Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Small Cell Lung Cancer Treatment Pathway Disease Pathway Management Secretariat Version 2014.03 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. Small Cell Lung Cancer Treatment Pathway Pathway Preamble Pathway Disclaimer This pathway is a resource that provides an overview of the treatment that an individual in the Ontario cancer system may receive. 2014.03 Page 2 of 6 Pathway Legend Primary Care (Family Physician, Nurse Practitioner, Emergency Department Physician) 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. Psychosocial Oncology (PSO) and Palliative Care and End of Life Care (PEOL) - Managing Physician(s) 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. Radiation Oncologist 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. Multi-disciplinary Cancer Conferences (MCC) 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. Managing Physician at Pathway Entry Point and Care Team Pathologist Diagnostic Assessment Program (DAP) Surgeon Medical Oncologist Interventional Radiologist Neurosurgeon No Specific Specialty Possible Action or Result Referral to Pathway Considerations § § § § § The family physician should be kept up-to-date throughout the pathway and usual ongoing care with the family physician is assumed to be part of the pathway. Counseling and treatment for smoking cessation should be initiated early on in the pathway and continued by care providers throughout the pathway as necessary. Clinical trials should be considered for all phases of the pathway. In order to minimize delays, processes may be carried out in parallel if disease management is not affected. Psychosocial care should be considered an integral and standardized part of cancer care for patients and their families at all stages of the illness trajectory. Refer to EBS #19-3 © 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. Small Cell Lung Cancer Treatment Pathway Limited (Stage I - III) 2014.03 Page 3 of 6 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. Small Cell Lung Cancer Complete or Partial Response Limited (Stage I to III) Radiation Oncologist Revisit goals of care conversation Ready to treat Assign Wait Time Priority2 AJCC Cancer Staging Manual 7th edition Managing Physician It is assumed that all patients entering the Lung Caner Treatment Pathway have undergone the recommended diagnostic procedures and imaging. Screen for and manage symptoms and consider functional status Consider Radiation of Chest If not given previously Ongoing screening, assessment and management of symptoms and consider functional status Baseline Assessment (in addition to previous imaging from staging): Chest X-Ray Physical Exam Blood work MCC1 Medical Oncologist Goals of Care Conversation Radiation Oncologist +/- Thoracic Surgeon For very small lesions, where certainty of diagnosis is unclear Prophylactic Cranial Irradiation (PCI) of Brain Refer to EBS #7-13-2 Ongoing screening, assessment and management of symptoms and consider functional status Ready to treat Assign Wait Time Priority2 First-Line Chemotherapy Refer to EBS #7-13-1 Early Concurrent Thoracic Radiation Therapy Refer to EBS #7-13-3 Ongoing screening, assessment and management of symptoms and consider functional status For more information about Multidisciplinary Cancer Conferences (MCC):Refer to MCC Standards and MCC Resources 2 For more information on radiation and systemic treatment wait time prioritization, visit: http://cancercare.on.ca/cms/One.aspx?portalId=1377&pageId=8870 http://cancercare.on.ca/cms/One.aspx?portalId=1377&pageId=8888 1 Pathway Consideration: Consider early activation of psychosocial oncology and palliative care approach Assessment of Response +/- Chest X-Ray Physical Exam Blood Work Other Imaging as Appropriate CT Scan if needed (midcourse for chemotherapy) Follow-up∞ Stable Disease Follow-up∞ Consider re-evaluation of pathology Following Treatment Re-assessment: CT Chest, Abdomen MRI (preferred) or CT Brain End of Life Care Implementation (Page 5,6 of 6) Second-line Chemotherapy Progressed Evaluate Patient: Symptom and performance status, and co-morbidities Age Pathology Ongoing screening, assessment and management of symptoms and consider functional status Revisit goals of care conversation Palliative Radiation Ongoing screening, assessment and management of symptoms and consider functional status Progression/Recurrence: Subsequent treatment depends on: · Symptom and performance status, and co-morbidities · Patient treatment goals/wishes § Time to relapse § Age § Consider possibility of different histology (mixed tumours, new primary) § Revisit goals of care conversation If progression If stable End of Life Care Implementation (Page 5,6 of 6) Follow-up∞ ∞Collaborative Follow-Up by Managing Physician(s) or Advanced Practice Nurse (APN) Suggested Frequency History, Physical Exam, and Smoking Cessation Counseling Every 3 months (year 1 & 2) Every 6 months (year 3) Annually (year 4 and onward) CT Chest (+/- Abdomen) with Chest X-Ray on Alternating Visits Every 6 months (year 1 & 2) Chest X-Ray Every 6 months (year 3) Annually (year 4 and onward) Ongoing screening, assessment and management of symptoms and consider functional status Retreatment with First-Line Chemotherapy If ≥ 3 months disease-free Refer to EBS #7-17 Ongoing screening, assessment and management of symptoms and consider functional status Second-Line Chemotherapy If < 3 months disease-free Refer to EBS #7-17 Ongoing screening, assessment and management of symptoms and consider functional status Palliative Radiation Ongoing screening, assessment and management of symptoms and consider functional status PSO & PEOL End of Life Care Implementation (Page 5,6 of 6) If progression If stable Follow-up∞ Small Cell Lung Cancer Treatment Pathway Extensive (Stage IV) 2014.03 Page 4 of 6 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. Small Cell Lung Cancer Extensive (Stage IV) AJCC Cancer Staging Manual 7th edition IDENTIFY Identify patients who could benefit from a palliative care approach early in the illness trajectory. At the very least use the following screening question: “Would you be surprised if this patient were to die in the next 6 -12 months?” If answer is NO ↓ Initiate Palliative Care Approach alongside treatments to control the disease if these are still appropriate. Start by screening for symptoms and functional status as outlined in “SCREEN” and continue along the pathway. Consider a referral to specialized palliative care services if the needs are complex*. If answer is YES ↓ Screen for and manage symptoms and functional status as outlined in “SCREEN” MCC1 Managing Physician Screen for and manage symptoms and consider functional status Medical Oncologist Goals of Care Conversation PSO & PEOL Activate a psychosocial oncology and palliative care approach (Primary/ generalist +/specialist level) If symptomatic brain metastases Ready to treat Assign Wait Time Priority2 Radiation Oncologist Treatment Plan Dependent on: Performance status Weight loss Disease symptoms Co-morbidities Sites of metastatic disease For more information about Multidisciplinary Cancer Conferences (MCC):Refer to MCC Standards and MCC Resources 2 For more information on radiation and systemic treatment wait time prioritization, visit: http://cancercare.on.ca/cms/One.aspx?portalId=1377&pageId=8870 http://cancercare.on.ca/cms/One.aspx?portalId=1377&pageId=8888 1 Pathway Consideration: Consider early activation of psychosocial oncology and palliative care approach Medical Oncologist If significant comorbidities, poor performance status and/or moderate-severe or complex symptoms *If patient is nearing the last weeks of life proceed to End of Life Care Pathway (page 5,6 of 6). Baseline Assessment (in addition to previous imaging from staging): Chest X-Ray Physical Exam Blood work End of Life Care Implementation (Page 5,6 of 6) Revisit Goals of Care Conversation And Radiation Oncologist Revisit Goals of Care Conversation Ready to Treat Assign wait time priority2 First-Line Chemotherapy Ongoing screening, assessment and management of symptoms and consider functional status Pleurodesis Or If symptomatic pleural effusion Thoracentesis Or Pleural Tunneled Catheter Radiation of Brain Ongoing screening, assessment and management of symptoms and consider functional status Therapy based on patient preference and physician assessment And / Chemotherapy Palliative Radiation Or Ongoing screening, assessment and management of symptoms and consider functional status Revisit Goals of Care Conversation Prophylactic Cranial Irradiation (PCI) of Brain Refer to EBS #7-13-2 If not given previously Ongoing screening, assessment and management of symptoms and consider functional status First-Line Chemotherapy Ongoing screening, assessment and management of symptoms and consider functional status Assessment of Response: Chest X-Ray Physical Exam Blood Work CT Scan (midcourse for chemotherapy) First-Line Chemotherapy Ongoing screening, assessment and management of symptoms and consider functional status Complete or Partial Response Radiation Oncologist Revisit Goals of Care Conversation Ready to Treat Assign wait time priority2 Stable Disease If progression End of Life Care Implementation (Page 5,6 of 6) Progressed Evaluate Patient: Symptom and performance status, and comorbidities Age Revisit goals of care conversation Second-line Chemotherapy And / Or Palliative Radiation If appropriate Ongoing screening, assessment and management of symptoms and consider functional status Consider Radiation of Chest Ongoing screening, assessment and management of symptoms and consider functional status Collaborative Follow-Up by Managing Physician(s) or Advanced Practice Nurse (APN) History Physical Exam Blood work Chest X-Ray Other Scans as Appropriate Smoking cessation counselling If progression End of Life Care Implementation (Page 5,6 of 6) If stable Follow-Up∞ Small Cell Lung Cancer Treatment Pathway End of Life Care (Last 3 Months of Life) 2014.03 Page 5 of 6 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 □ Discuss and document goals of care with patient and family · Pathway Target Population: Individuals with cancer approaching the last 3 months of life and their families. While this section of the pathway 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 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 · 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 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) □ Revisit advance care planning and discuss treatment withdrawal or withholding (e.g., advance directives, surrogate/substitute decision maker, code · · status, feeding tubes etc.) Review regularly, particularly when there is a change in clinical status Refer to EBS #19- 1 □ 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 an emergency home kit 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) Refer to Collaborative Care Plans □ Home care planning · · · · Connect with CCAC early (not just for last 2-4 weeks) Ensure resources and elements in place Consider an emergency home kit with access to pain, dyspnea and delirium mediation Identify family members at risk for abnormal/complicated grieving and connect them proactively with bereavement resources Small Cell Lung Cancer Treatment Pathway End of Life Care Continued (Last 3 Months of Life) cont. 2014.03 Page 6 of 6 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 Patient Death □ Implement the pre-determined plan for expected 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