Managing
Recurrent,
Residual or
Metastatic
Disease
Managing
Recurrent, Residual
or Metastatic
Disease

Managing recurrent, residual or metastatic disease

Managing recurrent, residual or metastatic disease is the sixth of seven steps of the cancer continuum as set out in the Optimal Care Pathways.

This step recognises the likelihood of recurrence depends on many factors such as type of cancer, the stage of cancer at presentation, and the effectiveness of treatment. The management of cancer and cancer-related symptoms for patients who present with recurrent, residual, or metastatic disease should be undertaken by a multidisciplinary team.

ACTIONS RELEVANT TO THIS step

2 Years
5 Years

STEP 6

Managing recurrent, residual or metastatic disease

Actions

3.2.2
Develop a national framework for networked, distributed comprehensive cancer care, to facilitate provision of services as close as safely possible to where patients live. This will include the role of Comprehensive Cancer Centres to enhance patient outcomes, strengthen transparency and accountability, and drive continuous improvements for all patients across the network regardless of where the care is provided.
3.2.3
Implement innovative, evidence-based and cost-effective models of care for people living with and beyond cancer.
3.2.4
Develop and refine integrated care models to maximise access to high-quality, timely and evidence-based palliative and end-of-life care, including voluntary assisted dying.
3.2.5
Lead a national approach to identifying and reporting Indigenous status in cancer care.
4.2.2
Ensure targeted and innovative research investment into areas of unmet and emerging need; and improve clinical trial design and equitable access.
4.2.3
Identify opportunities to improve equitable cancer care through the digital health ecosystem.
5.2.1
Identify current and emerging workforce undersupply in line with cancer workforce modelling and other national health workforce strategies, and initiate planning with the sector towards building future workforce capacity and capability.
5.2.2
Build on existing capability of the primary care workforce to collaboratively and sustainably support the needs of consumers.
5.2.3
Evaluate and extend cultural safety training programs to cancer service providers, including through community-based partnerships with priority population groups.
5.2.4
Identify priority areas of need for Aboriginal and Torres Strait Islander cancer care workforce and develop a plan to recruit, train and retain the Aboriginal and Torres Strait Islander cancer care workforce.

2 Years

STEP 6

Managing recurrent, residual or metastatic disease

Actions

3.2.2
Develop a national framework for networked, distributed comprehensive cancer care, to facilitate provision of services as close as safely possible to where patients live. This will include the role of Comprehensive Cancer Centres to enhance patient outcomes, strengthen transparency and accountability, and drive continuous improvements for all patients across the network regardless of where the care is provided.
3.2.3
Implement innovative, evidence-based and cost-effective models of care for people living with and beyond cancer.
3.2.4
Develop and refine integrated care models to maximise access to high-quality, timely and evidence-based palliative and end-of-life care, including voluntary assisted dying.
3.2.5
Lead a national approach to identifying and reporting Indigenous status in cancer care.
4.2.2
Ensure targeted and innovative research investment into areas of unmet and emerging need; and improve clinical trial design and equitable access.
4.2.3
Identify opportunities to improve equitable cancer care through the digital health ecosystem.
5.2.1
Identify current and emerging workforce undersupply in line with cancer workforce modelling and other national health workforce strategies, and initiate planning with the sector towards building future workforce capacity and capability.
5.2.2
Build on existing capability of the primary care workforce to collaboratively and sustainably support the needs of consumers.
5.2.3
Evaluate and extend cultural safety training programs to cancer service providers, including through community-based partnerships with priority population groups.
5.2.4
Identify priority areas of need for Aboriginal and Torres Strait Islander cancer care workforce and develop a plan to recruit, train and retain the Aboriginal and Torres Strait Islander cancer care workforce.

5 Years

STEP 6

Managing recurrent, residual or metastatic disease

Actions

2.5.3
Ensure multidisciplinary cancer care teams for Aboriginal and Torres Strait Islander people are trauma-aware and healing-informed.
3.5.2
Establish an Australian Comprehensive Cancer Network (ACCN) to ensure connectivity and sharing of expertise between Comprehensive Cancer Centres, other cancer services, regional hospitals, community and primary care. The establishment of an ACCN will increase equity of access across services for all patients, deliver cancer care close to home, and monitor evidence-based system performance.
4.5.1
Design and embed patient reported experience and patient reported outcomes into national performance monitoring and reporting for all providers, to assess services for all population groups and establish an evidence base.
4.5.2
Expand access to digitally enabled cancer care to improve equity and access to quality cancer care, particularly in regional, rural and remote areas.
4.5.3
Explore and test innovative approaches to health service funding models to address areas of need, and system improvement, in cancer care.
5.5.1
Implement a cancer care workforce pipeline that meets demand for optimal cancer care, with diversity measures in training, recruitment and talent management to ensure the cancer workforce represents the diversity of patient populations.
5.5.2
Assist the sector to support all cancer care practitioners to work at the top of their scope of practice, increase retention and ensure ongoing access to continuing professional development.
5.5.3
Routinely integrate cultural safety training programs for cancer service providers, including through community-based partnerships with priority population groups.
5.5.4
Support national coordination and implementation of a plan to recruit, train and retain the Aboriginal and Torres Strait Islander cancer care workforce
6.5.2
Implement strategies to embed culturally safe care within cancer-related services for Aboriginal and Torres Strait Islander people.

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