The key principles listed here are those presented in the Optimal Care Pathway for people with breast cancer (First edition; Cancer Council Victoria 2015; and informed by the draft Second edition) (OCP). The Optimal Care Pathway describes an integrated model of cancer care that puts the patient’s needs first, along with the best of technical care. The optimal care pathways have Australia-wide acceptance and are endorsed by Cancer Australia.
The seven principles define appropriate and supportive cancer care, put the patient at the centre of care throughout their experience, and prompt the healthcare system to deliver coordinated care. The principles underpin care. They apply broadly across the management and care of people with breast cancer, highlighting the individuality of each patient’s experience and care needs, and recognising the role of carers and families.
A key cross-cutting element of the principles is the need for shared decision-making, allowing people diagnosed with breast cancer to be actively involved in decision-making regarding their treatment and care to the extent they wish to be, and to be fully informed (including of financial implications) in order to make those shared decisions. The importance of patient preferences is also highlighted. It is important that a shared understanding of the goals of care is established at the outset between a person diagnosed with cancer and their treating team, and that these goals are taken into account at all points during treatment as well as follow up and survivorship care. These principles also align with Cancer Australia’s Principles of Cancer Survivorship. The Principles are included on this website to support all health professionals involved in the management and care of people with breast cancer to provide the best possible care.
Patient-centred care
Patient-centred care is respectful and responsive to the preferences, needs and values of patients and informs and involves patients in their care.
Patient-centred care respects the cultural and religious beliefs of patients and families and involves and informs the patient’s family and carers appropriately, with patient consent. It encompasses seeking out and understanding what is important to the patient ― this includes their preferences and goals of treatment ― and establishing a relationship of trust, working together in planning care and decision-making. Patient-centred care is a holistic approach to care that includes assessment of patient and cancer characteristics and patient preferences and is supported by a shared and integrated approach to care.
Patients should be fully involved and informed at every stage. Timely, evidence-based information that is tailored to the individual patient and their wishes should be provided to patients to support their involvement in shared decision-making. Topics for discussion include short- and long-term side effects, frequency of administration, length of course, and risk of second malignancies. Patients should be fully informed of the possible benefits and harms associated with each therapy under consideration or being offered to them. Importantly, patients should be fully informed of cost implications to enable informed financial consent [a cost icon is used to indicate out-of-pocket costs for medicines/treatments/referrals that are not PBS- or MBS-funded].
Cultural and religious beliefs should be respected, and the special needs of patients should be considered. These include the unique needs of Aboriginal and Torres Strait Islander people, culturally and linguistically diverse people, older people, younger people, men, and patients in rural or remote areas.
Patient-centred approaches to care can lead to improvements in safety, quality and cost-effectiveness, and improved patient and staff satisfaction.
Safe and Quality care
Health services and health professionals are responsible for providing safe and quality care.
Health professionals need to have appropriate training and experience to undertake treatment for breast cancer, undertake regular audits of their care, and be actively involved in continuing professional development.
Patients should be referred to an individual practice or service with appropriate expertise. Health care practice should remain current be informed by evidence and conform to appropriate standards.
Hospitals and clinics must have the equipment and staff numbers, and policies and procedures to support safe and quality care. Practices should be monitored and evaluated, and patient-reported experience measures and outcomes should be incorporated into routine cancer care.
Multidisciplinary care
Multidisciplinary care is an integrated, team-based approach that involves all relevant health professionals.
Underpinned by Cancer Australia’s Principles of multidisciplinary care, multidisciplinary care promotes an individualised and patient-centred approach, supporting the involvement of patients in making decisions about their treatment and care and incorporating patient preferences.
The multidisciplinary team considers all relevant modalities of treatment and options, including clinical trials, and collaboratively plans treatment and supportive care for each patient. Multidisciplinary care ensures that all patients have access to the full range of care, regardless of location.
The multidisciplinary team discusses all relevant treatment options prior to the start of treatment and at key points along the care continuum, including at diagnosis (not relevant for this guidance), prior to treatment (treatment planning), when treatment changes, and for follow-up and survivorship care. The team should have strategies and processes in place to ensure clarity of the respective roles of team members and to facilitate coordination of care and ongoing communication between team members especially across health sectors, and especially with the patient’s General Practitioner (GP) [written summaries preferred]. A multidisciplinary team may meet in person or by using technology such as telehealth. Shared care is an option for follow-up, depending on patient preference.
The multidisciplinary team composition should reflect the clinical and psychosocial needs of the patient, and involve all relevant health professionals including radiation and medical oncologists, breast physicians, surgeons, pathologists, general practitioners, breast care nurses, care coordinators, and allied health professionals – see Examples of multidisciplinary care teams.
Multidisciplinary teams may also include, where relevant, a health professional with expertise in providing culturally appropriate care for Aboriginal and Torres Strait Islander people (and use the Optimal Care Pathway for Aboriginal and Torres Strait Islander people with cancer), a fertility expert, a genetics specialist, an obstetrician, a perinatologist, a cardiologist, and a geriatrician.
Multidisciplinary care improves patient outcomes.
Supportive Care
Supportive care helps patients, families and carers deal with needs and issues that arise across the continuum of breast cancer care. Supportive care encompasses the services, information and resources patients may need to meet their physical, psychological, social (including educational, financial, and occupational), cultural, information, and spiritual needs. The benefits of supportive care are established.
All members of the multidisciplinary team have a role in providing supportive care, and support from family, friends, support groups, volunteers and other community-based organisations also make an important contribution to supportive care. At its core, it is about appropriate assessment, access, and referral.
Supportive care needs of patients should be routinely and systematically assessed at key points across the cancer pathway, particularly at times of increased vulnerability. Views of patients and their families and carers on the issues they need help with should be discussed and a mutually agreed approach to supportive care developed. Cultural appropriateness, as always, should be foremost.
Appropriate interventions and referrals should be made as required to promote optimal quality of life, such as referrals to allied health professionals (e.g. psychologist, dietitian, exercise physiologist (experience in breast cancer care), lympheodema specialist, genetic counsellor). General Practitioners (GPs) may play an active role in managing both physical and psychosocial issues. Access to services such as allied health professionals can be through a variety of arrangements in the public and private sectors, such as through GP-led Chronic Disease Management Plans, team care arrangements and Mental Health Plans [Where relevant these are highlighted in the guidance.]. Community support services may also be involved. Cancer care coordinators are encouraged to be aware of the opportunities available to them locally for accessing supportive care.
Referral to community support organisations (cancer-related non-government, not-for-profit and charities) that provide services to cancer survivors is also important. Many of the links to these organisations and relevant information and resources have been included in the guidance, as are relevant screening tools.
Clinical review and individual assessment are still required to ensure all patient concerns are identified, especially at key transition points.
Care coordination
Coordination of care is the responsibility of every professional, clinical and non-clinical, working with the patient, their family, and carers.
It is the application of a comprehensive approach to achieving continuity of care for patients. It seeks to ensure that care is delivered in a logical, connected, and timely manner so that medical and personal needs are met. A coordinated approach promotes efficiency and reduces the risk of duplication and over-servicing.
Care coordination brings together different health professionals, teams, and health services. It also encompasses MDMs, multidisciplinary assessment clinics, supportive care screening and assessment, referral practices, data collection, common protocols, information for patients and individual clinical treatment. Care coordination should cross the acute and primary care interface and should aim to achieve consistency of care through clear communication, linkages, and collaborative integrated care planning.
As indicated in the guidance, formal care coordination through appointed cancer care coordinators is ideal for managing and supporting patients through the health system, although the availability of dedicated care coordinators varies across regions.
Care coordination can be facilitated through electronic health record management such as My Health Record.
Care coordination occurs at the health professional level and at the whole-of-system level.
Communication
Everyone employed in the healthcare system is responsible for ensuring the communication needs of patients/families/carers are met.
While good communication between health professionals, particularly between oncology teams and GPs, is emphasised in some of the other key principles, this principle is focused on clear, good, open communication between the health professional and the patient, including carers and families.
Communication with patients should be comprehensive, evidence-based and easy to understand, in a form suited to their language, culture and health literacy. Written information should be provided wherever possible.
In communicating with patients, health care providers should allow sufficient time for communication, empower patients to be actively involved in decision-making, identify a patient’s substitute decision-maker if necessary (being cognisant of patient consent), be respectful if patients seek a second opinion, and ensure patients are not the conduit of information between areas of care.
Good communication will support shared decision-making. Consider offering patients a Question Prompt List in advance of their consultation, and/or recording or writing written summaries of their consultation.
Written care plans, treatment summaries, survivorship care plans and advance care directives are effective records and communication tools.
Communication skills training programs, using role-play to develop skills and observe patient interactions to provide feedback, should be available to health professionals at every level of practice.
Research and clinical trials
Where practical, patients should be offered the opportunity to participate in research and/or clinical trials at any stage of the care pathway.
Clinical trials are the foundation for improved cancer outcomes, allowing the testing of new treatments, and offering patients access to potentially more effective therapies than otherwise unavailable to them.
Health professionals should:
• be aware of or search for clinical trials that may be suitable for patients via www.australiancancertrials.gov.au
• be willing to refer patients to other treating centres for participation in trials
• encourage cross-referral between clinical trials centres by participating MDT members
• be able to discuss the pros and cons of participation in such trials
• understand the disappointment a patient may experience if ineligible to participate in trials and provide necessary support.
Health Services should facilitate equitable access, potentially via a telehealth model, to clinical trials for all patients, including culturally diverse patients, regional patients, and those from Aboriginal and Torres Strait Islander communities.
