Establishing Mater Women's Cancer Survivorship Clinic

Overview

Initiative type

Service Improvement

Status

Deliver

Published

June 2025

Summary

In response to the increasing number of cancer survivors in Queensland and the identified unmet needs among women after cancer treatment, Mater had established the Women's Cancer Survivorship Clinic in October 2024.

Key dates

29 October 2024 - ongoing

Implementation sites

The Mater Hospital

Partnership

Cancer Council Queensland

Aim

This pilot project aims to establish a sustainable, evidence-based survivorship care model for female cancer survivors in Southeast Queensland, focusing on post-treatment support for women with breast or gynaecological cancers to address their complex needs and improve quality of life.

Outcomes

An audit was conducted on 1 April 2025, covering clinic activity from 29 October 2024 to 31 March 2025. The clinic served 22 patients from 44 referrals.

  • Consultation format: 59% of patients chose in-person visits, and 41% selected virtual sessions, showing flexibility in care delivery.
  • Unmet needs: Common issues included fear of recurrence (91%), sexual health concerns (68%), and menopausal symptoms (68%)
  • Interventions included referrals to both internal and external allied health services.
  • Patient satisfaction: High patient satisfaction (overall mean score of 4.57), appreciating the information, reassurance, side effect management, and moral support received.
  • Sustainability: The clinic received referrals from multiple sites, indicating the potential for future expansion.

Background

Advancements in cancer treatment have led to a significant improvement in global survival rates, now reaching 72%1. In Queensland, it is projected that 350,000 individuals will be living with cancer by 20301. The five-year survival rate in Queensland reached 65.7% in 20221, approaching global averages. Concurrently, the incidence of breast cancer in Australia continues to rise, with one in seven women expected to be diagnosed in their lifetime2. The prevalence of endometrial cancer is also increasing, largely driven by rising rates of body mass index (BMI) and obesity3.

Both breast and gynaecological cancers represent substantial public health burdens, with affected patients often requiring a combination of surgery, chemotherapy, immunotherapy, radiotherapy, and hormonal therapy to improve survival rates. Although these treatments have significantly enhanced survival outcomes, they are frequently associated with long-term toxicities, which can lead to persistent post-treatment issues that affect survivors' quality of life, ability to return to work, and pre-treatment levels of function.

In Australia, a systematic evaluation of cancer-related symptoms has identified fear of cancer recurrence and uncertainty about the future as significant psychosocial concerns4. In 2016, the Clinical Oncology Society of Australia (COSA) published a model of survivorship care that outlined essential principles, although it provided limited guidance on their implementation. As a result, the delivery of survivorship care remains inconsistent, highly dependent on individual treatment pathways5. Following this, COSA issued a position statement on survivorship care that included two primary recommendations for effective implementation:

  1. Healthcare teams should develop a treatment summary and survivorship care plan upon the transition to follow-up care.
  2. Survivors must have equitable access to timely services, with a focus on minimising unnecessary use of healthcare services and resources.

Currently, no public tertiary hospital in Queensland, including Mater, routinely generates cancer survivorship care plans for patients following active treatment, and access to allied health resources remains a significant concern for those navigating private versus public care systems. However, the new service at Mater aims to generate survivorship care plans for all referred patients, with the long-term goal of establishing a model of care in which all cancer patients receive a tailored care plan in accordance with COSA's key recommendations.

The Mater Women's Cancer Survivorship Clinic pilot project provides comprehensive, multidisciplinary care to female cancer survivors throughout southeast Queensland. With a significant number of new breast cancer and gynaecological cancer diagnoses occurring annually in Queensland, there is an increasing demand for targeted survivorship care. National and international guidelines advocate for a systematic approach to survivorship care, emphasising the inclusion of multidisciplinary teams and personalised survivorship care plans. However, a gap remains in the provision of such services within Queensland tertiary hospitals.

Methods

The pilot project used the Joanna Briggs Institute (JBI) Seven-Step Evidence Implementation Framework7 to systematically develop, implement, and evaluate the pilot project for enhancing care for female cancer survivors.

In 2021, two senior oncology nurses at Mater identified significant gaps in post-treatment support for breast and gynaecological cancer survivors, who reported ongoing challenges such as fear of cancer recurrence, sexual dysfunction, menopausal symptoms, financial strain, and difficulties returning to daily life. A baseline assessment conducted under the Optimising Women's Cancer Survivorship Care project (Mater HREC Project ID: 114286) confirmed the absence of standardised follow-up care, inconsistent use of survivorship care plans, and limited access to allied health services.

Engagement with key stakeholders' - including medical oncologists, surgeons, nursing staff, allied health professionals, and administrative personnel - was fundamental to shaping the initiative. The Mater Cancer Care Centre (MCCC) took over the project with philanthropic support from the Mater Foundation. A Survivorship Nurse Navigator was appointed in September 2024 to lead implementation and coordinate service delivery.

A contextual analysis, including a SWOT assessment, identified key strengths such as Mater's established expertise in women's cancer care, a multidisciplinary model, and alignment with national and international survivorship care guidelines. Identified weaknesses included limited staffing, low visibility of the service, and referral barriers. Opportunities were noted in telehealth expansion, academic collaboration, and improved marketing strategies, while risks to sustainability included ongoing reliance on philanthropic funding and the potential for stakeholder disengagement.

Development of the clinic followed evidence-based frameworks including the Clinical Oncology Society of Australia's (COSA) Model of Survivorship Care (2016), Cancer Australia's Principles of Cancer Survivorship (2017), the Queensland Cancer Strategy (2024), and the Commission on Cancer's Standard 4.8 (American College of Surgeons, 2021). Benchmarking with established survivorship services in Victoria, New South Wales, and Western Australia ensured alignment with national standards of care.

Implementation followed the GRIP (Getting Research Into Practice) framework, encompassing baseline evaluation, identification of barriers and enablers, and the introduction of targeted interventions. Key enablers included strong clinical leadership, institutional support, telehealth integration, and multidisciplinary collaboration. Barriers such as limited funding, low program awareness, integration challenges, patient compliance, and resistance to change, were addressed through relevant strategies.

A post-implementation audit demonstrated improved access to survivorship services, enhanced care coordination, and increased utilisation of care plans. During the pilot phase, monthly quality assurance reviews are conducted, with a planned transition to quarterly evaluations as the service becomes more established.

Discussion

Overall, this project successfully established a sustainable, evidence-based survivorship model of care that supports female cancer survivors in Southeast Queensland. Following a patient-centred approach, the Mater Women's Cancer Survivorship Clinic was designed to meet the complex, multifaceted needs of survivors following treatment, focusing on the physical, psychological, practical, and informational domains of care. Multidisciplinary collaboration was central to the clinic's model, with medical oncologists, senior nurse, allied health professionals, and external partners providing coordinated and individualised care5.

The implementation of the clinic demonstrated the value of integrating Patient-Reported Outcome Measures (PROMs) to the early identification of unmet survivorship needs within the care continuum. Five months into the clinic's implementation, it became evident that the use of appropriate PROMs was essential for accurately assessing these needs. Existing literature indicates that many cancer survivors experience ongoing morbidity, with their supportive care needs often being under-assessed7. Through the utilisation of validated tools such as the Distress Screening and Cancer Survivors Unmet Needs (CaSUN), high-risk patients were identified, and their needs addressed through both internal and external allied health resources. This highlighted the value of evidence-based tools in identifying complex needs and enhancing the effectiveness of care. However, limitations in the accessibility of resources were noted, emphasising the necessity for further integration of relevant support services to adequately meet patient needs particularly internal psychological support.

On the other hand, key success factors included a hybrid care model offering both in-person and remote consultations, strong leadership support, and partnerships with external organisations such as Cancer Council Queensland to augment available resources. In addition, personalised survivorship care plans (SCPs) provided clear guidance and ensured coordinated care for long-term health management.

Based on lessons learned from the clinic's initial implementation, several improvements could be made. These include increasing awareness through a targeted marketing strategy and strengthening relationships with GPs and oncologists. Expanding psychological support services would better address patients' needs, while offering flexible scheduling and additional clinic options could improve patient engagement. Exploring diverse funding models would ensure long-term sustainability. Furthermore, integrating comprehensive follow-up systems is crucial for ongoing care, and utilising data analysis would provide deeper insights into patient outcomes, informing future strategies.

Finally, there is a clear opportunity to scale the program to benefit a broader population of cancer survivors across Queensland. Evidence suggests that the deliberate scaling of effective interventions can enhance health outcomes and system efficiency8. In alignment with Mater's strategic objectives, the clinic plans to expand to Mater North Queensland (MNQ) and Mater Central Queensland (MCQ).

References

1. Cancer Council (2022). Life After Cancer. Cancer Council Queensland. Retrieved 01/04/2025, from https://cancerqld.org.au./support-services/coping-with-cancer/life-after-cancer/
2. Uterine cancer statistics | Cancer Australia. Retrieved 01/04/2025, from: https://www.canceraustralia.gov.au/.
3. Cancer incidence | National Cancer Control Indicators. CancerAustralia.gov.au. Retrieved 01/04/.2025, from https://www.canceraustralia.gov.au/
4. Lisy K, Langdon L, Piper A, Jefford M. Identifying the most prevalent unmet needs of cancer survivors in Australia: A systematic review. Asia Pac J Clin Oncol. 2019;15(1):e68–e78.
5. Clinical Oncology Society of Australia (2016). COSA’s model of cancer survivorship: Clinical Oncology Society of Australia. Retrieved 01/04/2025, from: https://www.cosa.org.au/.
6. Porritt K, McArthur A, Lockwood C, Munn Z (Editors). JBI Handbook for Evidence Implementation. JBI, 2020. Available from: https://implementationmanual.jbi.global. https://doi.org/10.46658/JBIMEI-20-01
7. Hodgkinson, K., Butow, P., Hunt, G. E., Pendlebury, S., Hobbs, K. M., Lo, S. K., & Wain, G. (2007). The development and evaluation of a measure to assess cancer survivors' unmet supportive care needs: the CaSUN (Cancer Survivors' Unmet Needs measure). Psycho-oncology, 16(9), 796–804. https://doi.org/10.1002/pon.1137
8. Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. National Implementation Research Network. https://fpg.unc.edu/

Key contact

Leilani Way ; Simone Andrews

Survivorship Nurse Navigator/CNC

Mater Health Services

Email: survivorshipnursenavigator@mater.org.au

Last updated: June 2025

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