Pathways to wellness-shared care after colorectal cancer

Pathways to wellness-shared care after colorectal cancer Risk stratified follow-up pathway for patients treated with surgery (alone) for colon cancer

Key : EOT - End of treatment

MDM - multi disciplinary team meeting

Option: Add to MDM agenda List as shared care follow-up, not for discussion

After Year 5

Identify eligible patients MDM Clinic meetings Care coordinator

Surgery= EOT

Surgery review ~ 2 weeks post-EOT

Project officer / Care Coordinator

Consents patients Supports patients to

access a GP if needed

Care coordinator sends holistic needs assessment survey to patient +/- carer survey

Shared care intervention ~ 6 weeks post-EOT

Discuss problems and needs Identify lifestyle-related risks for recurrence Provide support, advice & referral Develop care plan with patient and provide

to patient and GP. Ensure understanding of shared care.

Preparation for shared care Year 2

12 month follow-up SURGICAL CLINIC CEA blood test Examination History +/-CT chest, abdo

3 month follow-up GP PRACTICE

CEA blood test Examination History

6 month follow-up SURGICAL CLINIC CEA blood test Examination History

9 month follow-up GP PRACTICE

CEA blood test Examination History

Year 1

12 month follow-up SURGICAL CLINIC CEA blood test Colonoscopy Examination History +/-CT chest , abdo

3 month follow-up GP PRACTICE

CEA blood test Examination History

6 month follow-up SURGICAL CLINIC CEA blood test Examination History

9 month follow-up GP PRACTICE

CEA blood test Examination History

12 month follow-up SURGICAL CLINIC

CEA blood test Arrange Colonoscopy Examination History +/- CT chest, abdo

Year 3

6 month follow-up GP PRACTICE

CEA blood test Examination History

Year 4

12 month follow-up GP PRACTICE

CEA blood test Examination History

6 month follow-up GP PRACTICE

CEA blood test Examination History

Year 5

12 month follow-up GP PRACTICE

CEA blood test Examination History

6 month follow-up GP PRACTICE

CEA blood test Examination History

GP Colonoscopy every 3 or 5 years

Other follow-up-as advised by doctor

Specialists will arrange colonoscopy within 12 months for patients unable to complete colonoscopy prior to surgery.