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Shared cancer follow-up and survivorship care: early breast cancer


Clinical practice guidelines recommend long-term follow-up care after treatment for early breast cancer. Shared follow-up and survivorship care for early breast cancer involves the joint participation of specialists and GPs in the planned delivery of follow-up care for women with early breast cancer or ductal carcinoma in situ (DCIS).

What is the purpose of follow up care for early breast cancer? 

  • Early detection of local, regional or distant recurrence
  • Screening for a new primary breast cancer
  • Detection and management of psychosocial distress, anxiety or depression
  • Detection and management of treatment-related side effects and late effects
  • Reviewing and updating family history information
  • Observation of outcomes of therapy
  • Reviewing treatment, including potentially relevant new therapies
  • Promotion of secondary prevention strategies (including maintaining a healthy body weight, regular exercise and limiting alcohol intake).

What are the benefits of shared follow-up care?

In this short video Professor Bruce Mann, Director of Breast Tumour Stream, Victorian Comprehensive Cancer Centre, highlights the value and benefit of the Cancer Australia model of survivorship care for survivors of early stage breast cancer. (Reproduced with permission from Professor Bruce Mann and the Australian Cancer Survivorship Centre).

Shared follow-up and survivorship 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 and survivorship care.
  • Studies demonstrate that follow-up care by a GP is a safe and effective alternative to follow-up by a specialist and provides better continuity of care (more consistent care over time).
  • A shared care approach may be 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.
  If needed, the GP can arrange rapid access to the specialist at any time.

Cancer Australia’s program of work in shared follow-up care for early breast cancer (2009–2015):

Cancer Australia has undertaken an extensive program of work to gather and build the evidence base to inform the development of a best practice model of shared follow-up care for early breast cancer in Australia.


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