Download Colon Cancer Treatment Pathway

Colon 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.
Colon Cancer Treatment Pathway
Pathway Preamble
Version 2014.03
Page 2 of 8
Pathway Disclaimer
Pathway Legend
This pathway is a resource that provides an overview of the treatment that an individual in the Ontario cancer system may
receive.
Primary Care Provider (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.
Pathologist
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.
Imaging
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.
Pathway Considerations
§
§
§
Endoscopist
Diagnostic Assessment Program (DAP)
Surgeon
Radiation Oncologist
Medical Oncologist
Psychosocial Oncology (PSO) and Palliative Care and End of Life Care (PEOL) - Managing Physician(s)
and Care Team
Multi-disciplinary Cancer Conferences (MCC)
No Specific Specialist Designated
Possible Action or Result
Referral to
Managing Physician at Pathway Entry Point
Pathway Target Population
Patients with a confirmed colon cancer diagnosis who have undergone the recommended diagnostic and
staging procedures as outlined in the Colorectal Cancer Diagnosis Pathway.
The family physician should be informed of all tests and consultations and usual ongoing care with the family physician is
assumed to be part of the pathway.
Clinical trials should be considered for all phases of the Colon Cancer Treatment Pathways, where available.
All patients under consideration for an ostomy should be referred to an Enterostomal Therapy Nurse preoperatively.
Patients should have access to an Enterostomal Therapy Nurse before and after ostomy surgery.
Ostomy Care and Management, Clinical Best Practice Guideline, Registered Nurses Association of Ontario.
§
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.
Colon Cancer Treatment Pathway
Stage 0
Version 2014.03 Page 3 of 8
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.
Stage 0
Tis | N0 | M0
AJCC Cancer Staging Manual
7th edition
Colonoscopy Surveillance
Refer to Guidelines for Colonoscopy Surveillance After Polypectomyα
Endoscopist
(Surgeon or
Gastroenterologist)
α To
Polypectomy or
Local Excision
Pathology
Review
Pathology
Report
Histopathology confirms
stage 0 and complete
resection
complement the colonoscopy standards, CCC adopted these surveillance guidelines:
Guidelines for Colonoscopy Surveillance after Polypectomy: A consensus update by the US MultiSociety Task Force on Colorectal Cancer and the American Cancer Society. Gastroenterology
2006; 130:1872-1885
Ongoing screening, assessment and management of symptoms and consider functional
status
Colon Cancer Treatment Pathway
Stage I
Version 2014.03 Page 4 of 8
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.
Colonoscopy Surveillance
Colon Cancer
Refer to Guidelines for Colonoscopy Surveillance After Polypectomyα
α To
Stage I
T1 | N0 | M0
T2 | N0 | M0
AJCC Cancer Staging Manual
7th edition
complement the colonoscopy standards, CCC adopted these surveillance guidelines:
Guidelines for Colonoscopy Surveillance after Polypectomy: A consensus update by the US MultiSociety Task Force on Colorectal Cancer and the American Cancer Society. Gastroenterology
2006; 130:1872-1885
Histopathology confirms
Stage 1 and complete
resection
Polypectomy
Pathology
Review
Pathology
Report
Ongoing screening, assessment and management of symptoms and consider functional
status
Histopathology:
- Cannot confirm complete resection margins
(negative margins are the goal of resection; can consider
further endoscopic resection) OR
- Unfavourable histopathological features (e.g., poorly
differentiated or undifferentiated, lymphovenous invasion)
(hemi) Colectomy With En
Bloc Removal Of Regional
Lymph Nodes
Refer to EBS #17-4
Resectable
Endoscopist
(Surgeon or
Gastroenterologist)
Surgeon
Pathology
Refer to EBS #17-4
Review
Pathology
Report
Screen for and manage
symptoms and consider
functional status
Goals of Care
Conversation
Review
Pathology
Report
Medically
Inoperable
(i.e., medically unfit
for surgery)
Pathology
For more information about Multidisciplinary Cancer Conferences (MCC):Refer to MCC Standards and
MCC Resources
Pathway Consideration: Consider early activation of psychosocial oncology and palliative care approach
1
Proceed to the Colon
Cancer Treatment Stage II
and Stage III Pathway
(page 5 of 8)
Proceed to the Colorectal
Cancer Follow-up Care
Pathway
Appropriate palliative therapy may include one or more of the
following:
Palliative
Chemotherapy
MCC1
MCC Guidelines
and Resources
Biopsy
Pathological
Stage II (High Risk*) or
Stage III
*High-risk includes
inadequate samples of
nodes, T4 lesions,
perforation, poorly
differentiated histology
or obstruction
Radiation
Oncologist
Medical
Oncologist
PSO & PEOL
Revisit Goals
of Care
Conversation
Palliative
Radiation
Therapy
Ongoing screening,
assessment and management
of symptoms
Symptom Management Guides-topractice and
Collaborative Care Plans
Observation
if asymptomatic
Surgical/interventional
management for
complications
(e.g., stent, diverting
stoma)
Colon Cancer Treatment Pathway
Stage II and Stage III
Version 2014.03 Page 5 of 8
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.
Colon Cancer
EBS #2-29 is older than 3 years old and is UNDER REVIEW for currency and relevance.
Stage II
Stage IIA
T3 | N0 | M0
Negative
Resection
Margins
Stage IIB
T4a | N0 | M0
Stage IIC
MCC especially
recommended
for any patients
with uncertain
features
Revisit Goals
of Care
Conversation
MCC1
High-Risk Stage II patients with
completely resected colon cancer
High-risk includes inadequately
sampled nodes, T4 lesions,
perforation, poorly differentiated
histology or obstruction
Refer to EBS #2-29
Medical
Oncologist
Consider Adjuvant
Chemotherapy Refer to
EBS #2-29
Ongoing screening,
assessment and
management of
symptoms and consider
functional status
Medical
Oncologist
Consider Adjuvant
Chemotherapy Refer to
EBS #2-29
Ongoing screening,
assessment and
management of
symptoms and consider
functional status
T4b | N0 | M0
Stage III
Stage IIIA
T1-T2 | N1/N1c | M0
T1 | N2a | M0
Resectable
Stage IIIB
(hemi) Colectomy
with en bloc
removal of
regional lymph
nodes
Refer to EBS #17-4
Pathology
T3-T4a | N1/N1c | M0
T2-T3 | N2a | M0
T1-T2 | N2b | M0
Stage IIIC
T4a | N2a | M0
T3-T4a| N2b | M0
T4b| N1-N2 | M0
AJCC Cancer Staging Manual
7th edition
Surgeon
Screen for and
manage symptoms
and consider
functional status
Goals of Care
Conversation
All Stage III patients with
completely resected colon
cancer
Refer to EBS #2-29
Review
Pathology
Report
Positive
Resection
Margins
Proceed to the Colorectal
Cancer Follow-up Care
Pathway
Low Risk Stage II Disease
Refer to EBS #2-29
Revisit Goals
of Care
Conversation
MCC1
Consider
re-resection
Medical
Oncologist
and
Proceed to the Colorectal
Cancer Follow-up Care
Pathway
Consider Radiation Therapy
(Chemoradiotherapy)
Chemotherapy
Radiation
Oncologist
Proceed to the Colorectal
Cancer Follow-up Care
Pathway
Ongoing screening, assessment and management
of symptoms and consider functional status
Appropriate referrals based on MCC
Locally
Advanced
Unresectable
Medically
Inoperable
MCC1
MCC1
Interventional
management for
symptomatic
primary, as
necessary
(e.g., stent, diverting
stoma, bypass)
Interventional
management for
symptomatic
primary, as
necessary
(e.g., stent, diverting
stoma, bypass)
*Opinion from a surgeon with relevant expertise should be obtained
1 For more information about Multidisciplinary Cancer Conferences (MCC):Refer to MCC Standards and
MCC Resources
Pathway Consideration: Consider early activation of psychosocial oncology and palliative care approach
Surgeon*
Radiation
Oncologist
Revisit Goals
of Care
Conversation
Medical
Oncologist
PSO &
PEOL
Chemotherapy
Or
Combined Modality
Chemoradiotherapy
Chemotherapy
Regardless of resectability
Ongoing screening,
assessment and
management of
symptoms and consider
functional status
Re-evaluate
resectability.
Resection if
feasible.
Ongoing screening, assessment and management
of symptoms and consider functional status
Appropriate palliative therapy may include one or more of the following:
Radiation
Oncologist
Medical
Oncologist
PSO &
PEOL
Revisit Goals
of Care
Conversation
Ongoing screening,
assessment and management
of symptoms
Symptom Management Guides-topractice and
Collaborative Care Plans
Palliative
Chemotherapy
Palliative Radiation
Therapy
Interventional management for
complications
(e.g., stent, diverting stoma)
Observation
if
asymptomatic
End of Life Care
Implementation
(Page 7,8 of 8)
Colon Cancer Treatment Pathway
Stage IV
Version 2014.03 Page 6 of 8
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.
Colon Cancer
Stage IV
Stage IVA
Any T | Any N | M1a
Stage IVB
Any T | Any N | M1b
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”
Resectable
Oligometastases
Liver and/or
Lung
Metastases*
Refer to
EBS #17-7
Directly to
Resection
(no neoadjuvant
therapy)
*If patient is nearing the last weeks of life proceed to End of Life Care Pathway (page 7,8 of 8).
Potentially
Resectable
Medical
Oncologist
Managing
Physician
from diagnosis
and staging
There are a variety of
physicians that may
bring the patient into the
stage IV Colon Cancer
Treatment Pathway
(e.g., surgeon,
gastroenterologist, family
physician, etc.)
Screen for and
manage
symptoms and
consider
functional
status
MCC
MCC especially
recommended for
any patients with
uncertain features
MCC Guidelines
and Resources
Symptomatic
primary must
be dealt with
initially
Surgeon***
Goals of Care
Conversation
PSO & PEOL
Activate a
psychosocial oncology
and palliative care
approach (Primary/
generalist +/- specialist
level)
For more information about Multidisciplinary Cancer Conferences (MCC): Refer to MCC Standards and
MCC Resources
*Individuals with isolated peritoneal metastases could be evaluated for resectability/peritoneal
debulking and hyperthermic intraperitoneal chemotherapy (HIPEC).
**Individuals with oligo-metastases who are not surgical candidates could be considered for
stereotactic ablative radiotherapy (SABR) or radiofrequency ablation.
***Opinion from a surgeon with relevant expertise should be obtained (e.g., Hepatobiliary or thoracic
surgeon)
1
Colon
Resection
Only if imminent
risk of
obstruction or
significant
bleeding
Extensive
Metastases or
Unresectable
Neoadjuvant
Chemotherapy
Ongoing screening,
assessment and
management of
symptoms consider
functional status
Chemotherapy
Ongoing
screening,
assessment and
management of
symptoms
consider functional
status
Staged or
Synchronous
Resection of
Metastatic and
Colon Cancer**
Adjuvant
Chemotherapy
Ongoing screening,
assessment and
management of
symptoms consider
functional status
Proceed to the
Colorectal
Cancer Follow-up
Care Pathway
Resectable
Re-evaluate
Resectability**
Unresectable**
Chemotherapy
Ongoing screening,
assessment and
management of
symptoms consider
functional status
Revisit Goals of
Care
Conversation
Consider stoma and/
or bypass or
surgical resection
If imminent risk of
obstruction or
significant bleeding
Chemotherapy
Ongoing
screening,
assessment and
management of
symptoms and
consider functional
status
Other therapy for palliation may include one or more of the
following:
Revisit Goals of
Care
Conversation
Ongoing screening,
assessment and management
of symptoms
Symptom Management Guides-topractice and
Collaborative Care Plans
Interventional management for
complications
(e.g., stent, diverting stoma)
Palliative
Chemotherapy
Palliative Radiation
Therapy
End of Life Care
Implementation
(Page 7,8 of 8)
Colon Cancer Treatment Pathway
End of Life Care (Last 3 Months of Life)
Version 2014.03 Page 7 of 8
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
Colon Cancer Treatment Pathway
End of Life Care (Last 3 Months of Life) contd.
Version 2014.03 Page 8 of 8
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