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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.

Shared cancer follow-up care – sometimes called survivorship care – is when specialists and GPs jointly provide post-treatment care for people who have completed their cancer treatment.

Shared or multidisciplinary follow-up care underpins the Clinical Oncology Society of Australia’s Model of Survivorship Care.

Follow-up care is essential for patients who have completed their active cancer treatment, to:

  • check whether the cancer has returned
  • discuss physical and emotional health
  • monitor and manage any risk factors and side effects of treatment.

Studies show that people living with cancer prefer shared follow-up care versus usual care. It is also more cost-effective for healthcare systems. This is important, because as the number of people diagnosed with and surviving cancer increases, more and more people will require follow-up care, thus increasing the demand on Australia’s health system.

See Cancer care in the time of COVID-19: A conceptual framework for advice about cancer care during the COVID-19 pandemic.

Benefits of shared follow-up care

Shared follow-up care has the potential to promote and support continuity of care and whole-person care. Primary care and GPs are well placed to deliver patient-centred, best-practice follow-up care. Benefits of shared follow-up care include:

  • better continuity of care and more convenient, as patients may have easier access to their GP than their specialist
  • patients may benefit from their GP overseeing all of their health issues
  • improvements in patient choice and shared decision-making
  • improved access to holistic and accessible care
  • easier for specialist teams to manage and support high-risk patients
  • strengthened care coordination between specialist and primary care teams.

If needed, the GP can arrange quick access to a specialist at any time.

Why follow-up care is necessary

Follow-up care for cancer is important for:

  • detecting local, regional or distant recurrence earlier
  • identifying, monitoring and managing treatment-related side-effects and co-morbidities
  • screening, assessing and managing supportive care needs
  • reviewing and updating family history information
  • providing holistic care
  • reviewing and updating family history information
  • observing therapy outcomes
  • exploring and managing the patient’s expectations
  • reviewing treatment, including potentially relevant new therapies
  • promoting secondary prevention strategies (such as maintaining a healthy body weight, exercising regularly and limiting alcohol intake).

Principles of shared follow-up care

Cancer Australia has developed 7 principles that underpin the delivery of shared follow-up care by health professionals and health services:

  • Person-centred care
  • Care is delivered according to best practice
  • Coordination of care
  • Support for living well
  • Support for the multidisciplinary team
  • Care is informed and improved by data.

These principles were developed specifically for early breast cancer and low-risk endometrial cancer, but apply to all types of shared follow-up care.

Follow-up care resources

My Care Plan is an online tool that can be used to create a personalised survivorship care plan after treatment for cancer. It helps patients to better understand their personal health risks depending on the type and combination of cancer treatments they received. My Care Plan can be used with the Shared care plan for early breast cancer follow-up and survivorship care.

Supportive care screening

Screening people for supportive care needs should be evidence based and systematic. The tool used to screen supportive care needs should be reliable and valid. A validated and widely used tool is the Distress Thermometer and Problem List.

Online education

Find out more

Principles of cancer survivorship (Cancer Australia, 2017)

Model of Survivorship Care (Clinical Oncology Society of Australia, 2016)

The important role of general practice in the care of cancer survivors (AJGP, 2020)

The effectiveness of shared care in cancer survivors – a systematic review (Int J Integr Care 2018)


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.