Shared care is an innovative model of care that shares the delivery of follow-up care after early breast cancer between the GP and the specialist.
The Shared care demonstration project, developed by the National Breast and Ovarian Cancer Centre*, gives women the option of having their follow-up care shared between their GP and specialist after treatment for early breast cancer or ductal carcinoma in situ (DCIS).
Four demonstration sites in South Australia, New South Wales and Victoria were selected to implement shared follow-up care for women. While sites are continuing to offer shared care, please note that recruitment to the Shared care demonstration project has now closed.
Below are some frequently asked questions for women and health professionals with specific information about the Shared care demonstration project.
Why is follow-up care after breast cancer important?
After treatment, it is important to have follow-up visits to check whether breast cancer or DCIS has come back, to monitor side effects of treatment and to provide practical and emotional support.
Is shared care safe?
Shared care between the GP and specialist has been implemented and documented in a range of health settings, such as paediatric oncology, mental health and obstetric services. Studies show that follow-up by a GP after breast cancer is a safe and effective form of follow-up care.1,2
What are the benefits of shared care?
Shared follow-up care has the potential to promote and support continuity of care and whole person care, as the woman’s GP can oversee all her health issues. Follow-up provided by a woman’s GP may improve access to care and be more convenient for the woman by reducing the need to travel for treatment.
Due to increasing incidence of breast cancer and improving survival rates,3 more and more women require regular clinical follow-up after breast cancer. Shared follow-up care has the potential to meet increasing health service demand and provides a team-based approach to breast cancer follow-up care, which could improve links between specialist teams and GPs.
How will follow-up care be managed?
Follow-up care after early breast cancer will be shared between the GP and specialist. Some or all of the follow-up visits will be with the GP rather than with the specialist. The GP will be supported by and will communicate with the specialist about providing ongoing follow-up care.
Who is participating in shared care?
Women who were diagnosed with early breast cancer or DCIS and had completed active treatment (including surgery, radiotherapy, chemotherapy and targeted therapies such as Herceptin®) at least three months prior to selection were eligible to participate in the project.
This may include women still receiving hormonal therapies (including tamoxifen and aromatase inhibators).
What resources will support shared care?
A patient-held Shared Care Plan [PDF 531 kB] has been developed for women to bring to all follow-up appointments for their GP and specialist to record information about their follow-up care. Women will have increased access to information about their follow-up treatment through the Shared Care Plan.
A Rapid Access Request [PDF 188 kB] has been developed to support communication between the GP and specialist if a specific clinical issue requires specialist advice or to arrange a consultation for the woman if required.
Please note – the Shared Care Plan and Rapid Access Request are only to be used by patients, GPs, specialists, other health providers and sites as part of the Shared care demonstration project and are not to be used as a substitute for existing referral arrangements between GPs and specialists.
What happens next?
As part of the project evaluation, women and health professionals who participated in the project will be surveyed to hear about their experiences of shared care. The project evaluation seeks to assess the outcomes and impact of the project, from which recommendations will be developed on the future delivery of shared care. Please be assured that individual participants will not be identified in any published information.
Contact details
Shared follow-up care is being offered at demonstration sites in South Australia, New South Wales and Victoria. While sites are continuing to offer shared care, recruitment to the Shared care demonstration project has now closed. Please contact your local site for more information.
- Adelaide - The Queen Elizabeth Hospital
Teresa Occhiodoro-Scott on This e-mail address is being protected from spambots. You need JavaScript enabled to view it or 08 8133 4104 - Newcastle - Calvary Mater Hospital
Phone 02 4014 4682 - Melbourne - Royal Melbourne and Royal Women’s Hospital, Sunshine Hospital
Kerry Shanahan and Bronwyn Flanagan on This e-mail address is being protected from spambots. You need JavaScript enabled to view it or 03 9342 8120 (Royal Melbourne Hospital)
Robyn Cordner and Monique Baldacchino on This e-mail address is being protected from spambots. You need JavaScript enabled to view it or 03 8345 3565 (Royal Women’s Hospital)
Danielle Spence This e-mail address is being protected from spambots. You need JavaScript enabled to view it on 03 8345 6896 (Sunshine Hospital) - Melbourne – Monash Medical Centre
Heather Davis This e-mail address is being protected from spambots. You need JavaScript enabled to view it on 03 9928 8602
Shared follow-up resources
- Shared follow-up care: Information for women [pdf 223 kB]
- Information for health professionals [pdf 221 kB]
- Roles and responsibilities of the shared care clinical team [pdf 231 kB]
- Principles of shared care [pdf 122 kB]
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Lewis RA, Neal RD, Williams NH, et al. Follow-up of cancer in primary care versus secondary care: systematic review. British Journal of General Practice 2009;59: 234-7
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Grunfeld E, Levine MN, Julian JA, et al. Randomized Trial of Long-Term Follow-Up for Early-Stage Breast Cancer: A Comparison of Family Physician Versus Specialist Care. Journal of Clinical Oncology 2006;24:848-55
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AIHW, Cancer Australia and AACR 2008. Cancer survival and prevalence in Australia: cancers diagnosed from 1982 to 2004. Cancer series no.42. Cat. no. CAN 38. Canberra: AIHW
