Authors: (including presenting author): :
Tang KS(1), Hung CB(1), Mui WH(2), Wo Barry(2), Tin Winnie(2), Ng YS(1), J Liang(1), Wong CS(2)
Affiliation: :
(1) Yan Oi Family Medicine Clinic, Department of Family Medicine & Primary Health Care, Tuen Mun Hospital, (2)Department of Oncology, Tuen Mun Hospital
Keyword 1: :
Cancer Survivorship
Keyword 3: :
Family Medicine
Keyword 4: :
Primary Health Care
Introduction: :
With advances in definitive cancer treatments and an aging population, the number of cancer survivors is expected to increase substantially. Their ongoing healthcare needs- including surveillance for recurrence, screening for secondary primary cancers, management of comorbidities, and preventive health care- cannot be met solely through hospital-based services. In view of this, the Departments of Oncology and Family Medicine & Primary Health Care in the NTWC have jointly established a new initiative: the Cancer Survivorship Program.
Objectives: :
* To design the infrastructure and delivery model for survivorship care in primary care settings for selected low-risk cancers. * To provide structured and coordinated cancer survivorship care through collaboration between Family Medicine and Clinical Oncology.
Methodology: :
With support from the Cluster Cancer Services Committee, the service framework began development in the Q3 2019. Staff from both departments formed a working group to initiate the project. The pilot phase involved prostate cancer survivors who were already receiving follow-up care for chronic diseases at a local Family Medicine Clinic (FMC). The oncologists developed surveillance guidelines and clinical protocols for prostate cancer, including step-down criteria and a referral-back mechanism. Patient inclusion and exclusion criteria were also established. At the same time, the investigations and prescription capacity in FMC have also expanded. Also, trace back system was enhanced to decrease default rate in FMC. The program was officially launched in the Q3 2020. Eligible patients were identified and recruited during oncology follow-up visits. Through effective interdepartmental communication, these patients were smoothly transitioned to FMC for continued follow-up of both chronic diseases and cancer surveillance. Program evaluation was conducted during the working group’s annual meetings. Following positive outcomes, the program was expanded from one FMC to several others across the NTWC. Building on this success, the same model was applied to thyroid cancer survivors beginning in the Q2 2024.
Result & Outcome: :
A total of 36 thyroid cancer survivors and 17 prostate cancer survivors have been managed under the program. Default rate was 1.9%. The rate of referral back to Oncology department was 9.4%. The recurrence rate was 5.6% while the rate of developing second primary cancer was 3.8%. By handling the chronic diseases and the cancer surveillance in one setting, it leads to win-win-win situation for cancer survivors, primary care and secondary care. Looking the way forward, there would be the possibility of collaboration with other departments such as Surgery / ENT.
