Implementing a nurse-coordinated, integrated, shared-care model involving specialists and general practitioners in breast cancer post-treatment follow-up: a Phase II randomised controlled trial

At completion of treatment [i.e., end of surgery, or adjuvant chemotherapy/ radiation therapy (whichever was delivered last)], patients will be enrolled in the study. Group 1 (The shared-care group): 1 x 20 minute Cancer Pharmacy consultation for medication reconciliation and education prior to specialist nurse consult (only patients who completed chemotherapy, radiotherapy or those who will receive aromatase inhibitor). 1 x 30-60 minute Specialist Nurse consult with patient 8+/-2 weeks post-treatment to: 1) provide survivorship patient education; 2) treatment summary; 3) co-develop a Survivorship Care Plan (SCP) including SMART goals (using motivational interviewing and self-efficacy techniques); and 4) follow-up appointment schedule. A completed draft treatment summary and SCP will be provided to the patient and the GP. A 'booster' nurse consult will be offered to patient where there delays greater than 3 months in GP involvement (up to 18 months) to update the SCP, where necessary. 1 x 20-30 minute case-conference between specialist nurse and GP within 4 weeks of nurse consultation to discuss intervention follow-up schedule, the draft SCP with the GP and negotiate GP role in facilitating SCP goals. 11 x alternating 6-monthly patient appointments with cancer specialist or GP for 5 years. At 5 years the patient will be discharged to the care of the GP. More specifically, 5 x GP appointments at <12 (initial), 18, 30, 42 and 54 months post-diagnosis for review of SCP, general health, and screening/management of comorbidities, psychosocial health cancer treatment toxicities, cancer-related symptoms; chronic disease management planning and allied health referrals. The GP will have direct telephone access to the specialist nurse in case of concerns or escalation for acute care review. 6 x cancer specialist appointments at 12, 18, 24, 36, 48 and 60 months post-diagnosis for review, physical examination and imaging (i.e., annual mammogram) at 12, 18, 24, 36, 48 and 60 months post-diagnosis. - A log of all consultations will be kept by treating nurse