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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.
