Responsibility for follow-up care should be agreed between the lead clinician, the general practitioner, relevant members of the multidisciplinary team and the woman, with an agreed plan documented that outlines: what medical follow-up is required (surveillance for cancer spread, recurrence or secondary cancers, screening and assessment for medical and psychosocial effects) care plans from other…

The lead clinician should ensure there is adequate discussion with the woman and her carer about the diagnosis and recommended treatment, including the intent of treatment and possible outcomes, likely adverse effects and supportive care options available.

Screening using a validated screening tool, assessment and referral to appropriate health professionals and community-based support services is required to meet the needs of individual women, their families and carers. In addition to the common issues outlined in the Appendix, specific issues that may arise include: treatment-related side effects including loss of fertility, sexual dysfunction…

Rehabilitation may be required at any point of the care pathway from preparing for treatment through to disease-free survival and palliative care. Issues that may need to be addressed include managing cancer-related fatigue, cognitive changes, improving physical endurance, achieving independence in daily tasks, returning to work and ongoing adjustment to disease and its sequelae.

Early referral to palliative care can improve the quality of life for people with cancer and, in some cases, may be associated with survival benefits (Haines 2011; Temel et al. 2010; Zimmermann et al. 2014). The lead clinician should ensure timely and appropriate referral to palliative care services. Referral to palliative care services should be…

The lead clinician should: discuss the management of any of the issues identified in section 5.5.1) explain the treatment summary and follow-up care plan provide information about the signs and symptoms of recurrent disease provide information about secondary prevention and healthy living provide clear information about the role and benefits of palliative care.

The lead clinician should ensure regular, timely, two-way communication with the woman’s general practitioner regarding: the follow-up care plan potential late effects supportive and palliative care requirements the woman’s progress recommendations from the multidisciplinary team any shared care arrangements a process for rapid re-entry to medical services for women with suspected recurrence.

After initial treatment, the woman, the woman’s nominated carer (as appropriate) and general practitioner should receive a treatment summary outlining: the diagnostic tests performed and results tumour characteristics the type and date of treatment(s) interventions and treatment plans from other health professionals supportive care services provided contact information for key care providers.

The lead clinician should: discuss with the general practitioner their role in symptom management, psychosocial care and referral to local services ensure regular and timely two-way communication regarding: the treatment plan, including intent and potential side effects supportive and palliative care requirements the woman’s prognosis and their understanding of this enrolment in research and/or clinical…

Screening, assessment and referral to appropriate health professionals is required to meet the identified needs of the woman, her carer and family. In addition to the common issues identified in the Appendix, specific issues that may arise at this time include: emotional and psychological distress from anticipatory grief, fear of death/dying, anxiety/ depression, interpersonal problems…