Shared follow-up care

Shared follow-up care is an innovative model of care that shares the delivery of follow-up care after early breast cancer between the GP and the specialist.

Shared follow-up care for women with early breast cancer

Shared follow-up care gives women the option of having their follow-up care shared between their GP and specialist after treatment for early breast cancer or ductal carcinoma in situ (DCIS).

A recent project by Cancer Australia demonstrated that shared care is a feasible model of follow-up care for early breast cancer. Cancer Australia is working with the hospitals listed below to evaluate the delivery of shared follow-up care for women with early breast cancer in line with best practice recommendations.

  • Austin Hospital, Melbourne
  • Monash Medical Centre Moorabbin, Melbourne
  • Royal Brisbane and Women’s Hospital, Brisbane
  • The Queen Elizabeth Hospital, Adelaide
  • Westmead Breast Cancer Institute, Westmead Hospital, Sydney

Below are some frequently asked questions for women and health professionals with specific information about shared follow-up care.

Why is follow-up care after breast cancer important?

After treatment, it is important to have follow-up visits to check whether breast cancer or DCIS has come back, to monitor side effects of treatment and to provide practical and emotional support.

Is shared care safe?

Shared care between the GP and specialist has been implemented and documented in a range of health settings, such as paediatric oncology, mental health and obstetric services. Studies show that follow-up by a GP after breast cancer is a safe and effective form of follow-up care.1,2

What are the benefits of shared care?

Shared follow-up care has the potential to promote and support continuity of care and whole person care, as the woman’s GP can oversee all her health issues. Follow-up provided by a woman’s GP may improve access to care and be more convenient for the woman by reducing the need to travel for treatment.

Due to increasing incidence of breast cancer and improving survival rates3, more and more women require regular clinical follow-up after breast cancer. Shared follow-up care has the potential to meet increasing health service demand and provides a team-based approach to breast cancer follow-up care, which could improve links between specialist teams and GPs.

How will follow-up care be managed?

Under the shared follow-up care model, follow-up care after early breast cancer will be shared between the GP and specialist. Some or all of the follow-up visits will be with the GP rather than with the specialist. The GP will be supported by and will communicate with the specialist about providing ongoing follow-up care. The GP will have rapid access to the specialist if follow-up raises a clinical issue requiring urgent specialist consultation or advice.

Who is participating in shared follow-up care?

Women who were diagnosed with early breast cancer or DCIS and have completed active treatment (including surgery, radiotherapy, chemotherapy and targeted therapies such as Herceptin®) at least three months ago, may be suitable for shared follow-up care.

This may include women still receiving hormonal therapies (including tamoxifen and aromatase inhibitors).

When would these follow-up visits be?

The frequency of follow-up visits and tests will be the same as if follow-up care was being managed by the specialist alone. The follow-up schedule will be based on each individual’s situation.

Following treatment for early breast cancer, the Cancer Australia recommended follow-up schedule4 is:

Method Years 1 and 2 Years 3–5 After 5 Years

History and clinical examination

Every 3–6 months

Every 6–12 months

Every 12 months

Mammography (and ultrasound if indicated)

Every 12 months*

 

Every 12 months

Every 12 months

Chest X-ray, bone scan, CT, PET or MRI scans, full blood count, biochemistry and tumour markers

Only if clinically indicated on suspicion of recurrence

 

CT: computed tomography; PET: positron emission tomography; MRI: magnetic resonance imaging

* First mammogram 12 months post-diagnosis

† Use of MRI may be considered in specific high-risk groups

What to do if you notice a symptom?

If you notice any new or unusual symptoms between follow-up visits, do not wait until your next scheduled appointment. See you GP as soon as possible so that the cause of the symptom can be explored.

What resources will support shared care?

A patient-held Shared Care Plan has been developed for women to bring to all follow-up appointments for their GP and specialist to record information about their follow-up care. The Shared Care Plan contains key elements required to provide ongoing comprehensive care to a patient who has received treatment for early breast cancer and allows women increased access to information about their follow-up treatment.

The Shared Care Plan consists of four parts:

  • Part A provides information about diagnosis and treatment. This section is to be completed by the specialist. Signed consent of the patient, the specialist and the GP to commence shared follow-up care is also included.
  • Part B provides information about the tailored follow-up schedule. It is to be discussed and agreed to by the patient, the specialist and the GP.
  • Part C is completed by the GP or specialist during each follow-up visit. GPs should keep a copy of this section for medical records and send a copy to the other members of the treating team.
  • Part D is completed by other healthcare providers (other than the GP or specialist).

A Rapid Access Request has been developed to support communication between the GP and specialist when follow-up raises a clinical issue requiring urgent specialist consultation or advice .

Please note – the Shared Care Plan and Rapid Access Request are only to be used by patients, GPs, specialists and other health providers as part of shared follow-up care. These resources should not be used as a substitute for existing referral arrangements between GPs and specialists.

Shared follow-up care resources for patients

Shared follow-up care resources for health professionals

Cancer Australia education resources for follow-up

Other follow-up care resources

References

  1. Lewis RA, Neal RD, Williams NH, et al. Follow-up of cancer in primary care versus secondary care: systematic review. British Journal of General Practice 2009;59: 234-7
  2. Grunfeld E, Levine MN, Julian JA, et al. Randomized Trial of Long-Term Follow-Up for Early-Stage Breast Cancer: A Comparison of Family Physician Versus Specialist Care. Journal of Clinical Oncology 2006;24:848-55
  3. AIHW 2012. Cancer survival and prevalence in Australia: period estimates from 1982 to 2010. Cancer series no. 69. Cat. no. CAN 65. Canberra: AIHW
  4. National Breast and Ovarian Cancer Centre (NBOCC). Recommendations for follow-up of women with early breast cancer. National Breast and Ovarian Cancer Centre, Surry Hills, 2010.