5.2 Post treatment care planning

5.2 Post treatment care planning

After initial treatment, the patient, their 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.

Care in the post-treatment phase is driven by predicted risks (such as the risk of recurrence, developing late effects and psychological issues), as well as individual clinical and supportive care needs.

Responsibility for follow-up care should be agreed between the lead clinician, the general practitioner, relevant members of the multidisciplinary team and the patient, with an agreed plan that outlines:

  • what medical follow-up is required (surveillance for recurrence, screening and assessment for medical and psychosocial effects)
  • care plans from other health professionals to manage the consequences of cancer and treatment (including assessing psychological distress)
  • a process for rapid re-entry to specialist medical services for suspected recurrence
  • the role of follow-up for patients, which is to evaluate tumour control, monitor and manage symptoms from the tumour and treatment and provide psychological support
  • that they will be retained within the multidisciplinary team management framework.

Follow-up should include access to a range of health professions (if required) including physiotherapy, orthotics, exercise physiology, occupational therapy, nursing, social work, dietetics, psychology and palliative care (in the hospital or community setting).

Specialist team surveillance should include:

  • regular clinical examination and routine surveillance for local recurrence
  • assessing function and possible complications from any reconstruction
  • imaging (includes MRI, CT and functional imaging such as PET, thallium or technetium bone scan)

These should be conducted at the following intervals:

  • three- to four-monthly for two years, then six-monthly for two years and yearly thereafter for four years – giving a total of eight years of follow-up for patients with fully resected disease.
  • In cases where additional surveillance is required, the timing and frequency will be discussed on its merits.
  • Patients should be referred from paediatric services to adult services as they transition between paediatric and adult age groups.