General practice plays a pivotal role in cancer survivorship. With increasing numbers of long term survivors, associated comorbidities and late effects of treatment are appropriately managed in a Community setting. The great diversity of general practice and the perception of cancer as complex and requiring tertiary care has meant that engagement between cancer services and community practice has been patchy at best.
The Western Health breast unit has used a number of strategies to establish and improve communication between these teams to enable joint survivorship care.
These include:
notification by one page fax at time of commencement of chemotherapy, including common side effects and rapid re-referral paths
development of survivorship care plans as part of shared care- and the agreement of the appropriateness of an "opt out" model
Development of an advanced breast cancer pathway with improvements in timing and provision of information to GPs.
hospital GP liaison officer promoting survivorship care in newsletters, and with primary health care networks
regular education sessions targeting practice nurses as well as general practitioners, showcasing multidisciplinary care and highlighting long term issues. Including a consumer has been particularly powerful in reinforcing the role of general practice.
practice nurse and GP placement in nurse led survivorship clinics
developong a pilot program of a GP representative at MDT to allow timely 2 way communication.
Change is reliant on excellent communication and development of mutual trust. It is inevitably slow but critical to enable better care for our patients.