Personalised Cancer Care

What is personalised cancer care?

Personalised cancer care* means providing individuals with cancer with access to care and support so that they can live as full, healthy and active a life as possibleIt is a partnership between the individual and their cancer team, providing support to talk about the things or outcomes that matter most to them and to agree the best course of action to achieve these outcomes.  Personalised cancer care is based on ‘what matters’ to the individual and their strengths and needs. 

Effective personalised cancer care provides people with information about maintaining a healthy lifestyle and support to self-manage their condition.  This includes helping to manage physical and emotional effects of cancer and its treatment and to access financial, emotional, practical and social support.

*Personalised cancer care is different from personalised medicine, which is the use of advanced genomic techniques to tailor treatment regimens.

Personalised Cancer Care programme

The personalised cancer care programme works in collaboration with our partners to enable all individuals, from the point of being diagnosed with cancer, to have access to individualised care, rehabilitation and support.  We focus on meeting both national and local priorities so that all people affected by cancer in our region benefit from support.

National Long Term Plan priorities:

  • Everyone diagnosed with cancer will have access to personalised care, including 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
  • Introduction of a Quality of Life metric

Local priorities

  • Personalised Cancer Care interventions
  • Personalised Stratified Follow-up
  • Rehabilitation
  • Psychological support

Our work in key areas

Supporting implementation of personalised care interventions:

  • Holistic Needs Assessments (HNAs):  A conversation between the person with cancer and a healthcare professional in which an individual’s needs and concerns can be identified and addressed at the earliest opportunity.
  • Treatment summaries:  A document that is completed by the medical team at the end of primary treatment.  It includes information on possible treatment toxicities and /or consequences of treatment, signs and symptoms that should be referred to a specialist team, an ongoing management plan, and a summary of information given to the individual about their cancer and future progress and any action required from the GP actions to support their patient.  Copies are sent to the GP and given to the patient when they are discharged.  
  • Cancer care reviews:  These are holistic conversations that take place in primary care, usually within 6-12 months of a person being diagnosed with cancer. The discussion will involve any current needs an individual might have, a medication review, and signposting to relevant services in the local community.
  • Health and Wellbeing support and information:  Providers are advised to enable people to know where to access resources and services to help them to manage during and after their cancer treatment and beyond treatment.  This covers emotional support, coping with side effects, physical wellbeing, financial advice, getting back to work and making healthy lifestyle choices, among others.

Personalised Stratified Follow up (PSFU) pathways

In this model the clinical team and the person living with cancer make a decision about the best form of aftercare based on the individual’s clinical and personalised needs. The Cancer Alliance is working to introduce PSFU pathways for people with breast, colorectal and prostate cancers. Individuals are directed to either a professionally led or a patient initiated follow up (PIFU) pathway:

Professional led pathway follow up: Individuals with cancer have face to face, video, phone or email contact with their clinical team as part of continuing follow up. Such appointments may be led by doctors, nurses or specialist allied health professionals. Follow ups may be delivered by the specialist team or the primary care team.

Patient initiated follow up pathway: Individuals are empowered with knowledge and skills to self-manage their condition. They are given information about symptoms to look out for and who to contact if they notice any of these, dates of future scheduled tests, and how to contact the specialist team if they have any concerns. PIFU pathways also include the following key features:

  • Effective needs assessment at end of treatment that identifies and addresses any outstanding needs and ensures the patient has knowledge and confidence to manage their own care.
  • Removal of routine follow up appointments from the pathway. The results will be reviewed by an appropriately qualified staff member and the patient is informed of the results (in line with clinical judgement and local protocols).
  • Good communication between specialist, community and primary care teams.
  • A robust remote monitoring system to manage on-going surveillance tests and ensure no-one is missed for follow up tests.
  • A system that allows rapid re-entry into the specialist cancer service if required. This reassures individuals that they can access appropriate, named support quickly should they need it without having to go via their GP.

Psychosocial support

We are working with our partners to ensure that emotional support is available across the cancer pathways. 

Quality of Life Survey

NHS England is rolling out a survey to ask individuals with cancer about their quality of life. Initially the survey will focus on people with breast, colorectal or prostate cancer, and later to people with other cancers.  This will be sent either electronically or via the post 18 months after diagnosis. The survey responses will help us to improve the way we support people to live their lives as well as possible.

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