Ietje Perfors

10 Chapter 1 Continuity of care In general, the cancer care trajectory consists of different phases: (prevention), diagnosis, choice of treatment, delivery of treatment, survivorship care (that entails follow-up care and palliative care) and end- of-life-care. In countries with gatekeeper systems, like in the Netherlands, there is a strict difference between primary care (e.g. general practitioner (GP)) and hospital care (i.e. secondary care and tertiary care). In the traditional cancer care pathway the GP refers patients for diagnostic workup in the hospital, and in case of confirmation of the cancer diagnosis, delivery of treatment (including the treatment choice), follow-up and palliative care are provided in the hospital. Typically, treatment options are discussed in a multidisciplinary specialist team, following guideline recommendation. Hereafter, options are discussed by the treating physician with the patient. Treatment is delivered by amultidisciplinary team(including oncology nurses). When treatment is given with a curative intent, follow up care in the first 2-5 years is usually provided by care professionals in the hospital. Afterwards, patients are dismissed with sometimes the exception of an annual control visit. In case of a palliative setting, which may cover several years and is usually characterized by sequential tumour-targeted treatments, patients continue to be under the guidance and supervision of the multidisciplinary team in the hospital. When a terminal phase has been reached the care will usually be mainly provided by the general practitioner (GP). The role of the GP at the start of the cancer journey is clear. The majority of the symptomatic patients visit their GP first, including patients with cancer types for which a screening program exists. 19 The key task of the GP is to identify those at increased risk for cancer and refer them for diagnostic work- up to the hospital. The responsibilities of the GP during the curative and palliative treatment of cancer are less well defined. 20 The extent to which GPs are involved following a cancer diagnosis varies. In general, the GP is informed about the diagnosis by phone or by mail after the multidisciplinary team in the hospital has