Authors: (including presenting author): :
Authors: Tsang SC (2), Chan WMM (2), Lai WYJ (1), Choy YP (1)
Affiliation: :
(1) Department of Oncology, Princess Margaret Hospital (2) Community Health Care, Kowloon West Cluster
Keyword 1: :
Cancer survivorship care
Keyword 2: :
Step‑down medical care model
Keyword 3: :
Hospital‑to‑community transition
Keyword 4: :
Cross‑sectoral partnership
Keyword 5: :
Primary healthcare integration
Keyword 6: :
KWC shared-care model initiative
Introduction: :
According to the HK Cancer Registry, the 5-year relative survival rate among cancer patients aged 15 years and above increased from 49.1% (2010-2013) to 55.7% (2018-2022). Evidence suggests that, compared with specialist-led care, shared-care models enhance patient satisfaction while maintaining comparable quality of life and survival outcomes. Building on this evidence, Hospital Authority Kowloon West Cluster (HA/KWC) and Hong Kong Medical Association (HKMA) jointly initiated the “CONNECT Hospital-to-Community Cancer Survivor Program” (“CONNECT”). This cross-sectoral partnership aims to align survivorship care, facilitate seamless transitions to primary healthcare, and empower patients to manage their health effectively through integrated, community-oriented support.
Objectives: :
1.To assess and address the training needs of community doctors in evidence‑based cancer survivorship, thereby aligning survivorship care with the shared‑care model.
2.To develop a bi-directional referral interface that enables step-down medical care for cancer survivors.
3.To implement a cluster-based, networked service model for breast cancer survivors in KWC as a pilot initiative to enhance care continuity.
Methodology: :
In partnership with HKMA, Department of Oncology and KWC Community Health Care adopted a multiphase approach to design, implement and evaluate “CONNECT”:
1. Needs Assessment (April - May 2024)
A survey was distributed among HKMA members to understand community-based medical practitioners' perspectives on shared-care model for cancer survivors and to identify training priorities 2. Certificate Course on Cancer Survivorship (4Q 2024)
Based on survey findings, a structured online certificate course on cancer survivorship was launched for community doctors. The program comprised four weekly one‑hour sessions and addressed key training priorities, including symptom recognition, care planning and coordination of oncology resources. Evidence‑based practice updates were scheduled regularly, or as needed, to ensure ongoing relevance and quality. 3. Service Interface Implementation for Breast Cancer Survivors (since February 2025)
A bi-directional referral mechanism with fast-track pathways to KWC Oncology for red-flag symptoms was established to strengthen hospital-community collaboration. Personalized treatment summaries and tools to develop survivorship plans, including holistic needs assessments and surveillance checklists, were introduced to support continuity of care. Ongoing monitoring of referral patterns, service outcomes and feedback from participating community doctors and patients was conducted to drive continuous improvement.
Result & Outcome: :
1.Survey Responses (April - May 2024): Collected perspectives from 109 community doctors, identifying training needs and interest in shared‑care for cancer survivors.
2.Capacity Building (4Q 2024): More than 600 community doctors were trained through the structured online certificate course on cancer survivorship, strengthening frontline capacity and aligning survivorship care with shared-care principles.
3.Pilot Service Interface (since February 2025): A pioneering shared-care model was developed and launched, incorporating bi-directional referral pathways and personalized survivorship plans for breast cancer survivors.
4.Step-Down Medical Care Referrals (February - December 2025): A total of 281 cancer survivors were transitioned into community care through 30 HKMA-registered community doctors, demonstrating the feasibility and scalability of the hospital-to-community interface. “CONNECT” pioneers cross‑sectoral survivorship care in Hong Kong, bridging hospital and community services for seamless transitions to primary healthcare. Strengthening continuity and patient empowerment, it has succeeded with breast cancer survivors and is set to expand to other groups, fostering sustainable, community‑based post‑treatment care.
