See validated screening tools mentioned in Principle 4 ‘Supportive care’.

Assess the patient’s response to all treatments using clinical outcome measures and patient-reported measures.

A number of specific challenges and needs may arise for patients at this time:

• assistance for dealing with emotional and psychological issues, including body image concerns, fatigue, quitting smoking, traumatic experiences, existential anxiety, treatment phobias, anxiety/depression, interpersonal problems and sexuality concerns
• access to expert health professionals with specific knowledge about the psychosocial needs of breast cancer patients
• potential isolation from normal support networks, particularly for rural patients who are staying away from home for treatment
• alteration of cognitive functioning in patients treated with chemotherapy and radiation therapy, which requires strategies such as maintaining written notes or a diary and repetition of information
• loss of fertility, sexual dysfunction or other symptoms associated with treatment or surgically or chemically induced menopause, which requires sensitive discussion and possible referral to a clinician skilled in this area
• general healthcare issues (e.g. smoking cessation and sleep disturbance), which can be referred to a general practitioner
• decline in mobility or functional status as a result of treatment
• management of physical symptoms such as pain, arthralgia and fatigue
• early management for acute pain postoperatively to avoid chronic pain
• side effects of chemotherapy such as neuropathy, cardiac dysfunction, nausea and vomiting; managing these side effects is important for improving quality of life
• managing complex medication regimens, multiple medications, assessment of side effects and assistance with difficulties swallowing medications – referral to a pharmacist may be required
• menopause symptoms, which may require referral to a menopause clinic
• upper limb problems following surgery including decreased range of movement, which may delay radiation therapy – referral to a physiotherapist may be required
• upper limb and breast lymphoedema following lymphadenectomy/radiation therapy – this is a potential treatment side effect in patients with breast cancer that has a significant effect on survivor quality of life; referral (preferably preoperatively) to a health professional with accredited lymphoedema management qualifications, offering the full scope of complex lymphoedema therapy, should be encouraged (prospective monitoring, particularly for high-risk patients is recommended)
• disfigurement and scarring from appearance-altering treatment (and possible need for a prosthetic), which may require referral to a specialist psychologist, psychiatrist or social worker
• weight changes – this may require referral to a dietitian before, during and after treatment
• bowel dysfunction, gastrointestinal or abdominal symptoms as a result of treatment, which may require support from a dietitian
• coping with hair loss and changes in physical appearance (refer to the Look Good, Feel Better program; see ’Resource List’ and/or consider scalp cooling)
• assistance with beginning or resuming regular exercise with referral to an exercise physiologist or physiotherapist (COSA 2018; Hayes et al. 2019).

Early involvement of general practitioners may lead to improved cancer survivorship care following acute treatment. General practitioners can address many supportive care needs through good communication and clear guidance from the specialist team (Emery 2014).

Patients, carers and families may have these additional issues and needs:

• financial issues related to loss of income (through reduced capacity to work or loss of work) and additional expenses as a result of illness or treatment
• advance care planning, which may involve appointing a substitute decision-maker and completing an advance care directive
• legal issues (completing a will, care of dependent children) or making an insurance, superannuation or social security claim on the basis of terminal illness or permanent disability.

Cancer Council’s 13 11 20 information and support line can assist with information and referral to local support services.

Breast Cancer Network Australia’s helpline (1800 500 258) and website can assist with information and support services.

For more information on supportive care and needs that may arise for different population groups, see A and B, and special population groups.

Rehabilitation may be required at any point of the care pathway. If it is required before treatment, it is referred to as prehabilitation (see section 3.6.1).

All members of the multidisciplinary team have an important role in promoting rehabilitation. Team members may include occupational therapists, speech pathologists, dietitians, social workers, psychologists, physiotherapists, exercise physiologists and rehabilitation specialists.

To maximise the safety and therapeutic effect of exercise for people with cancer, all team members should recommend that people with cancer work towards achieving, and then maintaining, recommended levels of exercise and physical activity as per relevant guidelines. Exercise should be prescribed and delivered under the direction of an accredited exercise physiologist or physiotherapist with experience in cancer care (Vardy et al. 2019). The focus of intervention from these health professionals is tailoring evidence-based exercise recommendations to the individual patient’s needs and abilities, with a focus on the patient transitioning to ongoing self-managed exercise.

Other issues that may need to be dealt with include managing cancer-related fatigue, improving physical endurance, achieving independence in daily tasks, optimising nutritional intake, returning to work and ongoing adjustment to cancer and its sequels. Referrals to dietitians, psychosocial support, return-to-work programs and community support organisations can help in managing these issues.

The lead or nominated clinician should take responsibility for these important aspects of treatment:

• discussing treatment options with patients and carers, including the treatment intent and expected outcomes, and providing a written version of the plan and any referrals
• providing patients and carers with information about the possible side effects of treatment, managing symptoms between active treatments, how to access care, self-management strategies and emergency contacts
• encouraging patients to use question prompt lists and audio recordings, and to have a support person present to aid informed decision making
• offering advice to patients and carers on the benefits of and how to access support
• initiating a discussion about advance care planning and involving carers or family if the patient wishes.

The general practitioner plays an important role in coordinating care for patients, including helping to manage side effects and other comorbidities, and offering support when patients have questions or worries. For most patients, simultaneous care provided by their general practitioner is very important.

The lead clinician, in discussion with the patient’s general practitioner, should consider these points:

• the general practitioner’s role in symptom management, supportive care and referral to local services
• using a chronic disease management plan and mental health care management plan
• how to ensure regular and timely two-way communication about:
  • the treatment plan, including intent and potential side effects
  • supportive and palliative care requirements
  • the patient’s prognosis and their understanding of this
  • enrolment in research or clinical trials
  • changes in treatment or medications
  • the presence of an advance care directive or appointment of a substitute decision-maker
  • recommendations from the multidisciplinary team.

Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.