Shared care is a model for patients with stable prostate cancer

Abstract

Introduction: Patients with prostate cancer (PC) have so far been followed in specialised hospital departments after diagnosis and initiation of treatment. The main obstacles associated with the transfer of this activity to general practice include lack of experience and uncertainty as to whether general practitioners (GPs) can handle follow-up.

Material and methods: A Steering Committee was established in collaboration with health-care professionals to devise a strategy for a shared care model. An action plan was designed that included 1) the development of a shared care model for follow-up and treatment, 2) implementation of the shared care model in cooperation between the parties involved, 3) design of procedures for re-referral, and 4) evaluation of effect, change processes and contextual factors.

Results: A total of 2,585 patients with PC were included in the study: 1,172 had disseminated disease, 754 had no recurrence after curative treatment, 244 who had been treated with a curative intent were being treated for relapse, 186 underwent watchful waiting, 135 underwent active surveillance, while other scenarios applied in the remaining 94 cases. A total of 530 patients were transferred to follow-up with a GP and 2,055 were not transferred to their GP. The main reason why patients were considered not suitable for transfer to primary health care was the patients' own desire (33%), followed by clinical or biochemical disease progression (33%). The evaluation found that 96% of the patients were very comfortable with the permanent or temporary closure of the hospital course.

Conclusion: The project focused on factors that are essential for the successful transfer of responsibility for long-term follow-up of patients with prostate cancer. Patient transfer succeeded with high initial patient satisfaction.

Funding: not relevant.

Trial registration: not relevant.