Breast Cancer Treatment Pathway Map · physician-patient relationship between Cancer Care Ontario (CCO) and the reader. While care has been taken in the preparation of the information

Disclaimer

The pathway map is intended to be used for informational purposes only. The pathway map is not

intended to constitute or be a substitute for medical advice and should not be relied upon in any such

regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may

not follow the proposed steps set out in the pathway map. 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 map. The information in the pathway map

does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.

Breast Cancer Treatment Pathway MapVersion 2015.11

Pathway Map Preamble Version yyyy.mm Page 2 of 15Confidential Draft

For Review Only

© CCO retains all copyright, trademark and all other rights in the pathway map, including all text and graphic images. No portion of this pathway map 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.

Pathway Map Preamble Version 2015.10 Page 2 of 15Breast Cancer Treatment Pathway Map

Pathway Map Disclaimer This pathway map is a resource that provides an overview of the treatment that an individual in the Ontario cancer system may receive.

The pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the pathway map. 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 map. The information in the pathway map 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 map, 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 map s content providers (including the physicians who contributed to the information in the pathway map) shall have no liability, whether direct, indirect, consequential, contingent, special, or incidental, related to or arising from the information in the pathway map 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 map 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 map.

This pathway map 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 map. It is possible that other relevant scientific findings may have been reported since completion of this pathway map. This pathway map may be superseded by an updated pathway map on the same topic.

Colour Guide

Primary Care

Supportive and End of Life Care

Pathology

Diagnostic Assessment Program (DAP)

Surgery

Radiation Oncology

Medical Oncology

Radiology

Multidisciplinary Cancer Conference (MCC)

Genetics Line Guide

Required

Possible

or

Shape Guide

Intervention

Decision or assessment point

Patient (disease) characteristics

Consultation with specialist

Exit pathway map

Off-page reference

Patient path

Referral

Wait time indicator time point

Pathway Map Legend

W

R

X

X

Pathway Map Considerations Consider recommendation for exercise. For more information visit

Primary care providers play an important role in the cancer journey and should be informed of relevant tests and consultations.

Ongoing care with a primary care provider is assumed to be part of the pathway map. For patients who do not have a primary care provider, is a government resource that helps patients find a family doctor or nurse practitioner.

Throughout the pathway map, 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 and

Hyperlinks are used throughout the pathway map to provide information about relevant CCO tools, resources and guidance

documents.

The term health care provider , used throughout the pathway map, includes primary care providers and specialists, nurse

practitioners, and emergency physicians.

Multidisciplinary Cancer Conferences provide a forum for discussing patients with breast cancer about whom there are complexities

regarding diagnosis and management. For more information on Multidisciplinary Cancer Conferences visit

For more information on wait time prioritization, visit:

Clinical trials should be considered for all phases of the pathway map.

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. For more information visit

The following should be considered when weighing the treatment options described in this pathway map for patients with potentia lly

life-limiting illness:- Palliative care may be of benef it 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

Target Population Patients with a confirmed breast cancer diagnosis who have undergone the recommended diagnostic and staging procedures outlin ed

in the Breast Cancer Screening and Diagnosis Pathway Map .

Health Care Connect,

MCC Tools

Surgery, Systemic Treatment, Radiation Treatment Wait Times prioritizations.

EBS #19-3

Person-Centered Care GuidelineEBS #19-2 Provider-Patient Communication*

* Note. EBS #19-2 is older than 3 years and is currently listed as For Education and Information Purposes . This means that the recommendations wil l no

longer be maintained but may still be useful for academic or other information purposes.

For more information on the systemic treatment QBP please refer to the Quality-Based Procedures Clinical

Handbook for Systemic Treatment

Exercise for people with cancer.

http://www.ontario.ca/health-and-wellness/find-family-doctor-or-nurse-practitioner

https://www.cancercare.on.ca/toolbox/mcc_tools/

http://cancercare.on.ca/common/pages/UserFile.aspx?fileId=117752

http://www.cancercare.on.ca/cms/One.aspx?portalId=1377&pageId=8888


http://ocp.cancercare.on.ca/common/pages/UserFile.aspx?fileId=83597

https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=340815


http://health.gov.on.ca/en/pro/programs/ecfa/docs/qbp_chemo.pdf


Ductal Carcinoma In Situ (DCIS) Version 2015.10 Page 3 of 15Breast Cancer Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in t he pathway map. 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 inform ation set out in the pathway map. The inform ation in the pathway map does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.

Surgeon

Conversation regarding type of

surgery4

Consider patient preference and clinically necessary procedures

Breast conserving

surgery5

EBS #1-10

Mastectomy8 (+/-

reconstruction) and sentinel lymph node

biopsy

Results

Pathology6

ER/PgR determination only at the request of the

oncologist. HER2 for

invasive cancer or at the request of oncologist for microinvasion (<1mm).

EBS #22-1

DCIS

Negative

margins9

Results

Invasive cancer

Re-excision To achieve

negative margins9

Pathology

& EBS #17-5EBS #1-10

Invasive cancer

Endocrine therapyFor prevention

EBS #1-10

Medical Oncologist

Proceed to Follow-up Care Pathway Map(Page 3)

Mastectomy8 (+/-


biopsy

R

RPlastic

Surgeon7

R

Pathology6

ER/PgR determination only at the request of the oncologist.

HER2 for invasive cancer or at the request of oncologist for

microinvasion (<1mm).EBS #22-1

Proceed to page 7

Proceed to page 7

Genetics Clinic If not previously

seen and potentially high

risk1, 2, 3

Treatment decision

Determine local disease extent (as required) for clinical decision

making

1 Consider referral to genetics clinic if patients meet one of the following criteria: First degree relative of a carrier of a gene mutation (e.g. BRCA1, BRCA2) and has not had genetic counselling or testing, or a personal or family history of at least one of the following:

- Two or more cases of breast cancer and/or ovarian cancer in closely related relatives - Bilateral breast cancers- Both breast and ovarian cancer in the same woman- Breast cancer at 35 years of age- Invasive serous ovarian cancer- Breast and/or ovarian cancer in Ashkenazi Jewish families- An identified gene mutation (e.g. BRCA1, BRCA2) in any blood relative- Male breast cancer

2 Consider urgent referral to genetics clinic if treatment will be affected by genetic status.3 Patients who are known/found to be carriers of a deleterious gene mutation (e.g. BRCA 1/2) may consider bilateral mastectomy.4 Consider referral to radiation oncologist to determine eligibility for radiation therapy. Some patients who are ineligible for radiation, may need a mastectomy.5 Consultation with plastic surgeon may be appropriate in some cases.6 For more information about CAP checklists and protocols visit www.cap.org.7 Consultation with a radiation oncologist should be considered for patients who may be considered for immediate reconstruction.8 Contralateral prophylactic mastectomy is not recommended for average risk women. 9 For the purpose of this pathway map, negative margins are defined as no ink on tumor [no cancer cells adjacent to any inked edge/surface of the specimen] and positive margins are defined as ink on tumour. This definition has been adopted as per the College of American Pathologist s Protocol for the Examination of Specimens from Patients with DCIS of the Breast.

Pathology Results

Invasive cancer

DCIS

Proceed to page 7

Results

Invasive cancer

DCIS

Proceed to page 7

Proceed to page 4

Proceed to page 4

Proceed to page 4

Proceed to page 4

& EBS #17-5

EBS #1-10

W

W5

Plastic Surgeon7

Positive

margins9

DCIS

Negative

margins9

Positive

margins9

A

D

B

G

From Diagnosis

Pathway Map (Page

9 or 10)

C

EF

H

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


http://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=34090






http://cancercare.on.ca/common/pages/UserFile.aspx?fileId=117752



https://www.cancercare.on.ca/toolbox/symptools/

https://www.cancercare.on.ca/cms/one.aspx?portalId=1377&pageId=8270

Ductal Carcinoma In Situ (contd) Version 2015.10 Page 4 of 15Breast Cancer Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in t he pathway map. 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 inform ation set out in the pathway map. The inform ation in the pathway map does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.

From page 3


Radiation therapy

Endocrine therapy

EBS #1-10

Radiation Oncologist

Medical Oncologist

R WMCC

CEFH

Peer Review







Invasive Breast Cancer: Assessment for Operability

and Neoadjuvant TherapyVersion 2015.10 Page 5 of 15Breast Cancer Treatment Pathway Map

The pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in t he pathway map. 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 inform ation set out in the pathway map. The inform ation in the pathway map does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.

Surgeon

Genetics Clinic If not previously seen and potentially high

risk1,2,3

Disease status

Operable

Locally Advanced Breast Cancer

(T4 and/or N2-N3)

Candidate for neoadjuvant therapy

(e.g. T3 N0, tumour > 2cm and triple

negative or Her2+, and especially if

breast conserving surgery is

desired

Candidate for primary surgical

management

Proceed to page 6

Determine

local disease extent (as required) for clinical decision

making

(e.g. tumour size, nodal status)

Proceed to page 8

Proceed to page 10

Distant metastases suspected

(e.g. clinical signs, symptoms, laboratory

values)

Consider the following to exclude metastatic disease

Abdominal and chest imaging As appropriate

Bone scan

EBS #1-14

Results

Distant metastases (Stage IV)

No distant metastases

Proceed to page 11

2 Consider urgent referral to genetics clinic if treatment will be affected by genetic status.3 Patients who are known/found to be carriers of a deleterious gene mutation (e.g. BRCA 1/2) may consider bilateral mastectomy.

Note. EBS #1-14 is currently listed as For Education and Information Purposes . This means that the recommendations wil l no longer be maintained but may stil l be useful for academic or other information purposes.

1 Consider referral to genetics clinic if patients meet one of the following criteria: First degree relative of a carrier of a gene mutation (e.g. BRCA1, BRCA2) and has not had genetic counselling or testing, or a personal or family history of at least one of the following:

- Two or more cases of breast cancer and/or ovarian cancer in closely related relatives - Bilateral breast cancers- Both breast and ovarian cancer in the same woman- Breast cancer at 35 years of age- Invasive serous ovarian cancer- Breast and/or ovarian cancer in Ashkenazi Jewish families- An identified gene mutation (e.g. BRCA1, BRCA2) in any blood relative- Male breast cancer

From Diagnosis

Pathway Map (Page

9 or 10)

I

J

K

L





Operable Invasive Breast Cancer: Candidates for

Primary Surgical ManagementVersion 2015.10 Page 6 of 15Breast Cancer Treatment Pathway Map


Pathology6,11,12

EBS #22-1

Breast conserving

surgery5 and

axillary lymph node dissection

EBS #17-5EBS #1-1 &

Breast conserving

surgery5 and

sentinel lymph node

biopsy10

EBS #17-5EBS #1-1 &

Mastectomy8 (+/-

reconstruction) and axillary lymph node

dissection

EBS #17-5EBS #1-1 &

Mastectomy8 (+/-


biopsy10

EBS #17-5EBS #1-1 &

Baseline staging May include bone scan and chest/abdominal

imaging13

EBS #1-14Node positive on biopsy and neoadjuvant therapy not

required

Node negative

R

R

Conversation regarding

type of surgery4

Consider patient preference and clinically necessary

procedures

From page 5

Treatment decision


type of surgery4

Consider patient preference and clinically necessary

procedures

Treatment decision

Re-excisionTo achieve

negative margins

Mastectomy (+/-

reconstruction)7

If positive margins14,15

Or Pathology

Pathology6,11,12

EBS #22-1

Pathology6,11,12

EBS #22-1


negative margins

Mastectomy (+/-

reconstruction)7


Or Pathology

Pathology6,11,12

EBS #22-1

Proceed to Page 7

Proceed to Page 7

Axillary lymph

node dissection15

EBS #17-5

Pathology

Proceed to Page 7


4 Consider referral to radiation oncologist to determine eligibility for radiation therapy. Some patients who are ineligible for radiation, may need a mastectomy. 5 Consultation with plastic surgeon may be appropriate in some cases.6 For more information about CAP checklists and protocols visit www.cap.org.7 Consultation with a radiation oncologist should be considered for patients who may be considered for immediate reconstruction.8 Contralateral prophylactic mastectomy is not recommended for average risk women.

10 If the number of positive lymph nodes will change the radiation or systemic treatment plans consider a frozen section. If positive, consider an axillary lymph node dissection. 11 If no cancer in surgical specimen (e.g. very small tumours, <1cm) refer to core biopsy pathology including biomarker testing. 12 For more information about HER2 testing see ASCO (2013). Recommendations for HER2 receptor testing in breast cancer: American Society of Oncology/College of American Pathologist Clinical Practice Guideline Update. (Journal of Clinical Oncology, 2013, 31(31) 3997-4013). 13 Stage I: Bone scanning and chest/abdominal imaging is not indicated as part of baseline staging; Stage II: Postoperative bone scan is recommended. Routine liver and chest imaging are not indicated but could be considered for patients with >4 positive lymph nodes; Stage III: Bone scan and chest/abdominal imaging are recommended postoperatively for baseline staging. For more information see 14 For the purpose of this pathway map, negative margins are defined as no ink on tumor [no cancer cells adjacent to any inked edge/surface of the specimen] and positive margins are defined as ink on tumour. This definition has been adopted as per the American Society of Clinical Oncology guideline (Journal of Clinical Oncology, 2014, 32(14), 1502-1506).15 May defer re-excision, mastectomy and axillary lymph node dissection until after systemic therapy if high risk of systemic recurrence.

Note. EBS #1-1 and #1-14 are currently l isted as For Education and Information Purposes . This means that the recommendations wil l no longer be maintained but may stil l be useful for academic or other information purposes.


imaging13

EBS #1-14


imaging13

EBS #1-14

Baseline staging May include bone scan and chest/

abdominal imaging13

EBS #1-14

If positive lymph nodes and high risk of residual disease

Axillary lymph

node dissection15

EBS #17-5

PathologyRadiation

Oncologist


W

W

W

W

EBS #1-14

MCC

MCC

Plastic Surgeon7

Plastic Surgeon7

M

N

O

I



























Primary Surgical Management (contd)Version 2015.10 Page 7 of 15Breast Cancer Treatment Pathway Map


Endocrine therapy

Targeted therapy (e.g. Trastuzumab)

EBS #1-21

Medical Oncologist

R


RChemotherapy

From Page 6

Molecular profile test16

(e.g. Oncotype Dx)RR MOAC-2

From Page 6

From Page 3

From Page 3

Breast conserving surgery for invasive

cancer

Breast conserving surgery for DCIS showed invasive

cancer

Medical Oncologist

Risk of local-regional

recurrence

High risk (e.g. Node positive, T2,

T3, presence of lymphovascular

invasion)

Low risk


Radiation therapyLocal +/- regional therapy

& EBS #21-3-2

Mastectomy for invasive cancer

Mastectomy with sentinel lymph node

biopsy for DCIS showed invasive

cancer

EBS #1-2 Radiation

Oncologist

Sentinel lymph node biopsy

Pathology6

ER/PgR and HER2 if not previously done

Endocrine therapy


EBS #1-21

Chemotherapy

R

R

EBS #17-5

Molecular profile test16

(e.g. Oncotype Dx) RR MOAC-2

Note. EBS #21-3-2 is older than 3 years and is currently listed as For Education and Information Purposes . This means that the recommendations wil l no longer be maintained but may stil l be useful for academic or other information purposes.


& EBS #21-3-2 EBS #1-2


& EBS #21-3-2 EBS #1-2

W

W

W

6 For more information about CAP checklists and protocols visit www.cap.org.16Candidates for molecular profile tests are patients with node negative (N0), ER positive and HER2 negative breast cancer in whom the decision

for chemotherapy is unclear.

O

N

D

G

Proceed to Follow-up Care Pathway Map (Page 3)



M

B

A

& Peer Review

& Peer Review

& Peer Review




















Neoadjuvant TherapyVersion 2015.10 Page 8 of 15Breast Cancer Treatment Pathway Map


Medical Oncologist

Neoadjuvant systemic therapy

Endocrine therapy



Chemotherapy

From page 5


type of surgery4

Consider patient preference and clinically necessary procedures

R

Not

responding17

Responding

No distant metastases and

operable

Distant metastases

Surgeon


Proceed to Page 11

No distant metastases And

Inoperable

Breast conserving

surgery5 and

sentinel lymph node

biopsy10

EBS #1-19

Mastectomy8 (+/-

reconstruction) and sentinel

lymph node biopsy10

EBS #1-19

Pathology6,12

EBS #22-1

Pathology6,12

EBS #22-1

Reevaluation of pathology

Examination of pathology report on core needle biopsy

results

Biomarkers

ER/PgR and HER2 if not

previously done6,12

Response to neoadjuvant

therapy

Treatment decision

& EBS #17-5

Proceed to Page 9

4 Consider referral to radiation oncologist to determine eligibility for radiation therapy. Some patients who are ineligible for radiation, may need a mastectomy. 5 Consultation with plastic surgeon may be appropriate in some cases.6 For more information about CAP checklists and protocols visit www.cap.org.7 Consultation with a radiation oncologist should be considered for patients who may be considered for immediate reconstruction.8 Contralateral prophylactic mastectomy is not recommended for average risk women.10 If the number of positive lymph nodes will change the radiation or systemic treatment plans consider a frozen section. If positive, consider an axillary lymph node dissection. 12 For more information about HER2 testing see ASCO (2013). Recommendations for HER2 receptor testing in breast cancer: American Society of Oncology/College of American Pathologist Clinical Practice Guideline Update. (Journal of

Clinical Oncology, 2013, 31(31) 3997-4013). 14 For the purpose of this pathway map, negative margins are defined as no ink on tumor [no cancer cells adjacent to any inked edge/surface of the specimen] and positive margins are defined as ink on tumour. This definition has been

adopted as per the American Society of Clinical Oncology guideline (Journal of Clinical Oncology, 2014, 32(14), 1502-1506).15 May defer re-excision, mastectomy and axillary lymph node dissection until after systemic therapy if high risk of systemic recurrence.17 Consider addition systemic options before considering other treatment options.


& EBS #21-3-2

EBS #1-19


W

W

W

Plastic Surgeon7

Surgeon

MCC


negative margins

Mastectomy (+/-

reconstruction)7


Or Pathology


J

P

Q

& Peer Review








https://www.cancercare.on.ca/pcs/treatment/multiconfers/





Neoadjuvant Therapy (contd)Version 2015.10 Page 9 of 15Breast Cancer Treatment Pathway Map


From Page 8


Axillary lymph

node dissection15

EBS #17-5

PathologyRadiation

Oncologist


W

15 May defer re-excision, mastectomy and axillary lymph node dissection until after systemic therapy if high risk of systemic recurrence.

MCC


& EBS #21-3-2

EBS #1-19


Q

& Peer Review










Locally Advanced Breast Cancer (Inoperable) Version 2015.10 Page 10 of 15Breast Cancer Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in t he pathway map. 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 inform ation set out in the pathway map. The inform ation in the pathway map does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.

Imaging for metastatic disease

To be considered for patients with clinically advanced but

operable disease and those who exhibit clinical signs, symptoms and laboratory values indicating

presence of metastases

Abdominal and chest imaging

As appropriate

Bone scan

Medical Oncologist

Needle cytology of axillary nodes

Clinical and radiological assessment of the axilla

Distant metastases


Results


Neoadjuvant systemic therapy

Endocrine therapy


Chemotherapy

Proceed to Page 11

From Page

5

Reevaluation of pathology

Examination of pathology report on core

needle biopsy results

Biomarkers

ER/PgR and HER2 if not

previously done7,12

MRITo determine disease extent in the breast

Operable

Surgeon

R

Distant metastases


and inoperable

Modified radical mastectomy

(+/- reconstruction)

Pathology6,12

EBS #22-1

EBS #1-19


Response to optimal

neoadjuvant systemic

therapy

R

Radiation therapyLocal +/- regional

therapy

& EBS #21-3-2EBS #1-19



Radiation therapyLocal +/- regional

therapy

& EBS #21-3-2

EBS #1-19Response

Operable

Inoperable

6 For more information about CAP checklists and protocols visit www.cap.org.7 Consultation with a radiation oncologist should be considered for patients who may be considered for immediate reconstruction. 12 For more information about HER2 testing see ASCO (2013). Recommendations for HER2 receptor testing in breast cancer: American Society of Oncology/College of American Pathologist Clinical Practice Guideline Update. (Journal of

Clinical Oncology, 2013, 31(31) 3997-4013).

W

WW

MCC

Plastic Surgeon7



K

R

& Peer Review

& Peer Review













Distant Metastases (Stage IV) Version 2015.10 Page 11 of 15Breast Cancer Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in t he pathway map. 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 inform ation set out in the pathway map. The inform ation in the pathway map does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.

Palliative radiation therapy

Palliative surgery (e.g. CNS, local-regional)

Appropriate therapy may include

one or more of the following:

Palliative systemic treatment

From Page 5, 8,

10 or 12

Psychosocial oncology and supportive care Referral to appropriate specialist if additional

support is required

PathologyER/PgR and HER2

status determination6

EBS #22-1

Proceed to End of Life Care Pathway Map (page 14)

Conversation regarding treatment Consider patient and tumour characteristics

End of life care planning

Medical Oncologist


Surgeon

Supportive &

End of Life

Care Teams

Consider re-biopsy of metastatic

6 For more information about CAP checklists and protocols visit www.cap.org.

MCCFrom

Follow-up Care

Pathway Map

(Page 3)

W

RS

PL

Peer Review







Local And/Or Regional Recurrence Version 2015.10 Page 12 of 15Breast Cancer Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in t he pathway map. 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 inform ation set out in the pathway map. The inform ation in the pathway map does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.

Clinical or radiographic

suspicion of new or recurrent local

disease

Most responsible

care provider

Normal/benign

Staging for distant metastases

Results

Distant metastases


Proceed to Page 13

Fromactive

treatment

Breast Imaging As appropriate

ResultsBiopsy

PathologyER/PgR and HER2

determination only at the request of the oncologist

CancerChest wall

recurrence (post mastectomy)

Ipsilateral breast tumour recurrence

(post breast conserving surgery)

Regional node recurrence

Proceed to Page 13

Proceed to Page 13

From Follow-up

Care Pathway

Map(Page 4)

Proceed to Page 11

MCC

MCC

MCC


T

U

V

S







Local And/Or Regional Recurrence (contd) Version 2015.10 Page 13 of 15Breast Cancer Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in t he pathway map. 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 inform ation set out in the pathway map. The inform ation in the pathway map does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.

Previous radiation

Mastectomy (+/- reconstruction) and

node stagingIf possible

SurgeonFrom

Page 12Surgical resection

If possible

Pathology6

ER/PgR and HER2 if not done on core excisional

specimen

RTreatment as

appropriate based on extent of disease

From Page 12

No previous radiation

Pathology6 R

Medical Oncologist


Treatment as appropriate based

on extent of disease

Breast conserving

surgery5

R

Pathology6 R

Medical Oncologist


Treatment as appropriate based

on extent of disease

From Page 12

Medical Oncologist


SurgeonSurgical resection

If possible

Pathology6

ER/PgR and HER2 if not done on core excisional

specimen

RTreatment as

appropriate based on extent of disease

Medical Oncologist


Breast conserving surgery not

possible

5 Consultation with plastic surgeon may be appropriate in some cases.6 For more information about CAP checklists and protocols visit www.cap.org.7 Consultation with a radiation oncologist should be considered for patients who may be considered for immediate reconstruction.

W

W

W

W

Plastic Surgeon7

T

U

V




End of Life Care Version 2015.10 Page 14 of 15Breast Cancer Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in t he pathway map. 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 inform ation set out in the pathway map. The inform ation in the pathway map does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.

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

within the Psychosocial &

Palliative Care Pathway Map

Triggers that

suggest patients

are nearing the

last few months

and weeks life

ECOG/Patient-

ECOG/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

End of Life Care

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)

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)

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

+

Screen, Assess & Plan

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

(refer to Collaborative Care Plan)

http://www.goldstandardsframework.org.uk/

https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=285263#page=4




http://www.goldstandardsframework.org.uk/

End of Life Care cont. Version 2015.10 Page 15 of 15Breast Cancer Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in t he pathway map. 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 inform ation set out in the pathway map. The inform ation in the pathway map 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 l ife and 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

Provide opportunities

for debriefing of care

team, including

volunteers

Patient Death

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

Documents

Breast Cancer Treatment Pathway Map · physician-patient relationship between Cancer Care Ontario (CCO) and the reader. While care has been taken in the preparation of the information