关键词: 乳腺癌, 全病程管理, 个案管理, 互联网平台, 智能随访

Abstract: Objective: To develop and validate a case manager-led, full-course management model for breast cancer. Methods: Guided by integration theory and the Rainbow Model of Integrated Care, the model was constructed through literature review, incorporating clinical guidelines, patient needs, and expert consensus. A non-concurrent controlled trial was conducted using convenience sampling. The control group included 130 patients treated from August 2022 to February 2023 and received routine care. The observation group included 114 patients treated from September 2024 to March 2025 and received full-course, case manager-led care delivered via both online and offline modalities across pre-hospital, in hospital, and post-hospital stages. Postoperative management efficacy and rehabilitation outcomes were compared between groups. Results: Compared with the control group, the observation group showed a significantly higher health education compliance rate, shorter follow-up intervals, and lower lymphedema incidence at 1, 6, and 12 months postoperatively (all P<0.05). The intervention group also demonstrated significantly higher quality-of-life scores and lower fear-of-cancer recurrence scores (all P<0.05). Conclusion: The case manager-led, full-course management model improves care efficiency, enhances rehabilitation outcomes, and promotes quality of life in breast cancer patients, supporting its broader implementation.

Key words: Breast cancer, Whole-course management, Case management, Internet platform, Intelligent follow-up