What does the organisation of care look like in the aftercare phase?



Chain care

The guideline development group recommends that an individual aftercare plan is created for each patient, made available to the patient, general practitioner and other parties involved.


The guideline development group is of the opinion that it should be assessed, together with general practitioners and  breast care teams, if and when aftercare is best coordinated by the general practitioner or case manager in the hospital. If it is decided that the general practitioner should play a greater role in this, then a fast, complete information transfer and competence advancement by the general practitioner including professional supporting staff is essential. Partial adoption of cancer aftercare by the general practitioner means an increased burden and makes an expansion of the capacity of the first-line essential.


It should be clear for the patient, general practitioner and all health care providers in each phase of and after treatment who the main treating physician is, who is coordinating the aftercare and who is the point of contact.


Which healthcare provider takes up that role can be decided in the  breast care team.


The clinical nurse specialist/nurse practitioner works according to the role description and competences under supervision of the medical specialist who is the main treating physician in the aftercare process.


As an example, the following structure may be chose:

1)     patients who are only treated surgically, are monitored by the surgeon or a clinical nurse specialist

2)     patients who have received surgery and radiotherapy, are either only monitored by the surgeon, or only by the radiotherapist-oncologist (or by a clinical nurse specialist)

3)     patients who receive or have received chemotherapy are monitored by the medical oncologist or a clinical nurse specialist

4)     patients who receive or have received hormonal therapy are monitored by the medical oncologist or a clinical nurse specialist

5)     patients who receive or have received a HER-2 blockage are preferably monitored by the medical oncologist, who also takes up the aftercare for the duration of treatment

6)     for patients with a BRCA1/2 mutation treated for breast cancer, it may be desirable to also continue to make visits to the Hereditary Tumours consultation, in order to adequately take advantage of new developments


Aftercare interventions

  • Especially in the first year there needs to be attention for psychosocial guidance.
  • Resuming work should be discussed and stimulated
  • Physicians and clinical nurse specialist/nurse practitioner should be up to date on referral possibilities for psycho-oncological care, social support group / contact with fellow patients and rehabilitation programmes.

Patients who would like to make use of this should be informed about these options.


Aftercare duration

The duration of aftercare should be determined jointly by the physician and patient. It should be agreed who will be the ongoing contact person and the general practitioner should also be notified of this.


Level 4

An individual aftercare plan enables systematic identification of problems, it provides direction to aftercare, it provides clarity about the tasks and responsibilities of the health care professionals involved and supports communication between professionals.


D         Institute of Medicine, 2005

Literature summary

Chapter 12 outlines which aspects in the aftercare phase need to be covered, how often the patient needs to be checked and what should happen during these check-ups in relation to physical examination and additional examination/tests. However, it is not sufficient to lapse into the routine of the schedules outlined in chapter 12; on the one hand, because important aspects in care are inadequately highlighted, and on the other hand, because healthcare services should not be unnecessarily burdened.


Chain care and individual aftercare plan

Chain care is the coherent entity of efforts provided by different care providers under a recognisable delineation of responsibilities, in which the client process is central and in which as much alignment is sought with the client’s environment. A chain care is formed consisting of diagnostics, treatment and guidance, but also of prevention, early detection and self-assessment. It is a plea for appointing a case manager to ensure there is a well coordinated safety net, the individual aftercare plan [Health Council, 2007; IGZ, 2009].


The individual aftercare plan contains at least information about:

  • physical and psychosocial effects of disease and treatment
  • desirability and content of the aftercare
  • the moment of reconsideration and remaining points of attention:
  • possible late effects of treatment
  • signals that should give rise to consulting a physician
  • agreements about the coordination and task division between care providers


The aftercare plan makes good transfer to more comprehensive care possible [Institute of Medicine, 2005]. Additional care programmes may be found at, and It is recommended that return to work is discussed and integrated in treatment goals. See [NVAB, 2009].


Care after completing aftercare in the hospital

The duration of aftercare in the hospital should be determined in consultation between the physician and patient. The choice of duration cannot be made without giving substance to the primary aspects of aftercare, such as patient information and care. Even more, because the patient loses contact with the healthcare providers in the hospital after completing follow-up and the patient and general practitioner do not always know what the long-term effects will be of the cancer and treatment [KWF, 2011]. After completing aftercare in the hospital, it should be agreed who will remain the contact person and the general practitioner should be notified of this.


The effect of aftercare plans on a reduction in cancer-related morbidity and mortality, on an improvement in knowledge about the disease and treatment and quality of life, and on adhering to a healthier lifestyle has not been researched.

Authorization date and validity

Last review : 13-02-2012

Last authorization : 13-02-2012

The national Breast Cancer guideline 2012 is a living guideline, in other words there is no standard term of revision. NABON continually watches at new developments and clinical problems in the areas of screening, diagnostics, treatment and aftercare, and whether this requires an update.

Initiative and authorization

Initiative : Nationaal Borstkanker Overleg Nederland

Authorized by:
  • Nederlandse Internisten Vereniging
  • Nederlandse Vereniging voor Heelkunde
  • Nederlandse Vereniging voor Psychiatrie
  • Nederlandse Vereniging voor Radiologie
  • Nederlandse Vereniging voor Radiotherapie en Oncologie

General details

Approximately 14,000 women (and 100 men) are diagnosed with invasive breast cancer each year in the Netherlands, and about 1,900 have an in situ carcinoma. A woman's risk of having breast cancer over the course of her life is 12-13%. This means that breast cancer is the most common form of cancer in women in the Netherlands. Early detection, particularly via national breast cancer screening, combined with adjuvant therapy followed by locoregional treatment, improves the prognosis in women with breast cancer

The guideline on Breast Cancer Screening and Diagnostics, published in 2000, was updated in 2007. In 2002, the first multidisciplinary National Breast Cancer Guideline was published, it was revised in 2004, 2005 and 2006. In 2008 both guidelines were combined to Breast Cancer Guideline, which 2012 revision is now effected.

Scope and target group

This guideline is written for all the members of the professional groups that have contributed to its development.


This guideline is a document with recommendations and instructions to support daily practice. The guideline is based on the results of scientific research and expert opinion, with the aim of establishing good medical practice. It specifies the best general care for women with (suspected) breast cancer and for those who are eligible for screening. The guideline aims to serve as a guide for the daily practice of breast cancer screening, diagnostics, treatment and aftercare. This guideline is also used in the creation of informational materials for patients, in cooperation with the KWF (Dutch Cancer Society).

Samenstelling werkgroep

A core group consisting of a radiologist, surgeon, pathologist, medical oncologist and radiation therapist began preparing for the revision of the breast cancer practice guidelines in 2009. A multidisciplinary guideline development group was formed in early 2010 to implement the revision. This group consisted of mandated representatives from all of the relevant specialisations concerned with breast cancer, plus two delegates from the BVN (Dutch Breast Cancer Society) (see list of guideline development group members). The benefits of such a multidisciplinary approach are obvious: not only does it best reflect the care, but it offers the greatest possible expertise for the guideline. In composing the development group, geographic distribution of the members, balanced representation of the various organisations and agencies concerned, and a fair distribution in academic background were taken into account as much as possible.


The guideline development group received procedural and administrative support from IKNL (Comprehensive Cancer Centre for the Netherlands) and support on methodology from Bureau ME-TA. Partial funding was obtained from SKMS (Quality Funds Foundation of Dutch Medical Specialists). This subsidy would not have been possible without the extensive assistance provided by the NVvR (Radiological Society of the Netherlands).

Declaration of interest

Partial funding for the guideline revision was obtained from the Society of Dutch Medical Specialists in the framework of the SKMS. IKNL sponsored some of the cost. On two occasions, as well as at the beginning and end of the process, all of the members of the guideline development group were asked to fill out a statement of potential conflicts of interest, in which they stated their relationship with the pharmaceutical industry. A list of these statements of interest can be found in the appendices.

Patient involvement

In developing this guideline, four clinical questions were formulated. These questions emerge from an inventory of clinical problems collected in the field from professionals, patients and patient representatives.


Also, A multidisciplinary guideline development group was formed in early 2010 to create and implement the revision. This group consisted of mandated representatives from all of the relevant specialisations concerned with breast cancer, plus two delegates from the BVN (Dutch Breast Cancer Society).


Method of development

Evidence based


Feasibility has been taken into account in developing the guideline. This included attention to factors that could promote or hinder putting the advice into practice. Examples include the implementation of an analysis of problems, the multidisciplinary composition of the guideline development group, and making active use of support from the guideline development group members. Presenting the draft guideline to the field and communicating what, if anything, is being done with the responses, also promotes implementation. In this manner, a guideline has been developed that answers current questions in the field.

The guideline is distributed widely and is available in digital form on the Dutch Guideline Database. The guideline may also be brought to the attention of a wider audience in other periodicals or continuing education sessions, for example. To promote use of the guideline, we recommend that the regional tumour working groups and group practices, as well as scientific and professional organisations, repeatedly bring the guideline to the attention of their members. Any problems that may arise in using the guidelines can then be discussed and, when appropriate, submitted to the national guideline development group, as it is a "living" guideline. If desirable, parts of the guideline can be made more explicit by formulating regional additions or translation to the local situation in departmental and/or hospital protocols.

In principle, indicators are determined during development of the guideline that can be used to monitor implementation of the recommendations. Via a documentation project, these indicators can then be used to determine the extent of compliance with the guideline. The information from the documentation project becomes input for the revision of the guideline.

Methods and proces

This module has been evidence-based revised in 2008 and consensus based updated in 2012.


A revision of an existing guideline consists of revised and updated text. Revised text is new text based on an evidence-based review of the medical literature; updated text is the old guideline text which has been edited by the experts without performing a review of medical literature. Each section of the guideline states what type of revision has taken place. Each chapter of the guideline is structured according to a set format, given below. The purpose of this is to make the guideline transparent, so that each user can see on what literature and considerations the recommendations are based on.


Description of the literature

To the greatest extent possible, the answers to the fundamental questions (and therefore the recommendations in this guideline) were based on published scientific research. The articles selected were evaluated by an expert in methodology for their research quality, and graded in proportion to evidence using the following classification system:


Classification of research results based on level of evidence


Research   on the effects of diagnostics on clinical outcomes in a prospectively   monitored, well-defined patient group, with a predefined policy based on the   test outcomes to be investigated, or decision analysis research into the   effects of diagnostics on clinical outcomes based on results of a study of   A2-level and sufficient consideration is given to the interdependency of   diagnostic tests.


Research   relative to a reference test, where criteria for the test to be investigated   and for a reference test are predefined, with a good description of the test   and the clinical population to be investigated; this must involve a large   enough series of consecutive patients; predefined upper limits must be used,   and the results of the test and the "gold standard" must be   assessed independently. Interdependence is normally a feature of situations   involving multiple diagnostic tests, and their analysis must be adjusted   accordingly, for example using logistic regression.


Comparison   with a reference test, description of the test and population researched, but   without the other features mentioned in level A.


Non-comparative   trials


Opinions   of experts, such as guideline development group members



Based on the medical literature, one or more relevant conclusions are made for each section. The most important literature is listed according to the level of evidential strength, allowing conclusions to be drawn based on the level of
evidence. All the medical literature included in the conclusion is described in the bibliography.


Classification of conclusions based on literature analysis


Based   on 1 systematic review (A1) or at least 2 independent A2 reviews.


Based   on at least 2 independent B reviews


Based   on 1 level A2 of B research, or any level C research


Opinions   of experts, such as guideline development group members


Other considerations

Based on the conclusion(s), recommendations are made. However, there are other considerations that contribute to formulation of the recommendation besides literature evidence, such as safety, the patients' preferences, professional expertise, cost-effectiveness, organisational aspects and social consequences. The other considerations are mentioned separately. In this manner, it is clear how the guideline development group arrived at a particular recommendation.



The final wording of the recommendation is the result of the scientific conclusion, taking into account the other considerations. The purpose of following this procedure and drawing up the guidelines  in this format is to increase transparency.



An alphabetical list of literature references can be found at the end of the guideline.


All draft texts have been discussed by the guideline development group.

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