Breast Cancer Survivorship Program and Shared Care

The Breast Cancer Survivorship Program aims to improve follow-up care for women who have completed active breast cancer treatment at VCCC hospitals.

The model of care actively involves patients and their GPs, and recognises the specific issues and opportunities that exist at the end of active treatment to support women to live well.

We would like patients to feel more empowered to manage their ongoing healthcare. This program will identify and address immediate and future needs in terms follow-up care, and improve systems that share information between a woman, her GP, other community services and the hospitals in order to improve quality of care.

For most patients, the model of care includes:

  • A consultation with a breast care nurse at the end of active breast cancer treatment
  • An individualised follow-up care plan
  • Shared-care between the hospital and the patient’s GP

The care plan includes:

  • Information on diagnosis, history and treatment
  • A health and wellbeing assessment including referrals (mental health, lifestyle, menopause, sexuality, fertility, etc.)
  • An individualised follow-up schedule for future examinations and investigations
  • Referral and contacts for different services
  • Resources.

Patients and their GPs will receive a copy of the care plan. The patient will be asked to make an appointment with her GP within one month of receiving the care plan in order to discuss ongoing care. This also provides GPs with the opportunity to set up their recall systems and develop team care plans or management plans as appropriate.