Follow Up Care in the Community

2025/08/18

Cancer survivorship starts when a person is diagnosed with cancer and continues through the cancer journey and beyond. As a cancer survivor, your journey of cancer survivorship also includes your caregivers and loved ones who care for you. Once treatment is completed, in addition to looking out for side effects related to treatment and regular monitoring by your physician to detect recurrence, it is important that you stay well and… live well!

Working closely with our primary care providers, the Follow Up Cancer Care in the Community Programme launched in July 2018, focusing on follow-up cancer care for our cancer survivors in the community. As a cancer survivor, our programme aims to integrate and provide continuity of care for you back in the community you live in.

This programme will see NCIS transitioning routine cancer care for stable breast and colorectal cancer survivors to our community partners* such as selected GPs in the National University Health System primary care network, Keat Hong and Frontier Family Medicine Clinics (FMCs) and the six polyclinics under the National University Polyclinics (NUPs).

*Our partner GPs and physicians at the FMCs and polyclinics have undergone training and certified by NCIS to provide cancer survivorship care.

For more information, please click on the accordions below.

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Who is Eligible?

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

How Does it Work?

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.

List of Participating Primary Care Providers

All National University Polyclinics

Bukit Batok
Bukit Panjang
Choa Chu Kang
Clementi
Jurong
Pioneer
Queenstown

Family Medicine Clinics

GP Clinics

Click here for the List of HealthierSG GP Clinics

FAQs (Frequently Asked Questions)

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.
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.
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.
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.
What happens when I receive abnormal results?
You will be fast-tracked back to the hospital for further assessment by our specialists.
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.
What if I forget my appointment?
You may check the NUHS App, call + 65 6908 2222 / 6773 7888 or email us at [email protected].

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]