Follow-up care providers and plan
Follow-up care - Selection of provider (Recommendation)
(a) The selection of the provider of follow-up care (specialist(s) and/or general practitioner (GP)) should be a decision made by the multidisciplinary team and the patient, and be based on the purpose of follow-up and the individual patient’s needs, risk of recurrence, circumstances, health literacy, and preferences for shared follow-up care. This decision should be reviewed over time.
(b) All patients should be offered the opportunity for their follow-up care to be shared between a GP and a specialist, to provide more accessible, whole-person care.
(c) All patients should be informed about the benefits of GP involvement in their follow-up care and other relevant information to make an informed choice.
How this guidance was developed
This recommendation was adapted from the CA 2010 guidelines (Australia). The source recommendation was based on a systematic review of the evidence conducted to January 2008 and was not graded by the source guideline authors. The source recommendation was adapted by making it gender neutral, including information on offering shared-care follow-up care, and the provision of information to support an informed choice.
This recommendation aligns with the 2017 Cancer Australia Statement – Influencing best practice in breast cancer: Practice 6.
Follow-up care plan - Development (Recommendation)
A patient’s follow-up care plan should be developed in consultation with the patient, the GP, and the multidisciplinary team following completion of active treatment. To support coordination of care, the care plan should be provided to the multidisciplinary team, including the GP, and indicate the health professional(s) designated to provide follow-up care and the patient’s individual follow-up schedule.
How this guidance was developed
This recommendation was adapted from the CA 2010 guidelines (Australia). The source recommendation was based on a systematic review of the evidence conducted to January 2008 and was not graded by the source guideline authors. The source recommendation was adapted by making it gender neutral and including consultative development of the plan.
Follow-up care plan - Patient-held (Recommendation)
The patient should be provided with an agreed follow-up schedule and shared care plan.
How this guidance was developed
This recommendation was adopted from the CA 2010 guidelines (Australia). The source recommendation was based on a systematic review of the evidence conducted to January 2008 and was not graded by the source guideline authors. The source recommendation was reworded to make the intent clearer, but there were no changes to the meaning or tone of the source recommendation.
Patient information
Information for patients on symptoms and signs of recurrence (Recommendation)
All patients should be provided with information about the symptoms and signs of local or regional recurrence and their individual risk of recurrence.
How this guidance was developed
This recommendation was adapted from the ACS/ASCO 2016 guidelines (US). The source recommendation was based on a systematic review of the evidence conducted to April 2015 and was not graded by the source guideline authors. The source recommendation was adapted by making it gender neutral, and initially by changing 'primary care clinicians' to 'cancer care team'. Subsequently, reference to a specific health care professional was removed. Communication of ‘individual risk of recurrence’ was added.
Information and support for patients on endocrine therapy (Recommendation)
Patients prescribed adjuvant endocrine therapy should be provided with information and support to continue their full course of therapy.
How this guidance was developed
This recommendation was adapted from the ACS/ASCO 2016 guidelines (US). The source recommendation was based on a systematic review of the evidence conducted to April 2015 and was not graded by the source guideline authors. The source recommendation was accepted with minor stylistic changes, but with no changes to the meaning or tone of the source recommendation.
