Download Rectal Cancer Treatment Pathway

Rectal Cancer Treatment Pathway
Disease Pathway Management Secretariat
Version 2013.5
Disclaimer
The Rectal Cancer Treatment Pathway (Pathway) is intended to be used for informational purposes only.
While the Pathway represents an overview of the treatment of a typical rectal cancer, it is not intended to
constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further,
all treatments are subject to clinical judgment and actual practice patterns may not follow the proposed
steps set out in the Pathway.
Rectal Cancer Treatment Pathway
Pathway Preamble
Pathway Disclaimer
The Rectal Cancer Treatment Pathway (Pathway) is a resource that provides an overview of the treatment of a typical rectal
cancer. The pathway is only intended for primary adenocarcinoma and familial cancers (Lynch/non-Lynch) and cancers
complicating inflammatory bowel disease are handled differently.
The information contained in this Pathway is intended for healthcare providers and other stakeholders in the cancer system,
including administrators and organizers. The Pathway is intended to be used for informational purposes only. While the
Pathway represents an overview of the treatment of a typical rectal cancer, it is not intended to constitute or be a
substitute for medical advice and should not be relied upon in any such regard. Further, all treatments are subject to
clinical judgment and actual practice patterns may not follow the proposed steps set out in the Pathway.
The Pathway is not intended for patients. In the situation where the reader is a patient, 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 CCO and the reader.
Version 2013.5
Page 2 of 7
Pathway Legend
Primary Care Provider (Family Physician, Nurse Practitioner, Emergency Department Physician)
Endoscopist
Pathologist
Diagnostic Assessment Program (DAP)
Surgeon
Radiation Oncologist
Medical Oncologist
Imaging
Multi-disciplinary Cancer Conferences (MCC)
Palliative Care and Psychosocial Oncology Team
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 expressed, 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.
Pathway Considerations
§
§
§
The family physician should be informed of all tests and consultations. 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 Rectal Cancer Treatment Pathway, 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.
No Specific Specialist Designated
Possible Action or Result
Referral to
Managing Physician at Pathway Entry Point
Pathway Target Population
Patients with a confirmed rectal cancer diagnosis who have undergone the recommended diagnostic
and staging procedures as outlined in the Colorectal Cancer Diagnosis Pathway.
Rectal Cancer Treatment Pathway
Stage 0
Version 2013.5
Page 3 of 7
Stage 0
Tis | N0 | M0
AJCC Cancer Staging Manual
7th edition.
Endoscopist
(Surgeon or
Gastroenterologist)
Polypectomy or
Local Excision
Pathology
Review
Pathology
Report
Histopathology confirms
stage 0 and complete
resection
Colonoscopy Surveillance
Refer to Guidelines for Colonoscopy Surveillance After Polypectomyα
α To complement the colonoscopy standards, CCC adopted these surveillance guidelines:
Guidelines for Colonoscopy Surveillance after Polypectomy: A consensus update by the US
Multi-Society Task Force on Colorectal Cancer and the American Cancer Society.
Gastroenterology 2006; 130:1872-1885
Rectal Cancer Treatment Pathway
Stage I
Rectal Cancer
AJCC Cancer Staging Manual
7th edition.
Polypectomy
Pathology
α To complement the colonoscopy standards, CCC adopted these surveillance guidelines:
Guidelines for Colonoscopy Surveillance after Polypectomy: A consensus update by the US
Multi-Society Task Force on Colorectal Cancer and the American Cancer Society.
Gastroenterology 2006; 130:1872-1885
Review
Pathology
Report
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)
Enterostomal
Therapy
Nurse
Endoscopist
(Surgeon or
Gastroenterologist)
Total Mesorectal Excision
with Low Anterior Resection
or Abdominoperineal
Resection
Refer to EBS #17-4
Proceed to the
Colorectal Cancer
Follow-up Care
Pathway
Pathology
Refer to EBS #17-4
Review
Pathology
Report
Radiation
Oncologist
MCC
Radiation
Oncologist
Review
Pathology
Report
Biopsy
Pathology
NOTE: Early referral to psychosocial oncology and palliative care team is recommended
Radiotherapy or
Chemoradiotherapy
Medically
Inoperable
(e.g., medically
unfit for surgery)
Medical
Oncologist
Local Surgical
Management
Adjuvant
(Postoperative)
Therapy
Chemotherapy
Pathological
Stage II or III
Surgeon
Page 4 of 7
Colonoscopy Surveillance
Refer to Guidelines for Colonoscopy Surveillance After Polypectomyα
If histopathological
features confirms
complete resection
Stage I
T1 | N0 | M0
T2 | N0 | M0
Version 2013.5
Medical
Oncologist
And/
Or
Chemoradiotherapy
Proceed to
the Colorectal
Cancer
Follow-up
Care Pathway
Rectal Cancer Treatment Pathway
Rectal Cancer
Stage II and III
Version 2013.5
Page 5 of 7
NOTE: EBS #2-4 is older than 3 years old and is UNDER REVIEW for currency and relevance.
Stage II
Stage IIA
T3 | N0 | M0
Stage IIB
Referrals for Preoperative Therapy
T4a | N0 | M0
Preoperative
Chemoradiotherapy
Refer to EBS #2-4
Stage IIC
Resectable
T4b | N0 | M0
Radiation
Oncologist
Stage III
Medical
Oncologist
Preoperative
Hypofractionated
Radiotherapy Alone
Refer to EBS #2-4
Stage IIIA
T1,T2 | N1/N1c | M0
T1 | N2a | M0
Stage IIIB
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
Managing
Physician
from diagnosis
and staging
Enterostomal
Therapy
Nurse
Pathology
Refer to
EBS #17-4
Adjuvant
Chemotherapy
Refer to
EBS #2-4
If un-resectable
Palliative
Chemotherapy
Refer to EBS #17-4
MCC
If resectable
MCC Guidelines
and Resources
AJCC Cancer Staging
Manual 7th edition.
Total Mesorectal Excision
with Low Anterior Resection
or
Abdominoperineal
Resection
Goal is to achieve clear
margins
Radiation
Oncologist
Medical
Oncologist
Radiation
Oncologist
Medical
Oncologist
Chemoradiotherapy
Re-evaluate
at MCC
Potentially downstage
to make resectable
Re-evaluate resectabilIty (ongoing
process).
Allow adequate time for downstaging.
Consider planning for more extensive
surgery if required (e.g., pelvic
exenteration)
Unresectable
NOTE: Early referral to psychosocial oncology and palliative care team is recommended
Palliative
Radiation
with or without Chemotherapy
Proceed to
the Colorectal
Cancer
Follow-up
Care Pathway
Rectal Cancer Treatment Pathway
Rectal Cancer
Stage IV
EBS #2-25 is older than 3 years old and is UNDER REVIEW for currency and relevance.
Stage IV
Multidisciplinary
Referrals to Create
Individualized Care
Plan
Stage IVA
Any T | Any N | M1a
Stage IVB
Any T | Any N | M1b
AJCC Cancer Staging Manual 7th edition.
Surgeon*
Sequence of care is individualized
and is dependent on symptomology
and resectability.
Managing
Physician
from diagnosis
and staging
MCC
Evaluate for
resectability of
primary and of
metastatic
disease
Symptomatic
primary must
be dealt with
initially
MCC Guidelines
and Resources
NOTE: 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.
Evaluate
Metastatic
Disease
Neoadjuvant
Chemo-radiotherapy
(neoadjuvant radiation is
preferred over an
adjuvant approach)
Resection of
Primary
Neoadjuvant
Chemotherapy
*Opinion from a surgeon
with relevant expertise
should be obtained (e.g.,
Hepatobiliary or thoracic
surgeon)
NOTE: Early referral to psychosocial oncology and palliative care team is recommended
Resection of
metastatic liver
lesion(s)
Radiation
Chemotherapy
Refer to EBS #2-25
Primary tumour requires
treatment even if asymptomatic.
Primary Tumour
Unresectable
If metastatic disease
is resectable, downstaging pelvic
disease to resectable
could be considered
Re-assess
metastatic
lesion(s)
Appropriate Palliative Therapy may
include one or more of the following:
Unresectable
Metastatic
Disease**
Medical
Oncologist
Page 6 of 7
Care is individualized. Items discussed and considered at the MCC:
§
Sequencing of primary and metastatic disease resection
§
Synchronous vs. staged approach for resection
The sequence of care presented below is a possible approach, however it may vary.
Refer to
EBS #17-7
Radiation
Oncologist
Palliative Care
& Psychosocial
Oncology Team
**Individuals with oligo-metastases who are not surgical
candidates could be considered for stereotactic ablative
radiotherapy (SABR) or radiofrequency ablation.
Primary
Tumour
Resectable
Or
Metastatic
Disease
After
Resection
of Primary
Resectable
or Potentially
Resectable
Metastatic
Disease**
Version 2013.5
Consider
neoadjuvant
therapy to convert
to resectable
Symptomatic treatment as
appropriate.
Chemoradiotherapy
Palliative Resection of Primary
Tumour
In the presence of overt, serious
symptoms, such as acute
significant bleeding, obstruction,
or unequivocal imminent risk of
obstruction
Diverting Ostomy
Stenting
Rectal Cancer Treatment Pathway
Local Recurrence
Version 2013.5
Page 7 of 7
Multidisciplinary
Referrals to Create
Individualized Care
Plan
Surgeon*
Resectable
From
Colorectal
Cancer Followup Care
Pathway
Locally
Recurrent
Disease
MCC
Evaluate for
resectability
MCC Guidelines
and Resources
Preoperative Chemoradiotherapy
Consider even in the setting of
previous pelvic radiotherapy
Resection
+/-
Chemotherapy
Radiation
Oncologist
Medical
Oncologist
Unresectable
Palliative Care
& Psychosocial
Oncology Team
*Opinion from a surgeon
with relevant expertise
should be obtained (e.g.,
Hepatobiliary or thoracic
surgeon)
NOTE: All patients under consideration for a temporary or permanent ostomy should be referred to an Enterostomal Therapy Nurse preoperatively.
Patients should have access to an Enterostomal Therapy Nurse before and after ostomy surgery.
NOTE: Once diagnosis is made, refer to early psychosocial oncology and palliative care team where appropriate
Radiation Therapy
Consider even in the
setting of previous
pelvic radiotherapy
with or without Chemotherapy
Appropriate
Palliative Therapy
Proceed to Colorectal
Cancer Follow-up
Care Pathway