self-manage.

“The nurse will liaise with and support the GP in the follow up care for these survivors. The nurse will also ensure GPs have a range of tools and resources available, including online modules and reimbursement items for their care provision.”

Professor Chan said the patient would then alternate follow-up visits at six monthly intervals between the GP and the specialist.

With the ever-growing number of cancer survivors, the specialist-only model is not sustainable as the clinics reach capacity. With this shared care model there will be no change to annual mammography and physical examination and appointments associated with their endocrine therapy but we expect survivors will have a better breast cancer-specific, health-related quality of life. Our aim is to give survivors better patient care, fewer unmet care needs, and a higher uptake of health lifestyle behaviors, while improving system sustainability to meet the future demand for care.”

Professor Ray Chan, QUT and Metro South Health

The IBIS-Survivorship study will recruit 1,358 participants from eight cancer centers in metropolitan, regional and rural Australia – two in Western Australia, two in New South Wales, two in Queensland, one in South Australia and one in the ACT.

The trial is funded by a $1.44 million NHMRC grant, and $1.6 million in-kind contribution from the McGrath Foundation and the eight cancer centers.