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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