See validated screening tools mentioned in Principle 4 ‘Supportive care’. Additionally, the ‘Cancer Survivors Unmet Needs (CaSun)’ is another validated screening tool that may help health professionals to identify the unmet needs of patients during survivorship.

A number of specific challenges and needs may arise for cancer survivors, which may require support:

• access to expert health professionals with specific knowledge about the psychosocial needs of breast cancer patients
• family distress if familial cancer pathogenic variant is identified
• weight changes, which may be a significant issue for patients and may require referral to a dietitian
• menopause symptoms, which may require referral to a menopause clinic
• general healthcare issues (e.g. smoking cessation and sleep disturbance), which can be referred to a general practitioner
• management of physical symptoms such as pain, arthralgia and fatigue
• decline in mobility and/or functional status as a result of treatment, which may necessitate a referral to physiotherapy or occupational therapy
• upper limb and breast lymphoedema following lymphadenectomy/radiation therapy, which is a potential treatment side effect in patients with breast cancer that has a significant effect on survivor quality of life – referral to a health professional with accredited lymphoedema management qualifications, offering the full scope of complex lymphoedema therapy, may be needed
• bowel dysfunction, gastrointestinal or abdominal symptoms as a result of treatment, which may require support from a dietitian
• neuropathy, cardiac dysfunction, nausea and vomiting (managing these issues is important for improving quality of life)
• coping with hair loss (refer to the Look Good, Feel Better program; see ’Resource List’ and/or consider scalp cooling)
• managing complex medication regimens, multiple medications, assessment of side effects and assistance with difficulties swallowing medications, which may require referral to a pharmacist
• financial and employment issues (such as loss of income and assistance with returning to work, and the cost of treatment, travel and accommodation)
• appointing a substitute decision-maker and completing an advance care directive
• legal issues such as completing a will.

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

Rehabilitation may be required at any point of the care pathway from the pre-treatment phase through to disease-free survival and palliative care (Cormie et al. 2017).

Issues that may need to be dealt with include managing cancer-related fatigue, coping with cognitive changes, improving physical endurance, achieving independence in daily tasks, returning to study or work and ongoing adjustment to cancer and its sequels.

Exercise is a safe and effective intervention that improves the physical and emotional health and wellbeing of cancer patients. Exercise should be embedded as part of standard practice in cancer care and be viewed as an adjunct therapy that helps counteract the adverse effects of cancer and its treatment.

Cancer survivors may find referral to specific cancer rehabilitation, optimisation programs or community-based rehabilitation appropriate and beneficial. Other options include referral to allied health supports through team care arrangements and mental health plans. Some community support organisations (cancer-related non-government, not-for-profit and charities) provide services to cancer survivors.

The lead clinician (themselves or by delegation) should take responsibility for these tasks:

• explaining the model of post-treatment care and the roles of health professionals involved in post-treatment care including the role of general practice
• explaining the treatment summary and follow-up care plan
• discussing the development of a shared follow-up and survivorship care plan where a model of shared follow-up care has been agreed
• discussing how to manage any of the physical, psychological or emotional issues identified
• providing information on the signs and symptoms of recurrent disease
• providing a survivorship care plan with information on secondary prevention and healthy living
• providing contact details of the care team involved
• providing clear information about the role and benefits of palliative care and advance care planning
• how to re-access specialist care if needed.

The lead clinician should ensure regular, timely, two-way communication with the general practitioner about:

• the patient’s progress
• the follow-up and survivorship care plan
• potential late effects
• supportive and palliative care requirements
• any shared care arrangements
• clarification of various roles in patient care
• a process for rapid re-entry to medical services for patients with suspected recurrence or if there are other concerns.

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