Rationale
Survivorship care remains an inconsistently delivered component of cancer management. To address persistent symptoms in early-stage breast and gynaecological cancer survivors, our service piloted a multidisciplinary, nurse-led survivorship clinic - with attached medical support - addressing cancer symptoms of unmet need identified on CaSUN (Cancer Symptoms of Unmet need) forms. The service created a survivorship care plan aligned with national and international frameworks such as COSA and ASCO for attending patients, with both face to face and telehealth options provided.
Methods
Eligible patients were referred from public and private settings. The model included a telehealth nurse navigator consultation, a single survivorship medical appointment, and multidisciplinary case conference discussion. Standardised tools (CaSUN), Distress Thermometer, and Fear of Cancer Recurrence Inventory-Short Form (FCRI-SF) informed tailored referrals to allied health and psychological services. Follow-up scores were collected at approximately three months to assess service impact.
Results
Unmet needs most frequently identified included fear of recurrence, menopausal symptoms including insomnia and sexual dysfunction and fatigue. Importantly, many concerns particularly sexual health, had not been previously documented in existing care to date, highlighting gaps in existing care pathways. Medications, including non hormonal and Menopause Hormonal Therapy were prescribed where appropriate, with referrals made to pelvic floor physiotherapy, psychology, psychosocial OT and general physiotherapy for exercise classes. Follow up symptom scores demonstrated significant reduction in unmet needs after the intervention. A key challenge with the model was patient engagement, with 15% declining enrolment and 10% failing to attend their initial appointments, identifying that flexible modes of survivorship care are needed.
Conclusion
This pilot highlights the potential of nurse-led, multidisciplinary survivorship care to reduce unmet needs. Success of this model will require integration with patients’ existing care pathways. Future models should incorporate digital tools and flexible approaches that minimise duplication, promote engagement, and support equitable access.