Background/rationale: Advances in cancer treatment and early detection have significantly increased the number of cancer survivors in Australia. However, persistent gaps in post-treatment care, particularly in coordination between specialist and primary care services and limited delivery of survivorship care plans (SCPs). The 2022 Victorian Health Experience Survey reported that only half of cancer patients receive comprehensive follow-up care plans, highlighting systemic issues in continuity and communication.
Aim: This pilot, led by the Western and Central Melbourne Integrated Cancer Service (WCMICS), assesses the feasibility of implementing a nurse-led survivorship pathway for patients completing curative anti-cancer treatment. The model uses a standardised Survivorship Needs Assessment (SNA) tool inclusive of the distress thermometer, to inform tailored SCPs.
Methods: Three WCMICS member health services piloted the integration of survivorship follow-up care into Symptom and Urgent Review Clinics (SURC). Two additional member health services are piloting model delivery via oncology nurses and clinical nurse consultants (CNCs). Each site aims to recruit ten patients who have recently completed treatment. Patients complete the SNA tool before or during a nurse-led consultation, alongside SCPs and treatment summaries are developed and shared with their general practitioner. Patient feedback is collected via REDCap surveys.
Impact on practice: Preliminary finds suggest the model is both feasible and acceptable:
Conclusion: A standardised, nurse-led survivorship model shows strong potential to improve patient experience, coordination and continuity of care. Findings will inform broader adoption across WCMICS region and support further evaluation of health and system outcomes.