Breast Cancer Survivorship Program

What we do

The Breast Cancer Survivorship Program provides improved follow-up care for patients who have completed active breast cancer treatment.

This model actively involves patients and their GPs, and recognises the specific issues and opportunities that exist at the end of active treatment to support people to live well. This includes developing a follow-up care plan and implementing a shared arrangement between the Breast Service and the General Practice.

This model of care results in better coordinated and more personal health care planning and management.

We would like patients to feel more educated and empowered about their ongoing health care and this program will identify and address the immediate and future needs in terms of follow-up care, and improve systems that share information between patients, their GP, other community services and the hospitals to improve quality of care.

Eligible patients will have:

• A consultation with a Breast Care Nurse at the end of active breast cancer treatment
• An individualised follow-up care plan developed at the hospital

The care plan includes:

• Information on diagnosis, history and treatment
• A health and wellbeing assessment including referrals (such as mental health, lifestyle, menopause, sexuality, fertility)
• An individualised timetable of future examinations and investigations
• Recommendations for follow-up care
• Referral and contacts for different services and
• Resources

Patients and their GPs will receive a copy of the care plan and patients need to make an appointment with their GP within one month of receiving the care plan 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.