Partnering with General practitioners to Optimise Survivorship for PatiEnts with Lymphoma: A Phase II randomised controlled trial.

Group 1 (The shared-care group): Both acute post-treatment and observation follow-up patients will be offered 1 x 30-60 minute Nurse-led clinic within 10 weeks after the end of treatment and/or at least 2 weeks prior to the GP case-conference to: 1) provide survivorship patient education including a written survivorship booklet on “Living Well After Treatment – A guide for patients and families” published by Leukaemia Foundation; 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 GP. Both acute post-treatment and observation follow-up patients will be offered 1 x 20-30 minute case-conference between specialist nurse and GP after the Nurse-led clinic to discuss intervention follow-up schedule, the draft SCP with the GP and negotiate GP role in facilitating SCP goals and surveillance activities. A completed SCP will then be forwarded to the GP and the patient. After GP case conference, acute post-treatment follow-up patients will be offered 3 x GP appointments (at 3, 9 and 18 months) and 3 x Haematologist appointments (at 6, 12 and 24 months). All appointments will be of variable duration depending on patient need and clinician preference. After GP case conference, observation follow-up (i.e., surveillance clinics) patients will be offered 2 x GP appointments (at 6 and 18 months) and 2 x Haematologist appointments (at 12 and 24 months). All appointments will be of variable duration depending on patient need and clinician preference. All GP appointments will be to conduct surveillance activities (i.e., history and physical examination for B-symptoms and order and review of full blood count, urea and electrolytes, liver function tests and lactate dehydrogenase) and review the 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. All Haematologist appointments will be to conduct surveillance activities (i.e., history and physical examination for B-symptoms and order and review of full blood count, urea and electrolytes, liver function tests and lactate dehydrogenase). At 2 years, both acute post-treatment and observation follow-up patients will return to standard care practices (either discharge to GP or continued specialist surveillance).