Follow-Up Care Clinics / Survivorship Clinics

On completion of treatment, children will continue to be monitored closely, within an out-patient follow-up clinic. The emphasis of these clinic visits is to monitor for disease recurrence but also to start monitoring for any potential long-term side effects of treatment.

Generally, after about two years of such follow-up, the emphasis shift from disease recurrence to that of monitoring for potential long-term side effects. Such clinics are often referred to as survivorship clinics.  

At these clinic visits, your child will continue to see their consultants / medical / nursing team. In addition to this, and if necessary, your child may be referred to another specialist for more specific medical management. For example a specialist in cardiology, endocrinology, fertility, nutrition, psychology or pulmonology. 

Graduation/Transition from CHI

Usually, your child will continue with CHI-centred follow-up for at least five years following completion of their treatment before graduating from follow-up. Some children may require longer follow-up, possibly up until 16 – 18 years of age before they graduate. The timing of graduation, and where your child graduates to, is variable relative to your child’s diagnosis, their treatment received and their need for ongoing medical management if applicable. The options of where your child graduates to after CHI can range from not requiring any specific further follow-up, to GP/community follow-up or possibly even to hospital-based adult care follow-up.

Your child’s medical and nursing team will help prepare you and your child to graduate/transition from CHI-centred care. This transition requires careful and accurate relaying of your child’s medical information to ensure your child and you as parents are fully in the knowledge of such. There are two important ‘documents’ that are important to ensure nothing is ‘lost in translation’ when your child graduates from CHI-centred/paediatric to community / adult care.

1. Medical summaries: an important first step

A medical summary is compiled by your child’s medical / nursing team on completion of their treatment, and is updated at each visit thereafter. This medical summary is freely available to you or your child at any time, however it is imperative you or your child receives a copy of this summary when your child graduates from CHI. 

This summary will give any other healthcare professional your child may encounter, a good insight into your child’s medical history.

2. Survivorship care plans

A very promising initiative by the CHI team is now starting to be rolled out – the Survivorship Care Plan (SCP). This SCP is given to survivors when they graduate from CHI.

In addition to incorporating the above medical summary, the SCP contains international surveillance/screening recommendations relative to the specific treatment your child received. 

This SCP has the potential of empowering all survivors to be aware of their cancer diagnosis, the treatment they received, the treatment-related late effects they may have and importantly, the international recommendations on how to monitor such in the future. As a result the SCP promotes survivor confidence, self-responsibility and healthy behavioural lifestyles. In addition, the SCP may empower the survivor to help educate any health-care professional they may come into contact with in the future thereby guiding future management.