This section provides tools and resources to support the delivery of shared follow-up and survivorship care for women with early breast cancer.
Shared cancer follow-up and survivorship care resources
Shared care plan for early breast cancer follow-up and survivorship care template
This individualised care plan template is a tool developed to assist the GP, specialist and patient to manage follow-up and survivorship care for early breast cancer and DCIS together. It aims to facilitate effective communication, define responsibilities for care providers, and support the delivery of best-practice care
The shared care plan is developed within the specialist setting at the initial follow-up appointment three months post completion of active treatment. It contains all the key elements required for follow-up care including a record of diagnosis and treatment summaries, appointment schedule, follow-up actions required and contact details of all involved.
Access: Shared care plan for early breast cancer follow-up and survivorship care template
Information for women on shared follow-up and survivorship care for early breast cancer
This information is for women who have been treated for early breast cancer or ductal carcinoma in situ (DCIS) and their carers. It provides information about shared follow-up and survivorship care, including the benefits of shared care and who is involved.
Information for health professionals
This resource is for all members of the shared follow-up and survivorship care team, including the specialist, registrar, cancer nurse, breast care nurse, cancer care coordinator, general practitioner (GP) and primary care nurse. It provides information to health professionals to support their delivery of best practice follow-up and survivorship care for patients with early breast cancer or ductal carcinoma in situ (DCIS).
Roles and responsibilities of the shared follow-up and survivorship care team
This resource is for all members of the shared follow-up and survivorship care team. It outlines the roles and responsibilities of the specialist, general practitioner (GP), nurses, and their respective teams, in delivering shared follow-up and survivorship care for patients with early breast cancer and ductal carcinoma in situ (DCIS).
Rapid Access Request template
The rapid access request is a template designed to be used by the GP when follow-up raises a clinical issue requiring urgent specialist consultation or advice. It is an integral part of the shared follow-up care model and helps facilitate effective communication between the GP and specialist.
Access: Rapid Access Request template
Continuing professional development - Online Education
Cancer Australia breast cancer online learning series
Cancer Australia has developed six accredited online courses for general practitioners, practice nurses and other health professionals to support learning and improved practice of evidence-based breast cancer treatment and care. The courses are hosted on the Australian College of Rural and Remote Medicine’s online learning platform. The course titled ‘Follow-up and survivorship care for early breast cancer’ addresses best practice follow-up care for women who have completed active treatment for early breast cancer, including shared follow-up care arrangements.
Registration to the courses is free through Cancer Australia, by clicking on Register at the bottom of the page and entering a few demographic details.
Other available online education:
- CA/eviQ Education: Oncology basics module
- CA/eviQ Education: Cancer survivorship – Introductory course modules
- Cancer Survivorship for Primary Care Practitioners course
Optimal care pathway
Optimal care pathway for women with breast cancer
This optimal cancer care pathway for women with breast cancer aims to foster an understanding of the whole cancer pathway and its distinct components through mapping the patient journey, to promote quality cancer care and patient experiences.
Cancer Council Victoria was commissioned by the Victorian Department of Health to develop the Optimal Cancer Care Pathways through consultation with a wide range of expert multidisciplinary teams, peak health organisations, consumers and carers. They are nationally endorsed by the National Cancer Expert Reference Group (NCERG) (includes representation from each jurisdiction and nationally), Cancer Australia and Cancer Council Australia.
An online patient version is also available.
Supportive care resources
- The Australian Cancer Survivorship Centre - My Care Plan - an online tool that can be used to create a personalised survivorship care plan following treatment for early breast cancer. The personalised survivorship care plan can be used in conjunction with the Shared care plan for early breast cancer follow-up and survivorship care. It helps patients to better understand their personal health risks depending on the type and combination of cancer treatments they received.
- Breast Cancer Network Australia (BCNA) – Fear of Cancer Recurrence - This BCNA fact sheet provides information on fear of cancer recurrence for people who have been diagnosed with early breast cancer; their partners, families, friends, and colleagues; and others who support people with early breast cancer.
- National Comprehensive Cancer Network distress thermometer and problem list – a tool that measures distress in a similar way to pain – on a scale of zero to ten (ten being the worst). This tool makes it easier for people to talk to their doctors about the emotional effects caused by the diagnosis, symptoms, and treatment of cancer.
Clinical practice guidelines
- Recommendations for the identification and management of fear of cancer recurrence in adult cancer survivors (Cancer Australia, 2014)
- Clinical practice guidelines for the management of early breast cancer (2nd ed.) (Cancer Australia, 2001)
- Guidance for the management of early breast cancer (Cancer Australia (2020)