Download Prostate Cancer Treatment Pathway

Prostate Cancer Treatment Pathway
Version 2015.11
Disclaimer
The pathway is intended to be used for informational purposes only. The pathway is not intended to
constitute or be a substitute for medical advice and should not be relied upon in any such regard.
Further, all pathways are subject to clinical judgment and actual practice patterns may not follow the
proposed steps set out in the pathway. In the situation where the reader is not a healthcare provider,
the reader should always consult a healthcare provider if he/she has any questions regarding the
information set out in the pathway. The information in the pathway does not create a physician-patient
relationship between Cancer Care Ontario (CCO) and the reader.
Pathway Preamble
Target Population
Patients with a confirmed prostate cancer diagnosis who have undergone the recommended diagnostic and staging procedures outl ined
in the Prostate Cancer Diagnosis Pathway.
Pathway Considerations
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Primary care providers play an important role in the cancer journey and should be informed of relevant tests and consultation s.
Ongoing care with a primary care provider is assumed to be part of the pathway. For patients who do not have a primary care
provider, Health Care Connect is a government resource that helps patients find a doctor or nurse practitioner.
Throughout the pathway, a shared decision-making model should be implemented to enable and encourage patients to play an
active role in the management of their care. For more information see Person-Centered Care Guideline and
EBS #19-2 Provider-Patient Communication*
Hyperlinks are used throughout the pathway to provide information about relevant CCO tools , resources and guidance documents.
The term health care provider , used throughout the pathway, includes primary care providers and specialists, nurse practitioners,
and emergency physicians
For more information on Multidisciplinary Cancer Conferences visit: MCC Tools
For more information on wait time prioritization, visit: Surgery, Systemic therapy and Radiation wait time prioritization
Clinical trials should be considered for all phases of the pathway.
Psychosocial care should be considered an integral and standardized part of cancer care for patients and their families at al l stages
of the illness trajectory. For more information visit EBS #19-3
The following should be considered when weighing the treatment options described in this pathway for patients with potentiall y lifelimiting illness:
Palliative care may be of benefit at any stage of the cancer journey , and may enhance other types of care – including
restorative or rehabilitative care – or may become the total focus of care
Ongoing discussions regarding goals of care is central to palliative care, and is an important part of the decision-making
process. Goals of care discussions include the type, extent and goal of a treatment or care plan, where care will be provided,
which health care providers will provide the care, and the patient s overall approach to care.
For more information on the systemic treatment QBP please refer to the Quality-Based Procedures Clinical Handbook for
Systemic Treatment
* Note. EBS #19-2 is older than 3 years and is currently listed as
For Education and Information Purposes . This means that the recommendations will no
longer be maintained but may still be useful for academic or other information purposes.
Confidential Draft
For Review Only
Version
Version 2015.11
yyyy.mm Page 22 of
of 11
11
Pathway Legend
Shape Guide
Colour Guide
Intervention
Primary Care
Decision or assessment point
Supportive and End of Life Care
Patient (disease) characteristics
Pathology
Consultation with specialist
Exit pathway
Diagnostic Assessment Program (DAP)
X
Surgery
or
X
Prostate Cancer Treatment Pathway
Off-page reference
Patient path
Radiation Oncology
Medical Oncology
R
Referral
Radiology
W
Wait time indicator time point
Multidisciplinary Cancer Conference (MCC)
Line Guide
Required
Possible
Pathway Disclaimer
This pathway is a resource that provides an overview of the treatment that an individual in the Ontario cancer system may
receive.
The pathway is intended to be used for informational purposes only. The pathway is not intended to constitute or be a
substitute for medic al advice and should not be relied upon in any such regard. Further, all pathways are subject to clinical
judgment and actual practice patterns may not follow the proposed steps set out in the pathway. In the situation where the
reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions
regarding the information set out in the pathway. The information in the pathway does not create a physician-patient
relationship between Cancer Care Ontario (CCO) and the reader.
While care has been taken in the preparation of the information contained in the pathway, such information is provided on
an as-is basis, without any representation, warranty, or condition, whether express, or implied, statutory or otherwise, as
to the information s quality, accuracy, currency, completeness, or reliability.
CCO and the pathway s content providers (including the physicians who contributed to the information in the pathway) shall
have no liability, whether direct, indirect, consequential, contingent, special, or incidental, related to or arising from the
information in the pathway or its use thereof, whether based on breach of contract or tort (including negligence), and even if
advised of the possibility thereof. Anyone using the information in the pathway does so at his or her own risk, and by using
such information, agrees to indemnify CCO and its content providers from any and all liability, loss, damages, costs and
expenses (including legal fees and expenses) arising from such person s use of the information in the pathway.
This pathway may not reflect all the available scientific research and is not intended as an exhaustive resource. CCO and
its content providers assume no responsibility for omissions or incomplete information in this pathway. It is possible that
other relevant scientific findings may have been reported since completion of this pathway. This pathway may be
superseded by an updated pathway on the same topic.
© CCO retains all copyright, trademark and all other rights in the pathway, including all text and graphic images. No portion of this pathway may be used or reproduced, other than for personal use, or distributed, transmitted or "mirrored" in any form, or by any means, without the prior written permission of CCO.
Prostate Cancer Treatment Pathway
Low Risk
Version 2015.11 Page 3 of 11
The pathway is intended to be used for informational purposes only. The pathway is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathways are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the
pathway. In the situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions regarding the information set out in the pathway. The information in the pathway does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the
reader.
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Consider the introduction of palliative care, early and across the cancer journey. Click here for more information about palliative care.
Watchful Waiting
Ongoing assessment for symptoms and monitoring development
of metastatic disease. Frequency up to dis cretion of managing
physician
PSA Test, DRE, Imaging as indicated
No
From
Diagnosis
Pathway
(Page 5)
Low Risk
(must include all of
the following):
T1-T2a,
Gleason score 6,
PSA 10ng/mL
R
Assess candidacy
for curative
treatment
(e.g. comorbidities,
life expectancy,
patient preference)
MCC
Life expectancy <10 years
Yes
PSA Test every
3-6 months
DRE every year
Urologist
Patient
considers
options
Patient s
treatment
decision
Patient education
regarding treatment
options
Active Surveillance EBS #17-9
Confirmatory
TRUS biopsy Serial biopsy at
within 6-12
a minimum
months
every 3-5 years
(minimum 12
thereafter
cores)
Radical Prostatectomy
Open, laparoscopic or robotic-assisted
EBS #17-3
W
Standard Pelvic Lymph Node
Dissection
EBS #17-3
.
Quality-Based Procedures
Clinical Handbook for
Cancer Surgery
External Beam
Radiation Therapy
W
1
A
Proceed
to Page 8
Patient
candidate for
curative
treatment?
Consultations to
discuss ALL
treatment options
Radiation
Oncologist1
Progression to
metastatic
prostate cancer
If low risk prostate cancer patients are seeking definitive treatment, a radiation oncology consultation should be sought.
Or
Brachytherapy
EBS #3-10
Peer Review
Multiparametric MRI
if discordance
between clinical and
pathological findings
or suspected disease
progression
Patient preference
Or
meets defined
progression or
reclassification criteria
Proceed to
Appropriate
Active
Treatment
EBS #17-9
B
Proceed
to Page 6
Proceed to
Prostate
Cancer
Follow-up
Pathway
Prostate Cancer Treatment Pathway
Intermediate Risk
Version 2015.11 Page 4 of 11
The pathway is intended to be used for informational purposes only. The pathway is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathways are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the
pathway. In the situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions regarding the information set out in the pathway. The information in the pathway does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the
reader.
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Consider the introduction of palliative care, early and across the cancer journey. Click here for more information about palliative care.
Watchful Waiting
Ongoing assessment for symptoms and monitoring development
of metastatic disease. Frequency up to dis cretion of managing
physician
PSA Test, DRE, Imaging as indicated
No
From
Diagnosis
Pathway
(Page 5)
Intermediate
Risk
Any one of the following:
PSA 10-20, Gleason score
7, T2b, and asymptomatic
for metastases
R
Assess candidacy
for curative
treatment
(e.g. comorbidities,
life expectancy,
patient preference)
MCC
Radiation
Oncologist
Radical Prostatectomy
Open, laparoscopic or robotic-assisted
EBS #17-3
Yes
W
Standard Pelvic Lymph Node
Dissection
EBS #17-3
D
Proceed
to Page 6
Quality-Based Procedures
Clinical Handbook for
Cancer Surgery
Patient
considers
options
Patient s
treatment
decision
Radiation therapy according to
Radiation Oncologist opinion3
Brachytherapy
EBS #3-10
Patient education
regarding
treatment options
Or
W
External Beam Radiation
Therapy
Or
Combined Modality Treatment
(Brachytherapy and External
Beam Radiation Therapy)
2 Active surveillance may
C
Proceed
to Page 8
Patient
candidate for
curative
treatment?
Consultations to
discuss ALL
treatment
options2
Urologist
Progression to
metastatic
prostate cancer
be considered for a highly selective subset of patients in the intermediate risk group
presenting with the following features: Stage T2 Gleason score 7/10 (3+4) with < 10% of total tumor pattern
Gleason 4 and patient life expectancy 10-15 years, refer to EBS #17-9
3Neoadjuvant/adjuvant androgen deprivation therapy can be considered for select patients.
Peer Review
Proceed to
Prostate
Cancer
Follow-up
Pathway
Prostate Cancer Treatment Pathway
High Risk/Locally Advanced
Version 2015.11 Page 5 of 11
The pathway is intended to be used for informational purposes only. The pathway is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathways are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the
pathway. In the situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions regarding the information set out in the pathway. The information in the pathway does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the
reader.
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Consider the introduction of palliative care, early and across the cancer journey. Click here for more information about palliative care.
Watchful Waiting
Ongoing assessment for symptoms and monitoring development
of metastatic disease. Frequency up to dis cretion of managing
physician
PSA Test, DRE, Imaging as indicated
No
From
Diagnosis
Pathway
(Page 5)
High Risk
Any one of the
following:
T2c or higher,
Gleason score 8,
PSA 20ng/mL, and
select patients with
nodal involvement
R
Assess candidacy
for curative
treatment
(e.g. comorbidities,
life expectancy,
patient preference)
MCC
Radical Prostatectomy
Open, laparoscopic or robotic-assisted
EBS #17-3
Yes
Consultations to
discuss ALL
treatment
options
Radiation
Oncologist
E
Proceed
to Page 8
Patient
candidate for
curative
treatment?
W
Urologist
Progression to
metastatic
prostate cancer
F
Proceed
to Page 6
Standard Pelvic Lymph Node
Dissection
EBS #17-3
Quality-Based Procedures
Clinical Handbook for
Cancer Surgery
Patient
considers
options
Patient s
treatment
decision
Patient education
regarding
treatment options
W
Neoadjuvant
Optimize
Androgen
bone
Deprivation
health
Therapy
External Beam
Radiation Therapy
Peer Review
Adjuvant
Androgen
Deprivation
Therapy
Optimize
bone
health
Proceed to
Prostate
Cancer
Follow-up
Pathway
Prostate Cancer Treatment Pathway
Low/Intermediate/High Risk continued
Version 2015.11 Page 6 of 11
The pathway is intended to be used for informational purposes only. The pathway is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathways are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the
pathway. In the situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions regarding the information set out in the pathway. The information in the pathway does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the
reader.
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Consider the introduction of palliative care, early and across the cancer journey. Click here for more information about palliative care.
G
Proceed
to Page 8
Positive
B
D
F
H
No
From Pages 3,
4, 5 (Radical
Prostatectomy)
Pathology
PSA
Test
Lymph node
status
Yes, if one or more
of the following:
surgical margins
positive, postprostatectomy PSA
is rising and is >
0.1ng/mL
R4
Radiation
Oncologist
Negative
No, if pT2, negative
margins and PSA
0.1ng/mL
4 Early referral
recommended, refer to EBS #3-17
Rising PSA
Patient
candidate for
adjuvant
treatment?
Yes
Further
treatment
required?
Observation
Proceed
to Page 7
Patient
considers
options
Patient s
treatment
decision
W
Adjuvant External
Beam Radiation
Therapy
Within 6-18 weeks
following
prostatectomy
EBS #3-17
& Peer Review
Proceed to
Prostate
Cancer
Follow-up
Pathway
Proceed to
Prostate
Cancer
Follow-up
Pathway
Prostate Cancer Treatment Pathway
Primary/Local Recurrence
Version 2015.11 Page 7 of 11
The pathway is intended to be used for informational purposes only. The pathway is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathways are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the
pathway. In the situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions regarding the information set out in the pathway. The information in the pathway does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the
reader.
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Consider the introduction of palliative care, early and across the cancer journey. Click here for more information about palliative care.
Yes
H
From Page 6
or Prostate
Cancer
Follow-up
Pathway
Imaging Tests
Bone Scan
and X-Ray
of
suspicious
areas
CT
Abdomen/
Pelvis
Yes, if local
recurrence
suspected and no
previous adjuvant
therapies
Biopsy
5
6
MCC6
No, if metastatic or patient
received adjuvant
radiation treatment
following radical
prostatectomy
Urologist
W
MRI is appropriate when used for targeted biopsy
Salvage radical prostatectomy following radiation therapy should be performed and offered at centres of known expertise
PSA
Test
I
Proceed
to Page 8
Metastatic
disease?
No, if negative lymph nodes
and PSA 0.1ng/mL
Proceed to
Prostate
Cancer
Follow-up
Pathway
J
No
Patient post
radical
prostatectomy
without
adjuvant
radiation
therapy with
detectable
rising PSA
Pathology
Patient candidate for
Salvage Radical
Prostatectomy?
MCC
Radiation
Oncologist
R
W
Proceed
to Page 8
Progression
Observation
Yes
Patient eligible
for local salvage
therapies with
curative intent
Pelvic
MRI5
EBS #26-4
Salvage
therapy based
on prior
treatment
Patient post
external beam
radiation,
brachytherapy, or
combined
modality
treatment with
detectable rising
PSA or positive
biopsy
R
Individualized
Local Salvage
(Surgery)
Quality-Based
Procedures
Clinical
Handbook for
Cancer
Surgery
Yes, if lymph nodes
positive and/
or post-prostatectomy PSA
is rising AND is > 0.1ng/mL
Neoadjuvant
Optimize
Androgen
bone
Deprivation
health
Therapy
Salvage External Beam
Radiation Therapy
Peer Review
Salvage
Radiation Therapy?
(Joint decision by
Urologist and Radiation
Oncologist)
Proceed to
Prostate
Cancer
Follow-up
Pathway
K
No
Observation
Progression
Proceed
to Page 8
Prostate Cancer Treatment Pathway
Metastatic/Secondary Recurrence - Hormone Naïve
Version 2015.11 Page 8 of 11
The pathway is intended to be used for informational purposes only. The pathway is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathways are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the
pathway. In the situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions regarding the information set out in the pathway. The information in the pathway does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the
reader.
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Consider the introduction of palliative care, early and across the cancer journey. Click here for more information about palliative care.
**The appearance of specific drugs on this pathway does not imply that the drugs are publicly funded.
A
C
E
G
I
J
K From
Treatment
Pathway
Pages 3, 4,
5, 6 or 7
Imaging Tests
If not performed
already
Secondary
Recurrence
Following
primary
treatment with or
without adjuvant
or salvage
therapy
Urologist
R
Radiation
Oncologist
Bone Scan
and X-Ray of
suspicious
areas
CT
Abdomen/
Pelvis
Pelvic MRI
From
Diagnosis
Pathway
(Page 5)
Negative
Bone Scan
and CT
PSA
rising and
testosterone
at castrate
levels
Follow-up /
Surveillance
Scheduling can
vary.
Managed by the
treating
physician.
PSA Test,
Imaging - As
needed
Consider ADT
when PSA >5ng/
mL and/or PSA
doubling time <3
months
Intermittent
Androgen
Deprivation
Therapy
Or
Orchiectomy
EBS #3-1
PSA rising and
testosterone at
castrate levels
PSA Test,
Testosterone
Levels
Frequency
determined by
treating
physician
Metastatic
Any of the following:
 Nodal Involvement7
 Evidence of Metastasis
Follow-up / Surveillance
Scheduling may vary. Managed by the treating
physician
Low volume
Or
Orchiectomy
EBS #3-1
Select patients with nodal involvement can be managed with the high risk/locally advanced pathway
High volume defined as visceral metastases and/or 4 or more bone metastases (at least 1 beyond pelvis and
vertabral column)
9 Limited course of docetaxel to androgen-depriv ation therapy in the setting of newly diagnosed metastatic
androgen-sensitive prostate cancer, refer to EBS #3-15
10 Secondary Hormone Manipulation may include: antiandrogen, antiandrogen withdrawal, antiandrogen switch,
luteinizing hormone releasing hormone (LHRH) switch, ketoconazole, or steroids
For more information about early palliative care for advanced cancer refer to Zimmermann et al., (2014) Early
palliative care for patients with advanced cancer: a cluster-randomized controlled trial. Lancet, 383(9930), 1721-30
Continue
Androgen
Deprivation
Therapy
EBS #3-1
Androgen
Deprivation
Therapy (ADT)
EBS #3-1
Disease
burden?
Optimize bone
health
High volume of
metastatic
disease at
presentation8
Continue Androgen
Deprivation Therapy
Intermittent or
continuous depending
on prior therapy
EBS #3-1
PSA Test,
Testosterone
Levels, Imaging
As needed
M
Progression
7
8
Radiation
Oncologist
R
Medical
Oncologist
Response
Evaluation
PSA
stable
PSA
stable
Positive
Bone Scan
and/or CT
EBS #3-1
PSA Test,
Testosterone
Levels
Frequency
determined by
treating
physician
Response
evaluation
Optimize bone
health
Metastatic
prostate
cancer?
Secondary
Hormone
Manipulation10
L
Proceed
to Page 9
Palliative Radiation
Therapy
Chemotherapy9
EBS #3-15
Page 8 for Secondary
Hormone Manipulation or
page 9 for Castrate Resistant
Prostate Cancer (CRPC)
depending on prior
treatments and/or current
presentation
Prostate Cancer Treatment Pathway
Metastatic/Secondary Recurrence - Castrate Resistant
Version 2015.11 Page 9 of 11
The pathway is intended to be used for informational purposes only. The pathway is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathways are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the
pathway. In the situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions regarding the information set out in the pathway. The information in the pathway does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the
reader.
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Consider the introduction of palliative care, early and across the cancer journey. Click here for more information about palliative care.
**The appearance of specific drugs on this pathway does not imply that the drugs are publicly funded.
L
M From
Treatment
Pathway
Page 8
CastrateResistant
Prostate Cancer
(CRPC)
Rising PSA
levels with
testosterone at
castrate level
Imaging
or
Restaging
Unless recently
perfomed and no new
or worsening symptoms
Bone Scan and XRay of suspicious
areas
Continue Androgen Deprivation
Therapy
(with or without androgen receptor
axis targeted therapy)
Negative Bone
Scans and CT
and
asymptomatic
Optimize bone health
PSA Test, Testosterone Levels
Appropriate therapy
includes one or more
of the following
depending on prior
therapies:
Androgen Deprivation
Therapy indefinitely
regardless of additional
therapies
EBS #3-15
Sequence of
specialties and
care is
individualized
Pelvic MRI
And
A systemic therapy with
demonstrated survival benefit
and quality-of-life benefits:
Medical
Oncologist
Positive Bone
Scans and/or
CT
Chemotherapy11,12
Urologist
R
Radiation
Oncologist
Primary
Care
Provider
Supportive
and End of
Life Care
Teams
EBS #3-15
W
Radioisotope Therapy for
Bone Metastases
EBS #3-15
Androgen Receptor Axis
Targeted Therapy13
EBS #3-15
And
Other therapies to consider:
Palliative Radiation Therapy
Optimize Bone Health
11 Docetaxel/prednisone
PSA doubling time <8 months,
symptoms suggestive of progression,
and 6 months since last staging
Appropriate therapies include:
Metastatic
CRPC?
CT Abdomen/Pelvis
CT Chest
Follow-up / Surveillance
Scheduling can vary.
Managed by the treating physician.
should be offered
12 Cabazitaxel and prednis one may be offered to men who experience progression with docetaxel
13 Therapies with demonstrated survival and quality-of-life benefit s are abiraterone acetate/prednisone; enzalutamide
14 Bone-Targeted Therapy may include zoledronic acid or denosumab
For more information about early palliative care for advanced cancer refer to Zimmermann et al., (2014) Early
palliative care for patients with advanced cancer: a cluster-randomized controlled trial. Lancet, 383(9930), 1721-30
Bone-Targeted Therapy14
Palliative
Radiation Therapy
Radioisotope
Therapy for Bone
Metastases
EBS #3-15
Follow-up/
Surveillance
Scheduling can vary.
Managed by the
treating physician.
PSA Test,
Testosterone
Levels, Imaging
As needed
Androgen Receptor
Axis Targeted
Therapy13
EBS #3-15
Progression
Chemotherapy11,12
EBS #3-15
Continuous
Androgen
Deprivation Therapy
EBS #3-15
Psychosocial
Oncology and
supportive care
Referral to
appropriate
specialist if
additional support
is required
End of Life Care
Planning
Progression
Proceed to
End of Life
Care
Pathway
(Page 10)
Prostate Cancer Treatment Pathway
End of Life Care
Version 2015.11 Page 10 of 11
The pathway is intended to be used for informational purposes only. The pathway is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathways are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the
pathway. In the situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions regarding the information set out in the pathway. The information in the pathway does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the
reader.
End of Life Care (refer to Collaborative Care Plan)


Pathway Map Target
Population:
Individuals with cancer
approaching end of life, and their
families.
While this section of the pathway
map is focused on the care
delivered at the end of life, the
palliative care approach begins
much earlier on in the illness
trajectory.
Refer to Screen, Assess & Plan
within the Psychosocial &
Palliative Care Pathway Map
Triggers that
suggest patients
are nearing the
last few months
and weeks life
 ECOG/PatientECOG/PRFS = 4
OR
 PPS 30
 Declining
performance
status/functional
ability
 Gold Standards
Framework
indicators of high
mortality risk
Revisit Advance Care Planning
Ensure the patient has determined who will be their Substitute Decision Maker (SDM)
Ensure the patient has communicated to the SDM his/her wishes, values and beliefs to help guide that SDM in future decision making
Discuss and document goals of care with patient and family
 Assess and address patient and family s information needs and understanding of the disease, address gaps between reality and expectation, foster
realistic hope and provide opportunity to explore prognosis and life expectancy, and preparedness for death
 Introduce patient and family to resources in community (e.g., day hospice programs)
Screen, Assess,
Plan, Manage
and Follow-Up
+
End of Life Care
planning and
implementation
Collaboration and
consultation
between
specialist-level
care teams and
primary care
teams
Develop a plan of treatment and obtain consent
 Determine who the person wants to include in the decision making process (e.g., substitute decision maker if the person is incapable)
 Develop a plan of treatment related to disease management that takes into account the person s values and mutually determined goals of care
 Obtain consent from the capable person or the substitute decision maker if the person is incapable for an end-of-life plan of treatment that includes:
- Setting for care
- Resuscitation status
- Having, withholding and or withdrawing treatments (e.g. lab tests, medications, etc.)
Screen for specific end of life psychosocial issues
Specific examples of psychological needs include: anticipatory grief, past trauma or losses, preparing children (young children, adolescents, young
adults), guardianship of children, death anxiety
 Consider referral to available resources and/or specialized services

Identify patients who could benefit from specialized palliative care services (consultation or transfer)
 Discuss referral with patients and family
Proactively develop and implement a plan for expected death
Explore place-of-death preferences and assess whether this is realistic
Explore the potential settings of dying and the resources required (e.g., home, residential hospice, palliative care unit, long term care or nursing home)
Anticipate/Plan for pain & symptom management medications and consider a Symptom Response Kit (SRK) for unexpected pain & symptom
management
 Preparation and support for family to manage
 Discuss emergency plans with patient and family (who to call if emergency in the home or long-term-care or retirement home)
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Home care planning
Connect with CCAC early (not just for last 2-4 weeks)
Ensure resources and elements in place
Consider a Symptom Response Kit (SRK) with access to pain, dyspnea and delirium medication
Identify family members at risk for abnormal/complicated grieving and connect them proactively with bereavement resources
Eastern Cooperative Oncology Group Performance Status (ECOG); Palliative Performance Scale (PPS); Patient Reported Functional Status (PRFS)
For more information on the Gold Standards Framework, visit http://www.goldstandardsframework.org.uk/
Prostate Cancer Treatment Pathway
End of Life Care cont.
Version 2015.11 Page 11 of 11
The pathway is intended to be used for informational purposes only. The pathway is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathways are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the
pathway. In the situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions regarding the information set out in the pathway. The information in the pathway does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the
reader.
At the time of death:
Pronouncement of death
Completion of death certificate
Allow family members to spend time with loved one upon
death, in such a way that respects individual rituals, cultural
diversity and meaning of life and death
Implement the pre-determined plan for expected death
Patient Death
Arrange time with the family for a follow-up call or visit
Provide age-specific bereavement services and resources
Inform family of grief and bereavement resources/services
Initiate grief care for family members at risk for complicated
grief
Encourage the bereaved to make an appointment with an
appropriate health care provider as required
Bereavement Support and Follow-Up
Offer psychoeducation and/or counseling to the bereaved
Screen for complicated and abnormal grief (family members, including
children)
Consider referral of bereaved family member(s) and children to
appropriate local resources, spiritual advisor, grief counselor, hospice
and other volunteer programs depending on severity of grief
Provide opportunities
for debriefing of care
team, including
volunteers