5.2.2 Follow-up care

There is no evidence that follow-up investigations of asymptomatic patients with non-specific CUP affects outcome. Patients in the specific-CUP subgroup should be followed up as per disease-specific guidelines. Specific examinations should be undertaken as clinically indicated (Fizazi et al. 2015).

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.

The responsibility for follow-up care should be agreed between the lead clinician, the person’s GP, relevant members of the MDT 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
  • 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 MDT management framework
  • the arrangements for follow-up with the neurosurgeon for a postoperative evaluation, which should occur four to eight weeks after surgery.

In particular circumstances, follow-up care can safely and effectively be provided:

  • in the primary care setting
  • by other suitably trained staff (for example, nurse-led follow-up)
  • in a non-face-to-face setting (for example, by telehealth).