Abstract: Objective To establish whole process management of breast cancer with general characteristics in general hospital, explore general management mode as chronic disease. Methods By referring to domestic and foreign literature related to the diagnosis、treatment and management of breast cancer, and referring to the disease management process in breast department of our hospital, a whole-process management of breast cancer suitable for the general practice was constructed. Results Step 1, to conduct individualized lifestyle education through the search of risk factors. Step 2, prevention and management of related complications and side effects during the therapy, adhere the standard treatment. Step 3, follow up after discharge to prevent recurrence and manage long-term side effects concomitant diseases. Conclusion The standard process management of breast cancer embodies the concept of general practice, and effectively realizes the whole-process chronic disease management of breast cancer.

Key words: breast cancer, whole process management, general practice

摘要： 目的 建立综合医院有全科特色的乳腺癌全程管理流程,探索乳腺癌全科慢病管理模式。方法 通过查阅国内外乳腺癌诊治、管理相关文献,参考我院乳腺专科的疾病管理流程,构建适合全科的乳腺癌全程管理流程。结果 流程第一步,通过危险因素查找,进行个体化生活方式教育;第二步,治疗期间预防和治疗相关并发症、副作用、坚持规范治疗;第三步,出院后随访,预防复发、管理远期副作用、伴随疾病。结论 体现全科理念的乳腺癌标准流程管理,有效实现了乳腺癌全人全程慢病管理。

关键词: 乳腺癌, 慢病管理, 全科