Advancing survivorship across the WCMICS region
Living with and beyond cancer: across all cancers, the 5-year survival rate is ~71% for people living the WCMICS region.
The Project
As more people live longer after cancer, the need for structured, coordinated survivorship care is growing. Yet follow-up care often remains fragmented, with limited routine assessment of patient needs and inconsistent care planning.
To address this, the Western and Central Melbourne Integrated Cancer Service (WCMICS) partnered with five health services to pilot a nurse-led survivorship model of care. The model embeds a structured survivorship needs assessment (SNA) and tailored survivorship care plan (SCP) at the transition from treatment to post-treatment care.
Delivered across Royal Melbourne Hospital, St Vincent’s Hospital Melbourne, Western Health, Peter MacCallum Cancer Centre, and Werribee Mercy Hospital, the pilot tested feasibility, scalability, and adaptability across tumour streams and service contexts.
Why this matters
Cancer survivorship is a growing priority under the Victorian Cancer Plan 2024–2028, with increasing recognition that patients require support beyond treatment.
This pilot responds to key system gaps:
- limited structured follow-up care planning
- unmet physical and psychosocial needs
- unclear coordination between hospital and primary care
What we did
Across two implementation phases, the pilot:
- delivered 131 survivorship consultations across multiple tumour streams
- embedded routine needs screening and care planning into clinical workflows
- tested delivery across diverse settings, including tumour streams, SURC, and day units
- supported implementation through Communities of Practice, shared tools, and project coordination
Care was delivered primarily via telehealth (84%), improving accessibility for patients.
What we found
Strong demand and feasibility
- 7 of 8 pilots met or exceeded recruitment targets
- High completion rates for key components:
- SNA: 94%
- SCP: 98%
- GP communication: 90%
Unmet needs are common — and identifiable
Structured screening consistently identified:
- psychological distress and fear of recurrence
- fatigue, neuropathy, and physical impairment
- sexual health and menopausal concerns
- gaps in follow-up understanding and care coordination
Nurse-led care improves coordination and confidence
Survivorship consultations:
- provided reassurance and education
- improved clarity around follow-up and “who to contact”
- strengthened links between hospital teams and GPs
- enabled timely, targeted referrals to supportive care services
The model is adaptable and scalable
The pilot demonstrated that survivorship care can be:
- embedded within existing tumour streams
- delivered across multiple service contexts
- supported by digital tools and modest workforce investment
What changed in practice
The pilot led to immediate system improvements, including:
- routine use of survivorship needs assessments
- increased and more consistent provision of care plans
- improved referral pathways to allied health and community services
- stronger integration between tertiary care and primary care
What’s next
Based on these findings, WCMICS is progressing:
- scale and spread of the nurse-led survivorship model across the region
- development of a practical implementation toolkit
- continued workforce capability building through Communities of Practice
- a light-touch regional evaluation approach to monitor uptake and impact
Learn more
The nurse-led survivorship pilot demonstrates that structured, nurse-led models can improve coordination, identify unmet needs, and support patients during one of the most vulnerable points in the cancer pathway.
