Guideline oncological aftercare in primary care

November 2, 2022

Every year, about 36,000 people are diagnosed with cancer in Belgium. The majority survive this diagnosis, but these so-called cancer survivors are confronted with all kinds of side effects of the cancer (treatment). The most frequently reported complaints are fatigue, pain, cognitive but also psychosocial problems. The restrictions and participation problems that go along, often hinder or prevent the reintegration of the cancer survivor in his or her daily activities.

The rehabilitation for this often combined and heterogeneous symptomatology can take place in a hospital, but also in primary care closer to the patient home with general practitioner, physiotherapist, home nurse and/or psychologist. However, the following barriers are identified for ensuring a qualitative and person-centered care:

  • unclear agreements on task division among various care institutions and providers
  • communication difficulties across different care settings
  • the individual patient's combined and heterogeneous symptomatology
  • (educational) assistance with optimal patient guidance

To address these barriers, the Federal Public Service Health, Food Chain Safety and Environment commissioned and funded a project group to create a multidisciplinary good clinical practice guideline on oncology aftercare in primary care. This follows the international standards for the development of an evidence-based guideline and the criteria used by the Belgian Centre for Evidence-Based Medicine (CEBAM) for the validation of guidelines. The project group is made up of a multidisciplinary core consortium of academic partners from both sides of the country (guideline development group), as well as a large network of stakeholders (Figure 1). The guideline development group possesses expertise in guideline development as well as a broad understanding of the patient in his or her biopsychosocial context.

Figure 1

Figure 1. Overview of different members of the guideline development group and stakeholder group

Ultimately, the guideline will answer the following two clinical questions:

1) Which biomedical and biopsychosocial interventions should or should not be done to improve the outcome of the rehabilitation process in oncology patients?

2) In what way should the cooperation between the involved caregivers take place and what agreements should be made to improve the outcome of the rehabilitation process?

Starting from these two clinical questions, the following specific research questions were identified in collaboration with the guideline development group and the input of the stakeholder group. Questions describe the target intervention. Further details regarding the target population and outcome measures are provided in Table 1.

1) Specific research questions regarding INTERVENTIONS

A. Which biomedical interventions (e.g. pharmacological treatments) are appropriate in oncology patients during the different phases of aftercare?
B. What physical rehabilitation interventions (sports and exercise, manual therapy, psychomotor therapy, exercise therapy) are appropriate in oncology patients during the different phases of aftercare?
C. What lifestyle recommendations (exercise, nutrition, sleep, limited alcohol intake, no smoking, supplements) are appropriate in oncology patients during the various phases of aftercare?
D. What psychosocial support (e.g. self-care and management, mindfulness) are appropriate in oncology patients during the different phases of aftercare?

2) Specific research questions regarding COOPERATION

A. What tools and procedures identify the capacity of different disciplines to contribute to the biomedical and psychosocial needs of individual oncology patients in primary care, including vulnerable audiences?
B. What tools and procedures can be used to plan the distribution of tasks and functions among providers involved in the primary care of oncology patients, including vulnerable populations?
C. What tools and procedures formalize (regulations, structures, financing) the collaborations within primary care on the one hand, and between primary and secondary care on the other, in order to stabilize them and allow for adaptation to the needs of professionals and to the medical and psychosocial needs of the population?
D. What are the tasks that fall under the umbrella of coordination and how are they integrated (e.g., coordinator) to allow for adaptation to the needs of the providers and the biomedical and psychosocial needs of the oncology patient, including vulnerable populations?
E. What tools and procedures are used for communication (e.g., face-to-face, remote, by file, with what vocabulary) with patients and between providers involved in oncological aftercare in primary care to meet the needs of providers and the biomedical and psychosocial needs of the cancer patient, including vulnerable populations?
F. What skills are relevant for collaboration among primary care professionals and how can they be developed?

Table 1. Detailed information regarding the population and outcome measures that will be addressed in the guideline.

Population of interest

Oncology patients who are not hospitalized, after completion of intensive specialist treatment. Both patients in remission and chronic patients who can no longer be treated curatively are eligible, however not in a palliative stage.

Professionals targeted

General practitioners, physiotherapists, psychologists, exercise coaches, primary care nurses, oncologists

Outcome and endpoints of interest

  • Physical and psychological needs of patients: pain, fatigue, anxiety, depression, physical function, cardiopulmonary function, quality of life, perceived stress, acceptance, existential wellbeing
  • Social needs of patients: employment, participation in daily activities, participation in social life, satisfaction with sexual and emotional quality of life
  • Professional needs: improved collaboration among providers, burnout among out among professionals, job satisfaction of professionals; respective roles of professionals, motivation of professionals, conflict management, ability to innovate
  • Reduction of social inequalities in health: access to services, acceptance of proposed treatments; cost of services for patients, cost of services for the patient, participation of patients in decision-making

Healthcare setting and context

Primary care setting e.g. general practice and other ambulatory care providers, home setting


Up to now, relevant literature has already been identified and evaluated for quality in a thorough literature review. The following phase will involve formulating a draft version of clinical recommendations in response to the clinical questions, which will then undergo internal and external review for content and applicability. The guideline is expected to be finalized in the summer of 2023.


Blog post written by: Dams Lore, PhD

In the name of principal investigators:

van Olmen Josefien

De Groef An

Van Royen Paul

Van Puyenbroeck Karolien