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This was an innovation project supported by the former Better Care Victoria Innovation Fund.

Lead organisation

Loddon Mallee Integrated Cancer Service


  • Bendigo Health
  • Peter MacCallum Cancer Centre
  • Murray Primary Health Network
  • Bendigo Community Health
  • Echuca Regional Health


National cancer screening programs and advancements in treatment have led to an increase in the survival rate of people diagnosed with cancer, and cancer services are shifting their focus to the support and care provided after treatment is over in response.

Cancer survivors have specific needs and concerns that are often left unmet, including physical, psychosocial, and spiritual needs. Research also shows that the time after cancer diagnosis can provide a valuable opportunity to educate and motivate patients to adopt risk-reducing behaviours.

To better meet these patients’ needs, a project team led by the Loddon Mallee Integrated Cancer Service established a clinic at the Bendigo Cancer Centre, providing specialist support for survivors of breast cancer and helping to ease their transition from the hospital into primary care.


  • Establish a sustainable breast cancer survivorship service in the Bendigo Cancer Centre
  • Create and implement survivorship care plans for use between the patient’s primary and acute care teams
  • Develop a sustainable survivorship service model that can be implemented for other tumour streams


  • Saw 23 breast cancer patients at the survivorship clinic during the pilot phase
  • Referred 13 patients (56 per cent) to at least one supportive care service
  • Cancelled two unnecessary appointments through clinic activity, which could then be used for other patients
  • Received positive feedback from patients, with 100 per cent of post-clinic survey respondents saying they were satisfied with their care
  • Increased the patient survivorship information communicated to GPs, including eight mental health plan recommendations
  • Developed a specially tailored 12-week exercise program for breast cancer patients at Bendigo Community Health


March 2018 – Due to the success of the breast cancer survivorship clinic, the project team is now considering implementing the survivorship clinic model for prostate or colorectal tumour patients. 

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