Victorian Cancer Survivorship Program: Pilot Project Survivorship program for patients completing definitive breast cancer treatment FINAL REPORT Acknowledgements Project Officer Sita Vij, The Royal Women’s Hospital, Email: [email protected] Project Leads Prof Bruce Mann, The Royal Melbourne/Royal Women’s Hospitals Ms Carolyn Bell, The Royal Women’s Hospital Dr Ines Rio, The Royal Women’s Hospital and Inner North West Melbourne Medicare Local Ms Meron Pitcher, Western Health Ms Alison Amos / Ms Lee Kennedy, BreaCan Project Executive Steering Committee and Working Group Ms Bianca Bell Western Health Ms Robin Curwen-Walker BreaCan Ms Paula Drum Consumer Representative Prof Martha Hickey The Royal Women’s Hospital Ms Pat Jankus Consumer Representative Ms Fiona McCormack The Royal Melbourne Hospital Dr Angela Rutherford GP Representative Ms Kerry Shanahan The Royal Melbourne Hospital Ms Leanne Storer Western Health Dr Claire Veith GP Representative Special thanks to: Monique Baldacchino, Robyn Cordner, Anastasia Dean, Melanie Fisher, Bronwyn Flanagan, Spiridoula Galetakis, Sue Hookey, Tracy Jeffery, Meredith Layton, Linda Nolte, Allan Park, Sunita Sharma, Kate Schofield, Graham Taylor, Susan Thomas, Kathryn Whitfield and Shirley Wong. Table of Contents Executive Summary ............................................................................................................................ 1 Key Messages ..................................................................................................................................... 3 Section 1: Background / Context ........................................................................................................ 4 1.1 Health service ................................................................................................................... 4 1.2 Eligible population ............................................................................................................ 4 1.3 Needs assessment ............................................................................................................ 4 Section 2: Project – Model of Care..................................................................................................... 5 2.1 Aims and objectives .......................................................................................................... 5 2.2 Pilot model ........................................................................................................................ 5 2.3 Evaluation plan................................................................................................................. 6 2.4 Resources developed to aid evaluation ........................................................................... 8 Section 3: Project Implementation .................................................................................................... 8 3.1 Implementation strategy ................................................................................................. 8 3.2 Modifications made to the model ................................................................................... 9 3.3 Intended and unintended outcomes ............................................................................. 10 3.4 Key learnings .................................................................................................................. 11 3.5 Resources utilised / developed to support the model .................................................. 12 3.6 Workforce training and education ................................................................................. 13 3.7 Communication strategies ............................................................................................. 13 3.8 Sustainability strategies ................................................................................................. 14 Section 4: Evaluation Results – Summary ........................................................................................ 14 4.1 Aims and objectives ....................................................................................................... 14 4.2 Pilot project evaluation summary .................................................................................. 15 4.3 Issues and challenges with evaluation ........................................................................... 19 4.4 Overall assessment of pilot model of care .................................................................... 19 Section 5: Sustainability Considerations .......................................................................................... 20 5.1 Sustainable aspects of the model .................................................................................. 20 5.2 Requirements for sustainability ..................................................................................... 20 Section 6: Potential Scope for Roll-Out of Survivorship Care .......................................................... 20 6.1 Capacity for model of care to be extended to other cancer types/clinical sites ........... 20 6.2 Recommended workflow / key steps for adopting the model ...................................... 20 Section 7: Next Steps for Project Locally (next 2 years) ................................................................... 21 Section 8: Overview of Project Impact / Conclusion ........................................................................ 22 8.1 Impact / value .................................................................................................................. 22 8.2 Summary of key learnings ............................................................................................... 22 8.3 Recommendations ........................................................................................................... 23 8.4 Policy and system level questions that have been raised by this project ....................... 23 8.5 Top ten tips ...................................................................................................................... 23 Section 9: Expenditure Report ......................................................................................................... 25 Report Certifications ........................................................................................................................ 27 Section 10: Appendices (refer to separate document) A. Evaluation Plan B. Shared Care Agreement C. Risk Stratification Pathway D. Screening Tools (FACT-B, MRS, SCT) E. Screening Tools Translated for Project F. Follow-Up Care Plans G. Treatment Plan Template H. Nurse-Led Clinic Checklist I. Administration Checklist J. Evaluation Summary Report K. Evaluation Surveys L. Evaluation Survey Results M. Evaluation Interviews N. Bio-psycho-social issues facing breast cancer patients after definitive treatment O. Communication Strategy P. Case Study Abbreviations ACSC Australian Cancer Survivorship Centre BCN breast care nurse BCNA Breast Cancer Network Australia CPD Continuing Professional Development DCIS Ductal Carcinoma In-Situ GP general practitioner MDM multidisciplinary meeting NBOCC National Breast and Ovarian Cancer Centre (now Cancer Australia) NLC nurse-led clinic RMH The Royal Melbourne Hospital RWH The Royal Women’s Hospital VCCC Victorian Comprehensive Cancer Centre VCSP Victorian Cancer Survivorship Program WCMICS Western and Central Melbourne Integrated Cancer Service WH Western Health Executive Summary The goal of the Breast Cancer Survivorship Project was to develop, implement and evaluate a model of survivorship care as part of the government-supported Victorian Cancer Survivorship Program. The twin objectives were to improve the quality of care for women completing treatment for early breast cancer at The Royal Melbourne/Royal Women’s Breast Service and Western Health Breast Service, while reducing the intensity of hospital-based care in order to create greater capacity for new patients. This model of care actively involves patients at completion of definitive treatment for early breast cancer, and identifies the specific issues and opportunities that exist at the end of hospital treatment to support women to live well. Definitive treatment defines the completion of surgery, chemotherapy, trastuzumab and radiotherapy – patients may still be taking hormone tablets and were included in the project at this stage. The project aims to ensure that all women receive optimal care at the end of definitive treatment for early breast cancer including high quality follow-up in the primary care setting, identification and response to information and support needs and smooth transitions back to hospital-based care if required. Outcomes of the project have included a sustainable model of survivorship care for breast cancer patients across acute, primary care and community sectors. The integration of this model of care into routine systems and practice supports: Survivorship care planning, needs assessment and referral processes Effective shared care between GPs and the Breast Service Optimal GP access to and utilisation of specialist breast services e.g. advice, rapid referrals Keeping patients informed about their diagnosis, treatment and planned follow-up care Improved electronic referral to peer support service, BreaCan, and innovative digital information resources in the form of navigator tools. Women who had completed definitive treatment for early breast cancer were invited to a nurse- led clinic (NLC) where the disease,