Masterclass 4 - Cancer Survivorship and End-of-Life Care in the Community

Prostate cancer ranks as the third most prevalent cancer among men in Hong Kong, with an impressive 10-year survival rate exceeding 80%. Despite this positive prognosis, many survivors experience significant long-term declines in mental and physical quality of life, highlighting critical gaps in supportive care post-treatment.


This pilot program, developed in collaboration with the Hong Kong Anti-Cancer Society, aims to enhance the survivorship experience for men diagnosed with prostate cancer. Our initiative adopts a holistic approach, addressing the comprehensive needs-physical, psychosocial, and spiritual-of survivors and their families.


The program integrates hospital-based specialized follow-up care with community support, ensuring that patients receive continuous assistance throughout their treatment journey and beyond. Key components include routine health maintenance, management of treatment-related side effects, and the provision of psychosocial support.


By fostering coordinated care through a multidisciplinary team, we aim to improve health monitoring and enhance overall well-being. This initiative not only supports patients during their treatment but also facilitates their reintegration into the community post-recovery. Through this innovative model, we aspire to set a new standard in prostate cancer survivorship care, ultimately empowering survivors to achieve an optimal quality of life.

The increasing number of breast cancer survivors, driven by advances in early detection and treatment, has created a growing demand for long-term follow-up care in oncology outpatient clinics. As a tertiary care center, our clinic faces a heavy daily workload, with a significant proportion of visits dedicated to breast cancer survivors who are clinically cured but require ongoing surveillance, management of treatment-related side effects, and psychosocial support. Recognizing the chronic nature of survivorship care and the need for a more sustainable model, we initiated a breast cancer survivorship nursing clinic by training specialized nurses to take on a central role in the care of these patients.


The primary goal of this initiative was to provide personalized, holistic, and accessible care for breast cancer survivors while alleviating the burden on oncologists. Nurses were trained to conduct survivorship visits, which included monitoring for recurrence, managing long-term side effects (e.g., fatigue, lymphedema, and hormonal symptoms), addressing psychosocial concerns, and promoting healthy lifestyle changes. Survivorship care plans were developed to ensure continuity of care and patient empowerment.


In Princess Margaret Hospital, nurse-led breast cancer survivorship clinic was established in October 2024. Before its implementation, our team had several preparatory work done to lead its successful running of the clinic with good number of patients enrolled in the initial phase. By shifting survivorship care to trained nurses, oncologists can focus on active cancer treatment, while survivors receive dedicated attention tailored to their unique needs. This model not only addresses the challenges of rising patient volumes and long survival times but also highlights the critical role of nurses in delivering high-quality, patient-centered survivorship care.


In conclusion, the breast cancer survivorship nursing clinic represents an innovative and sustainable approach to meeting the complex needs of breast cancer survivors, ensuring their long-term well-being while optimizing healthcare resources in a tertiary care setting.

The rapidly aging population and extension of the longevity of terminally ill patients in Hong Kong may only result in deterioration of their quality of life if their need for adequate care could not be addressed. A growing demand for a paradigm shift from a heavy hospital-centric care to a care model supplemented with a community-based integrated care is also applied in Hong Kong. From 2022 onward, a home-based end-of-life service has commenced to support terminally ill patients and caregivers in Kowloon West Cluster. The collaboration between hospital and community partners imposes an intention to move from fragmented and disease‐oriented care to coordinated and holistic care. However, integrating care across different sectors, organizations and system interfaces to deliver person-centered care is a complex process influenced by a variety of enablers and barriers. Some studies pointed out the gap in the local existing collaboration and identified key factors that promote or impede successful integration of care across diverse settings internationally. Nevertheless, there is a lack of detailed information in Hong Kong about how the gap to be filled up from a rounded stakeholder perspective. A qualitative study was carried out to explore views and experience of key stakeholders including palliative care doctors, home care nurse, patients and caregivers, community care workers and medical social workers. Together with the experience of medical social collaboration in the past few years, we would like to take this opportunity to share our insights like the important role of a link person, two-tier communication and case stratification mechanism etc., and possible challenges from both our current experience and qualitative study so as to generate insight on refining current community care collaboration practice in the future.