Follow Up Care in the Community

Breast and colorectal cancer patients who are no longer on active treatment and have gone through > 5 years of cancer surveillance in the hospital.

*To note: Suitable patients will be identified by their physicians for the transfer of care. Patients can choose from a list of primary care providers in partnership with the NCIS for their continuity of care in the community. If you are not sure of your eligibility, please check with your doctor.

Programme Benefits

• More convenient locations
• Less waiting at the hospital

Breast Cancer Survivors

You will have your annual follow-up with your primary care provider and fast track back to NUH for further assessment, if abnormal results are being detected in your annual screening mammogram. Subsidised annual mammogram will be done under Breast Screen Singapore (BSS) in one of the National University Polyclinics. Non-subsidised annual mammogram will be done in NUH.

Colorectal Cancer Survivors

You will have your annual follow-up with your primary care provider and fast track back to NUH for further assessment, if abnormal results are being detected in your surveillance colonoscopy. Your surveillance colonoscopy will be done once every 3 - 5 years in NUH.

All National University Polyclinics

• Bukit Batok
• Bukit Panjang
• Choa Chu Kang
• Clementi
• Jurong
• Pioneer
• Queenstown

Singhealth Polyclinics

• Bedok
• Bukit Merah
• Eunos
• Marine Parade
• Outram*
• Pasir Ris
• Punggol
• Sengkang
• Tampines
• Tampines North*

Notes:

*For eligible colorectal cancer survivors, the discharge will only be piloted in Tampines North and Outram polyclinics for now until further notice.

All SHP sites are now ready to accept eligible breast cancer survivors on the Cancer Survivorship Programme.

Family Medicine Clinics

• Frontier Family Medicine Clinic @ Clementi
• Keat Hong Family Medicine Clinic @ Choa Chu Kang
• Lakeside Family Medicine Clinic @ Jurong West

GP Clinics

Click here for the List of HealthierSG GP Clinics

How to book a breast mammogram in the community?

Breast cancer survivors discharged to the community are eligible for annual mammogram screenings.

Breast cancer screening services are offered at selected polyclinics:

How much does a screening mammogram cost? 

The cost of a mammogram is more than $100. HPB subsidises the cost of your mammogram under Healthier SG Screening.

The remaining amount for you to pay after the subsidy is:

1. What is Cancer Survivorship in the Community?
   Cancer Survivorship in the Community is a programme that focuses on follow-up cancer care for survivors. By working closely with our primary care providers, we aim to integrate and provide continuity of care for patients back in the community.
   
   
2. I’ve been told that I’ve been discharged from NCIS. What’s next?
   A care coordinator will be in touch to brief you on the details. Depending on your choice of primary care partner, an appointment may be scheduled for you. Please attend your scheduled appointment and bring your NCIS Cancer Treatment Summary and Survivorship Care Plan along.
   
   
3. What is the NCIS Cancer Treatment Summary and Survivorship Care Plan?
   It is a document that contains information on the cancer treatment that you have received at NCIS and screening recommendations to keep you well. This information is essential for your subsequent care.
   
   
4. Will the primary care doctors know what to look out for and how to continue my care plan?
   Yes, the primary care doctors whom you will be referred to have the necessary skills and knowledge to follow-up on your condition. Your general health and wellbeing will also be looked after through regular screening.
   
   
5. What happens when I receive abnormal results?
   You will be fast-tracked back to the hospital for further assessment by our specialists. 
   
   
6. If I am a subsidised patient and have my follow-up done at a GP / FMC, will I become a private patient if I am fast-tracked back to hospital to see a specialist? 
   Your subsidised status will be retained if you are a CHAS/Pioneer Generation/Merdeka Generation card holder referred from a CHAS GP clinic.
   
   
7. What if I forget my appointment?
   You may check the NUHS App, call + 65 6908 2222 / 6773 7888 or email us at [email protected].
   
   

General FAQs

1. What is Follow-Up Cancer Care in the Community? 
   Follow-Up Cancer Care in the Community is a programme that focuses on follow-up care for cancer survivors. By working closely with our primary care providers (PCPs), we aim to integrate and provide continuity of care for patients into the community
   
   
2. What is my responsibility as a primary care provider (PCP) if I receive a cancer survivor?
   As a PCP, your key roles include:
   • Monitoring for cancer recurrence or new symptoms
   • Managing chronic conditions and treatment-related side effects
   • Promoting preventive health (e.g. screenings, vaccinations)
   • Supporting mental health and psychosocial needs
   • Coordinating referrals back to specialists when needed
   You will receive a Survivorship Care Plan (SCP) to guide follow-up care. Cancer survivorship follow-up in primary care includes but is not limited to:
   
   Breast Cancer Survivors
   • Annual Mammogram (or as per SCP care plan recommendations)
   • Annual clinical breast examination (CBE) (or annual chest wall examination if patient had bilateral mastectomy)
   • Health screening for chronic diseases and cervical / colon cancer
   • Vaccinations (if recommended) 
   • Bone monitoring (if age appropriate)
   • Advise patient to continue monthly breast self-examination
Colorectal Cancer Survivors
• Colorectal cancer screening 
• Repeat colonoscopy 3-5 years from the last colonoscopy 
• Health screening for chronic diseases (for men and women) and breast / cervical cancer (for women) 
• Vaccinations (if recommended) 
• Bone monitoring (if age appropriate)
3. What should I do if patient has abnormal symptoms?
   
   Escalation Criteria for Breast Cancer Survivors
   Persistent symptoms such as:

• Blood in stools
• Per rectal bleeding
• Change in bowel habits
• Unintended weight loss
• Abdominal pain, cramps, or discomfort
• Sensation of bowel not emptying completely
• Anaemia
• Fatigue or weakness

If you notice symptoms suspicious of cancer recurrence or treatment complications, the patients can be referred back to be seen by their cancer care team within 2 weeks:

• For Polyclinic Doctors:
  • Refer the patient directly to their original Breast Surgery or Oncology care team.
  • Contact NCIS Case Manager at [email protected] if required further or urgent assistance.
• For General Practitioners (GPs):
  • Contact the Coordinator at NUHS Regional Health System Office (RHSO) Primary Care Liaison Team (PCLT) team at [email protected]
  • Contact the survivorship team (doctor, nurse, or coordinator) listed in the Survivorship Care Plan (SCP)

Breast FAQs

1. How is mammogram screening arranged in primary care?
   The National Cancer Institute Singapore (NCIS) case manager will assist patients in scheduling the first BreastScreen Singapore (BSS) mammogram upon referral to primary care. Patients are encouraged to manage their own screening appointments thereafter. However, your clinic coordinator can assist patients who need help with scheduling their routine mammograms.
   
   
2. Are breast cancer survivors eligible for mammogram screening at BreastScreen Singapore(BSS)?
   Breast Cancer survivor is eligible for BSS mammogram if:
• She has not had breast cancer in the past 5 years and has been discharge to the community
• She has not been breastfeeding in the past 6 months
• She has no symptoms such as lumps or pain in her breasts

Note: Mammograms for breast cancer survivors should be done annually regardless of age.

3. Is a breast cancer survivor with breast implant(s) eligible for BSS Mammogram?
   Yes. Breast cancer survivors with breast implant(s) will need to undergo screening mammograms at designated restructured hospitals (BSS assessment centre). The same screening fees apply.
   
   
4. How much does breast cancer screening (BSS Mammogram) cost and what does it cover?(Cited from Healthier SG Screening – National Health Screening Programme)
   
   Under Healthier SG Screening, the subsidised mammogram at participating screening centres cost:
• Pioneer Generation cardholders: $25
• Merdeka Generation cardholders: $37.50
• Eligible Singapore Citizens: $50
• Permanent Residents: $75

If you are 50 years old or above, you may use your Medisave or the Medisave of an immediate family member for your mammogram at Medisave-approved centres, including those under the Medisave500 scheme.

For eligible Singapore Citizens who are enrolled with Healthier SG, you will enjoy additional subsidies for your screening mammogram test (i.e. $0).

5. Can I access the BSS mammogram report?
   Yes, you can. The reports are available in NEHR. Under "Screening/Indicators" and "Medical Screening", you will find the binary report showing either normal or abnormal results. If abnormal, the patient will need to be referred to their nearest BSS mammogram assessment centre.
   
   
6. If I do not have access to NEHR, how can i access BSS mammogram reports?
   There are two ways to access the reports:
1. Ask patients to bring their BSS Mammogram result letter to their consultation.
2. If you wish to receive a BSS result letter, complete the CHAS referral form for the patient to bring to BSS Screening Centre, ensuring you indicate your clinic name and programme name (Breast Cancer Survivorship Programme).
7. What should I do if the patient has an abnormal mammogram report from BreastScreen Singapore (BSS)?
   BreastScreen Singapore (BSS) will send mammogram results directly to patients via post. The letter will indicate whether the mammogram findings are normal or abnormal. Patients with abnormal results will receive specific instructions in their letter directing them to schedule an appointment at their nearest BSS mammogram assessment centre (located at a restructured hospital) for further evaluation. Please verify that the patient has made their follow-up arrangements. If she has not done so, please assist the patient directly or engage your clinic coordinator to help with appointment scheduling.
   
   
8. What should I do if patients decline their annual mammogram?
   If a patient declines the annual mammogram:
• Document the patient's decision in their medical records
• Explore and address their concerns or reasons for declining
• Provide education about the importance of regular screening for breast cancer surveillance
• Ensure they understand the risks of missing regular screenings
• Continue to offer screening at subsequent visits
• Perform annual clinical breast examinations during their annual reviews.
• Advise patient to do monthly breast self-examination.
9. Am I responsible for arranging annual mammogram and appointments for breast cancer survivors?
   Yes. Through the cancer survivorship shared care model, primary care providers (PCPs) play a supportive role in breast cancer surveillance. Under the Survivorship Care Plan (SCP), PCPs are advised to continue cancer survivorship care with patients by offering (scheduling?) annual clinical breast examinations and ensuring that patients complete their annual mammogram with BreastScreen Singapore (BSS). While patients are encouraged to manage their own appointments, PCPs or clinic coordinators should provide guidance and assistance when needed.
   
   
10. Is the BSS mammogram adequate?
    Yes. BSS mammograms are read by Radiologists. The BSS mammogram is deemed adequate by Breast Surgeons, Radiologist and Oncologists.
    
    
11. Are mammograms from Specialist Outpatient Clinics (SOC) different from Breast Screen Singapore (BSS)?
    No. The mammogram imaging technology and reporting standards are the same for both services. The main differences are:
• SOC mammograms are diagnostic screenings ordered by specialists for patients under their care
• BSS mammograms are part of the national screening programme for eligible women in the community
12. What is the difference in mammogram under Screen for Life and HealthierSG?
    The Screen For Life (SFL) programme has been renamed Healthier SG Screening. Under Healthier SG Screening, eligible Singapore Citizens and Permanent Residents will continue to enjoy the same subsidised screening tests provided under SFL today. There is no change to the benefits that are provided today with the change in name.
    
    
13. At what age should mammogram screening stop for breast cancer survivors?Generally, annual screening should continue until at least age 75, but the decision should be individualised after discussion with the patient.
    
    Key considerations for continuing or stopping screening include:
• Overall health status and comorbidities
• Life expectancy (consider stopping if less than 5 years, continue if more than 10 years and in good health)
• Patient preferences
• Risks and benefits of ongoing screening

Note that HPB/Screen for Life/HSG programmes support screening beyond age 70 for patients discharged from specialist care. Primary care providers should refer to the Survivorship Care Plan (SCP) for guidance and discuss these factors during routine reviews.

14. Is annual BMD testing necessary for breast cancer survivors? Can primary care providers revert to less frequent testing as per usual outpatient practice?
    Yes, primary care providers can follow standard risk-based testing intervals rather than routine annual testing. The recommended freqency should be based on the patient's BMD status:
    
    Recommeded Testing Intervals
    
    1. For patients with normal BMD (> -1 SD below young adult mean):
       • Test every 2-5 years
       • For patients with stable bone health and no new risk factors
    2. For patients with osteopenia (BMD 1-2.5 SD below young adult mean):
       • Test every 1-2 years
    3. For patients with osteoporosis:
       • Test at minimum yearly intervals for monitoring disease progression and treatment response assessment

Note that HPB/Screen for Life/HSG programmes support screening beyond age 70 for patients discharged from specialist care. Primary care providers should refer to the Survivorship Care Plan (SCP) for guidance and discuss these factors during routine reviews.

Colorectal FAQs

1. What should I do if patient has abnormal scope?
   Our medical team will schedule a follow-up appointment at the clinic. During this visit, the doctor will review the scope results and explain the findings and implications. Moving forward, they will discuss any further necessary tests or procedures and outline the potential treatment options.
   
   

This ensures that the patient fully understands their results and is involved in decisions about their ongoing care and management.

2. How to refer patient for colonoscopy?
   There are two main pathways to get a referral for a colonoscopy:


Subsidised Status:

• Visit your nearest polyclinic or Chas-approved GP clinic
• Obtain a referral letter to NUH Colorectal Clinic
• NUH will schedule an initial physical consultation in which your colonoscopy will be arranged during this consultation

Private Status (with choice of preferred doctor):


You may either contact NUH Colorectal Clinic directly, or

• Visit any GP or polyclinic to obtain a referral letter to NUH Colorectal Clinic specifying your preferred doctor
• NUH will schedule an initial physical consultation in which your colonoscopy will be arranged during this consultation

Please take note that the private route allows you to choose your doctor but will have different cost implications compared to the subsidized option.

3. Any alternatives if patients refused colonoscopy?
   There are several alternative screening options for colorectal cancer, though colonoscopy is generally considered the most comprehensive method. Alternatives include:
1. Fecal Immunochemical Test (FIT) or Fecal Occult Blood Test (FOBT): Collects a small stool sample at home using a special kit, which is then sent to a laboratory for analysis to detect the presence of blood.
2. CT Colonography (Virtual Colonoscopy): Uses X-rays and computers to produce images of the entire colon.
3. Flexible Sigmoidoscopy: Examines only the lower part of the colon whereas Colonoscopy examines the entire colon.
4. Barium Enema: An X-ray examination of the colon and rectum.

These alternatives may be less invasive but might not be as thorough as a colonoscopy. Some may need to be done more frequently than a colonoscopy. If these tests show abnormalities, a follow-up colonoscopy may still be necessary. Discuss with your doctor to determine the most appropriate option for you based on your individual risk factors and medical history.

Contact Us

To find out more about this programme, please reach us via the following channels:

Appointment-related enquiries:

Call +65 6908 2222 or email us at [email protected].

Cancer survivorship programmes:

Call +65 9836 8204 or email us at [email protected]