Digital Care Companion Brings Patient Voices Into Nurse-Led Breast Cancer Survivorship Care

When breast cancer treatment ends, many patients describe a strange sense of abandonment. The regular hospital visits stop, the surveillance scans become less frequent, and the clinical team that once surrounded them thins out just as new problems, from lymphoedema to anxiety and fatigue, begin to surface. A team at the Royal Melbourne Hospital in Australia has now tested a way to keep those patients connected to their care team without requiring them to walk through the hospital doors: a digital platform called Care Companion, built directly into the hospital’s electronic medical record and designed to collect patient-reported outcome measures, or PROMs, before nurse-led survivorship appointments.

The study, published in BMC Health Services Research, is described by its authors as the first Australian evaluation of electronic medical record-linked PROMs integrated into a nurse-led breast cancer survivorship clinic. It was a prospective pilot conducted between September 2022 and March 2024, enrolling women with breast cancer six to twelve months after they had completed their active treatment. The central question was practical rather than theoretical: would patients actually use a digital companion in the months after treatment, would they complete the questionnaires it delivered, and could their answers give breast care nurses a real-time window into symptoms and unmet needs before the consultation began?

The technology itself was a collaborative design effort rather than an off-the-shelf product. The hospital’s electronic medical record team worked alongside breast care nurses, surgeons and consumer representatives to build a platform that integrates and distributes electronic PROMs with automated reminders, gives clinicians real-time access to patient responses, and triages patients according to symptom severity ahead of clinic visits. That triage function is the technically significant piece. Instead of a nurse discovering a distressing symptom mid-consultation, the platform surfaces it in advance, allowing the clinical team to prioritise patients whose reported scores suggest they need more urgent or more intensive attention.

Patients invited to the nurse-led clinic were asked to complete three validated instruments through Care Companion four weeks before their appointment. Each measures a different dimension of recovery. The SCST, a screening tool for cancer-related concerns, achieved a completion rate of 98 percent, suggesting that patients found the most clinically focused questionnaire worth their time. The FACT-B + 4, which assesses quality of life across physical, emotional, social and functional domains with additional breast-cancer-specific items, was completed by 52 percent of participants. The Menopause Rating Scale, or MRS, relevant because many breast cancer survivors experience treatment-induced menopausal symptoms, reached 58 percent completion.

Those divergent completion rates are among the most instructive findings in the study. A near-universal response to the screening tool paired with roughly half of patients completing the longer quality-of-life instrument tells implementation researchers something important about digital burden: questionnaire length, relevance and perceived value all shape whether patients engage. The authors are candid that engagement was incomplete. Of the 133 patients invited to the nurse-led clinic, only 47, or 35.3 percent, completed the pre-clinic PROMs and attended. That uptake figure is the study’s sobering counterweight to its enthusiasm, and the team explicitly states that further refinement is required to improve patient engagement and fully realise the potential of digital survivorship care models.

Where patients did engage, however, their response was strikingly positive. In a satisfaction survey administered to a subset comprising ten percent of participants, 100 percent reported satisfaction with the program and said they would recommend the Care Companion breast survivorship program to others. Among respondents, 89 percent felt able to complete the tasks, felt actively involved in their care, found the platform easy to use, and were comfortable using the devices required. For a hospital-built tool rather than a polished commercial app, those usability numbers carry real weight, particularly given that the cohort spanned a wide age range of women who did not grow up with smartphones.

The clinical logic behind the platform rests on a well-documented gap in oncology care. Survivorship is the phase in which many of the long-term and late effects of treatment emerge, yet it is also the phase with the least structured contact between patients and their treating teams. Breast care nurses sit at the centre of the Australian response to that gap, coordinating follow-up, managing symptoms and providing psychosocial support, often with limited visibility into how patients are coping between appointments. PROMs are designed to close that visibility gap by systematically capturing what patients experience, rather than relying on symptoms to be volunteered opportunistically during a consultation. Evidence from oncology more broadly has repeatedly shown that routine symptom monitoring can improve outcomes, but translating that evidence into routine practice has proven difficult, which is precisely why an EMR-embedded approach is significant.

Embedding the platform in the electronic medical record, rather than running it as a standalone app, solves several chronic problems of digital health pilots at once. Patient responses flow into the same record clinicians already use, so there is no separate portal to check and no duplicate data entry. Automated reminders can be triggered from scheduling data without manual chasing. And because the platform was built by the hospital’s own EMR department in collaboration with the nurses who would use it, the workflow reflects the realities of a survivorship clinic rather than the assumptions of an external software vendor. The trade-off is that such bespoke systems require institutional investment and maintenance, and their portability to other hospitals with different record systems is not guaranteed.

The study’s limitations are those of a pilot. It was conducted at a single centre, the number of patients who completed both the PROMs and the clinic visit was modest, and the satisfaction survey sampled only a small subset of participants, which makes the 100 percent satisfaction figure encouraging but statistically fragile. The authors do not claim that the platform improved clinical outcomes; the secondary aim of the study was simply to describe patient-reported outcomes, not to test whether digital monitoring changed them. What the study does establish is feasibility and acceptability in an Australian public hospital context, filling a documented gap in the local literature on digitally enabled survivorship models.

The broader significance lies in what comes next. If digital companions like Care Companion can raise their engagement rates, perhaps through shorter instruments, better-timed reminders or targeted support for patients less comfortable with technology, they could transform nurse-led clinics from episodic check-ins into continuously informed encounters. The Royal Melbourne team has demonstrated that the plumbing works: patients will answer questionnaires on a hospital-built platform, nurses can read the answers before the patient arrives, and the patients who do engage overwhelmingly approve of the experience. The unfinished work, as the authors acknowledge, is persuading the majority who did not engage to join them, and proving that this richer stream of patient-reported data ultimately translates into better survivorship care.

Subject of Research: Digital patient-reported outcome measures in nurse-led breast cancer survivorship care

Article Title: Introduction of a digital care companion to facilitate patient reported outcome measures and breast care nurse-led survivorship

Article References: Mao, C., Shanahan, K., Keen, R., Louie, J., Vu, M., Fazio, T., Boulton, A., Alvandi, A. O., & Skandarajah, A. (2026). Introduction of a digital care companion to facilitate patient reported outcome measures and breast care nurse-led survivorship. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15796-1

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15796-1

Keywords: breast cancer, survivorship care, patient-reported outcome measures, digital health, nurse-led clinic, electronic medical record, breast care nurses, e-health, health services research, patient engagement, quality of life, Australia