SCORE: Shared care of Colorectal cancer survivors – A randomised controlled trial of hospital-based follow up versus shared hospital / community follow up for survivors of colorectal cancer.

Survivors of colorectal cancer can experience a range of issues from the disease and its treatment, including ongoing side effects, emotional, psychological and practical concerns. Patients frequently report a greater need for more information and greater support.

In Australia, after completing treatment most patients have ongoing follow up with a cancer specialist that involves 3 monthly hospital visits in the first year.

We are interested in involving general practitioners (GPs) in routine follow-up care to potentially allow for more efficient use of healthcare resources. We aim to compare usual specialists follow up care with a shared cared (GP + Specialist) model to evaluate the acceptance and implementation of care coordination between community and hospital.

This is the first international study of shared care for survivors with colorectal cancer.

If you are interested in this trial and have received and or receiving treatment for colorectal cancer from Peter MacCallum Cancer or Royal Melbourne Hospital or St Vincent’s Hospital or Western Hospital or Austin Hospital, please talk to your doctor.

Who is eligible? 

Patients are eligible for this study if they:

  • Have a confirmed diagnosis of colon or rectal cancer: Stage I-III disease
  • Have completed treatment with curative intent at one of the participating sites within the previous 3-months
  • Over 18 years of age
  • Able to read and write in English
  • Have a GP willing to participate in the study.

Patients are excluded from this study if:

  • Treated from a previous cancer (except non-melanoma skin cancer)
  • Have a GP already participating in the study
  • Have certain cognitive or psychological difficulties

What does the study involve? 

Participants in this study are randomly allocated (by chance) to one of two groups: usual hospital-based follow up care or shared care between the hospital and the patients preferred GP in the year after end of treatment. Participants will be asked to complete a short questionnaire at time of enrolment into the study (baseline) and again at 6 months and 12 months.

Usual care group

Participants in the usual care group will receive care according to current practice. This consists of 4-routine hospital-based visits and includes a physical examination and blood tests for carcinoembryonic antigen (CEA) testing at 3, 6, 9 and 12-months post end of treatment.

Shared care group

Participants in the shared care group will have 2 of the 4 routine hospital visits in the year after end of treatment replaced by GP visits at the 3 and 9-month post end of treatment. An additional GP visit at 2 weeks post end of treatment is included to discuss the follow up plan and establish common ground about the model of shared care.

Participants will receive a survivorship care plan that is tailored to each participant by the research team and comprise a summary of diagnosis and treatment as well as recommendations for follow up care and strategies to remain well. Participating GPs will receive a copy of the survivorship care plan along with management guidelines in line with the Australian Cancer Network Colorectal Cancer Guidelines to assist with the common issues survivors of colorectal cancer experience.


Peter MacCallum Cancer Centre


Cancer Australia

Principal Investigator/s

Prof Michael Jefford

Email: [email protected]

Contact Details

Mr Mustafa Mohamed

Project Manager

Phone: (03) 8559 7844

Email: [email protected]