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:

• lymphoedema – referral to a trained lymphoedema practitioner may be needed
• advice for ongoing oral health maintenance by a dentist with experience in head and neck cancer
• speech pathologist management for:
• assessing and managing communication and swallowing problems, particularly when a risk of aspiration is identified
• patients who have undergone a laryngectomy or who have a permanent tracheostomy, to maximise communication, humidification/airway management and swallowing outcomes (referral to a physiotherapist with expertise in the respiratory management may also benefit)
• dietitian management for patients requiring oral nutrition support or who are fed via gastrostomy or via a nasogastric tube
• physiotherapy for ongoing musculoskeletal pain and dysfunction at the neck, shoulder and temporomandibular joint (Head and Neck Cancer Guideline Steering Committee 2020)
• speech pathology to manage and maximise any communication impairments, an occupational therapist or psychologist for social skills training and/or a social worker for family liaison to help reduce psychosocial difficulties (difficulty with communication and social interactions is relatively common for patients with head and neck cancer and can place the patient at high risk of depression)
• referral to one or more appropriate disciplines (e.g. social work, psychology service, financial advisor) for longer than expected time to return to work or previous level of functioning (Morales et al. 2020)
• accurate information about HPV aetiology and future transmission risks – some patients may benefit from referral for psychosexual support
• require referral to the appropriate discipline (e.g. social work, speech pathology, dietetics or nursing) for further assessment and identification of appropriate funding support (additional costs related to managing ongoing impairments, such as communication devices, enteral feeding and chronic wound management)
• referral for financial and employment issues (e.g. 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.

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

• the patient’s progress
• the follow-up 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.