As the number of Australian cancer survivors continues to increase, due to advances in early detection, treatment, and the aging population, the pressure on our health system to provide quality survivorship care also increases. There are a number of models of follow-up (survivorship) care, some are described below.
Clinical Oncology Society of Australia (COSA) Model of Survivorship Care
The COSA Model of Survivorship Care, released in 2016 is a guide for quality survivorship care in Australia.
It includes five key recommendations that were released in the 2019 COSA position statement on cancer survivorship care that summarises the critical components of the model. These include:
- Healthcare teams should implement a multidisciplinary, systematic approach to enhance coordinated and integrated survivorship care
- Personalised stratified pathways of care are required, meaning that care should be tailored based on individual needs and determined by factors such as type of cancer and treatment, current symptoms and concerns and risk of long-term and late effects
- In addition to surveillance and managing treatment-related symptoms and late effects, survivorship care should support wellness, healthy lifestyle, and primary and secondary prevention
- At transition to follow-up care, healthcare teams should develop a treatment summary and survivorship care plan
- Survivors require equitable and timely access to services, while minimising unnecessary use of healthcare services and resources
There are five fundamental principles underpinning the COSA model, care should be:
- Survivor centred, enabling individuals to participate in decision-making, engaging individuals to motivate positive health choices and empowering individuals to seek information and support
- Integrated across all service levels, at every time point
- Coordinated across all services
- Accessible and equitable
- Promote wellbeing, prevent illness and manage symptoms and problems
Cancer Australia Principles of Survivorship Care
Cancer Australia’s national framework provides a guide to planning, policy, and health system responses to cancer survivorship. It includes five key principles promoting personalised care, self-management and health and wellbeing during and after cancer treatment. The five principles are:
- Consumer involvement in person-centred care
- Support for living well
- Evidence-based care pathways
- Coordinated and integrated care
- Data-driven improvement and investments in research
Optimal Care Pathways
The Optimal Care Pathways outline specific steps and expected standards for optimal, quality cancer care in Australia. They map the patient journey from prevention and early detection to end-of-life care. Survivorship and follow-up guidance are specifically addressed in the pathway’s fifth step: Care after initial treatment and recovery. The Optimal Care Pathways have been endorsed by the National Cancer Expert Reference Group, Cancer Australia and Cancer Council Australia.
- Clinical Optimal Care Pathways for 18 tumour streams and for Aboriginal and Torres Strait Islander people with cancer
- Quick reference guides for general practitioners and primary care staff for 11 tumour streams
- What to expect – A guide to optimal cancer care (consumer website), provides an easy English guide on what should happen for someone diagnosed with cancer
Models of care
Traditional follow-up for cancer survivors, which is often still the current model of care, is typically oncologist or haematologist-led and delivered in the hospital setting. It largely focuses on surveillance for recurrence and new cancers with care provided in line with recommended follow-up schedules. There is a non-systematic approach to symptom management and health promotion and it often leaves survivors with significant unmet needs (1). Other characteristics of traditional follow-up include inconsistent coordination of care and limited engagement with primary care providers. The hospital setting may not always be the ideal place for care for a diverse population of survivors and survivorship care may not represent the best use of oncology specialist expertise. Additionally, given the growing number of cancer survivors and the limited health workforce, traditional follow-up may not be sustainable.
Shared care is follow-up care that is shared between the hospital-based oncology team and a primary care provider, usually a GP. Some aspects of patient care are undertaken by the oncology team and some by the GP. Both parties have ongoing involvement in the patient’s care. Follow-up care still proceeds according to recommended follow-up schedules. Shared follow-up care can be safe and effective. Compared to traditional oncology-led follow-up there is limited difference in terms of quality of life, unmet needs, clinical outcomes and mental health outcomes (2). Cancer Australia recommends a shared care model for survivors of early breast cancer and the evidence is building through other trials for a shared care approach for early colorectal and prostate cancer survivors. For patients, shared care offers care closer to home and provides greater support for holistic needs, comorbidity management, health promotion and self-management.
To learn more about shared follow-up care for cancer survivors, watch this short 3 minute rapid learning video.
- Cancer Australia shared cancer follow-up and survivorship care: early breast cancer
- Cancer Australia shared cancer follow-up and survivorship care: low-risk endometrial cancer
- SCORE: Shared care of colorectal cancer survivors: Protocol for a randomised controlled trial (2017) (related article)
- ProCare Trial: A phase II randomised controlled trial of shared care for follow-up of men with prostate cancer (2017) (related article)
In GP-led care, routine follow-up occurs in the primary care setting with a GP and may also include the involvement of a primary care nurse. Trials have shown GP-led care to be safe and effective for some cancer types. When compared to traditional, oncology-led follow-up, there appears to be limited difference in patient quality of life, wellbeing, satisfaction with care, clinical outcomes, recurrence or survival (3, 4). GP-led care may be suitable for low-risk patients, can offer a more holistic approach to survivorship care and provide care closer to home. Core components of this model include clear guidance for GPs on the management of common problems for cancer survivors and a plan for rapid access back to the hospital if recurrence is suspected or detected.
- Follow-up of cancer in primary care versus secondary care: systematic review (2009)
- A better model of care after surgery for early endometrial cancer – comprehensive needs assessment and clinical handover to a women’s general practitioner (2017) (related article)
For more information about how primary care can support cancer survivors: The important role of general practice in the care of cancer survivors (2020)
There are a range of models that include nurse-led survivorship care delivered by a specialist nurse. These include:
- Nurse-led consultations as part of hospital based, oncology-led follow-up
- Nurse-led consultations during transition from end of treatment to a shared care model
- Nurse-practitioner led follow-up
- Nurse-led care can also take place in the primary care setting.
Trials have shown nurse-led care to be safe and effective. Compared to traditional follow-up, there are few differences in survival, recurrence or psychological morbidity (5, 6). Nurses are ideally placed to provide survivorship care, and have the skills and capabilities to do so. They can offer a holistic and personalised approach to care, recognise and deal with psychosocial distress, coordinate care efficiently, promote behaviour change and support self-management. Patients also report a high level of satisfaction with nurse-led care.
- Nurse-led vs. conventional physician-led follow-up for patients with cancer: systematic review (2009)
- Breast cancer nursing interventions and clinical effectiveness: A systematic review (2020) (related article)
- Systematic review and meta-analysis of patient reported outcomes for nurse-led models of survivorship care for adult cancer patients (2019) (related article)
Multidisciplinary rehabilitation (allied health-led follow-up)
Multidisciplinary care is an integrated team approach that involves a range of medical, nursing and allied health professionals working collaboratively to provide optimal care. The value of rehabilitation following cancer treatment is being increasingly recognised. Rehabilitation can help patients to reach optimal physical, social, physiological and vocational functioning. Allied health professionals are well placed to lead this type of follow-up within an established program in a hospital or community-based setting. Rehabilitation programs that focus on exercise prescription and returning to daily activities have been shown to benefit survivors. They can support patients to self-manage, assist with psychological wellbeing, symptom management and improve overall quality of life. A range of allied health professionals can be involved, for example an exercise physiologist or physiotherapist, occupational therapist, dietitian, social worker or psychologist.
- The state of cancer rehabilitation in Australia (2018) (related article)
- ReActivate – A goal-orientated rehabilitation program for adolescent and young adult cancer survivors (2018) (related article)
Visit our self-management page for information and resources to support survivors to self-manage post-treatment.
Mode of delivery
Telehealth is care that is provided via a phone or video call. It offers a flexible approach to the provision of personalised care. All survivorship models of care can be delivered via telehealth, if appropriate for the patient. If required, care can be provided in partnership with a local primary care provider who can provide physical surveillance. Telehealth improves access to care for people living in regional and remote areas, reducing the travel burden and the impact of care on day-to-day life. Currently, it is a widely used for the provision of healthcare during the COVID-19 global pandemic.
- Jefford M, Koczwara B, Emery J, Thornton-Benko E, Vardy J. The important role of general practice in the care of cancer survivors. Australian Journal for General Practitioners. 2020;49:288-92.
- Alfano CM, Jefford M, Maher J, Birken SA, Mayer DK. Building personalized cancer follow-up care pathways in the United States: lessons learned from implementation in England, Northern Ireland, and Australia. American Society of Clinical Oncology Educational Book American Society of Clinical Oncology Annual Meeting. 2019;39:625-39.
- Lewis RA, Neal RD, Williams NH, France B, Hendry M, Russell D, et al. Follow-up of cancer in primary care versus secondary care: systematic review. The British Journal of General Practice: 2009;59(564):e234-47.
- Rio I, McNally O. A better model of care after surgery for early endometrial cancer – comprehensive needs assessment and clinical handover to a woman's general practitioner. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2017;57(5):558-63.
- Lewis R, Neal R, Williams N, France B, Wilkinson C, Hendry M, et al. Nurse-led vs. conventional physician-led follow-up for patients with cancer: systematic review. Journal of Advanced Nursing. 2009;65(4):706-23.
- Moloney J, Partridge C, Delanty S, Lloyd D, Nguyen M. High efficacy and patient satisfaction with a nurse-led colorectal cancer surveillance programme with 10-year follow-up. ANZ Journal of Surgery. 2019;89(10):1286-90.