Personalised approach to cancer follow-up

The East of England Cancer Alliances are committed to supporting systems and providers across the region to deliver the personalised care ambitions set out in the NHS Long Term Plan including:

'Every person diagnosed with cancer will have access to personalised care, including a health needs assessment, a care plan and health and wellbeing information and support.'

'After treatment, patients will move to a follow-up pathway that suits their needs and ensures they can get rapid access to clinical support where they are worried that their cancer may have recurred.'

The implementation of patient centred follow-up (PCFU) /personalised stratified follow-up pathways (PSFU), tailored to individual needs, aims to improve patient experience and quality of life for people following treatment for cancer. Increasing numbers of our patients across the East of England region are now receiving follow-up care that is personalised to their needs.

The East of England Cancer Alliances have produced a flexible resource for ‘self-managed’ follow-up pathway for patients with breast and colorectal cancers. The regional guidance is evidence-based suggesting an approach with ongoing cancer surveillance,  but with fewer face-to-face appointments, and rapid access to support, advice and interventions with the most appropriate clinicians when needed.

Patients who complete their primary treatment and experience PCFU pathways will be offered:

  • Information about signs and symptoms, which could suggest their cancer has recurred or progressed, or which may be the side-effects of treatment
  • Rapid access back to their cancer team, including telephone advice and support if they are worried about any symptoms
  • Regular surveillance scans or tests (depending on cancer type), with quicker and easier access to results so that any anxiety is kept to a minimum
  • Personalised care and support planning and support for self-management to help them to improve their health and wellbeing in the long term.

Please click here for the handbook 'Living with and beyond cancer:​​​​​​'Implementation Personalised Stratified Follow Up Pathways' (March 2020). We also have PSFU breast, colorectal and prostate cancer guidance available here.

The East of England Cancer Alliances will continue to support health and care systems to develop further PCFU pathways recognising the key factors influencing development of an effective PCFU service including:

  • A whole pathway approach where PCFU is viewed as integral to the whole cancer pathway.
  • Use of digital solutions to track patient pathways and enable remote monitoring. The East of England Cancer Alliances are adopting a regional approach including development of patient portals with 24-hour access to information to support patients to make real-time informed health and lifestyle decisions.
  • Appropriately skilled and resourced workforce to operate an effective PCFU service. Our Cancer Alliance teams have supported workforce development across the East of England region, including the implementation of the cancer support worker (or similar) role to provide additional support for patients and the wider workforce.
  • Health inequalities including health literacy, digital and service accessibility.
  • Moving PCFU pathways to business as usual: The East of England Cancer Alliances have been working with systems and providers to transition transformation projects to sustainable commissioned services for breast, colorectal and prostate PCFU pathways. Having a model approach to commissioning and contracting arrangement will support PCFU becoming business as usual for all cancer sites in the long term.
  • Impact of COVID-19: The pandemic has resulted in a different approach to the delivery of all cancer care with increasing use of virtual consultations.