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.
Endometrial Cancer Treatment & Follow-Up Pathway MapDisease Pathway Management
Version 2018.12
Pathway Map Preamble Version yyyy.mm Page 2 of 16
© 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 2018.12 Page 2 of 16Endometrial Treatment & Follow Up 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.
Line Guide
Required
Possible
or
Shape Guide
Intervention
Decision or assessment point
Patient (disease) characteristics
Consultation with specialist
Exit pathway
Off-page reference
Patient/ Provider interaction
Referral
Wait time indicator time point
Pathway Map Legend
W
R
Colour Guide
Primary Care
Palliative Care
Pathology
Gynecologic Oncology
Radiation Oncology
Medical Oncology
Radiology
Gynecology
Genetics
Multidisciplinary Cancer Conference (MCC)
Psychosocial Oncology (PSO)
Target Patient Population Women presenting with endometrial cancer
Pathway Map Considerations For more information about the optimal organization of gynecologic oncology services in Ontario refer to .
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 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 healthcare provider , used throughout the pathway map, includes primary care providers, specialists, midwives, nurse practitioners, gynecologists, emergency physicians or other healthcare providers
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 oncology (PSO) is the interprofessional specialty concerned with understanding and treating the social, practical, psychological, emotional, spiritual and functional needs and quality-of-life impact that cancer has on patients and their families. 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 potentially life-limiting illness:
- Palliative care may be of benefit 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
EBS #4-11
Health Care Connect,
Person-Centered Care Guideline
EBS #19-2 Provider-Patient Communication*
MCC Tools
Surgery, Systemic Treatment, Radiation Treatment Wait Times prioritizations.
EBS #19-3*
* Note. EBS #19-2 and EBS#19-3 are older than 3 years and is currently listed as For Education and Information Purposes . This means that the
recommendations will no longer be maintained but may still be useful for academic or other information purposes.
Clinical Stage I Version 2018.12 Page 3 of 16Endometrial Cancer Treatment & Follow Up 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 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.
Primary Staging Surgery
Minimally Invasive Surgery is
best practice
Total Hysterectomy
Bilateral Salpingo-
oophorectomy
Possible Pelvic Lymph Node
Assessment Primary Staging Surgery
Minimally Invasive Surgery
is best practice
Total Hysterectomy
Bilateral Salpingo-
oophorectomy
Pelvic Lymph Node
Assessment
Possible Para-aortic Lymph
Node Dissection
Pathology16
Sexual Health
Discussion
Fertility
Discussion1
Yes
No
Meets Criteria
for Fertility
Sparing? 7
Appropriate
for primary
surgery?6
Primary Staging Surgery
Minimal Invasive Surgery is best practice
Total Hysterectomy
Bilateral Salpingo-oophorectomy
Pelvic Lymph Node Assessment
Omentectomy
Possible Para-aortic Lymph Node Dissection
Serous,
Carcinosarcoma,
Clear cell,
Mixed histology
Endometrioid
Grade 1 or 2
Endometrioid
Grade 3
Proceed
to Page 8
Proceed
to Page 9
Proceed
to Page
12
Results
Proceed
to Page
6
1 Discussion to be individualized for each patient; however, may include the following: fertility options, hormone replacement therapy, referral for infertility consultation, etc.2 All tumours with MSH2/MSH6, MSH6, PMS2 and MLH1 (without hypermethylation) deficiency are candidates for genetic testing and should be referred for genetic counselling. 3 Endometrioid Grade 1: If grade I endometriod cancer diagnosed at a non- gynecologic oncology center (GOC), the pathology must be reviewed by a second pathologist. Both pathologists must be in agreement with diagnosis of grade I endometriod cancer; otherwise, referral of patient to a GOC is necessary.4 Endometriod Grade 2, 3 or High Risk Histology: Pathology review by a pathologist with an interest in gynecologic pathology at a gynecologic oncology center (GOC)5 The following should be taken into consideration: performance status, surgical resectability, and patient comorbidities6 Referral to gynecologist oncologist is optional for patients with grade 1 disease, however patients who are unfit for surgery or have a clinically enlarged cervix should be referred to a gynecologist oncologist7 Patients should undergo counseling that fertility sparing is for highly selected and motivated patients who meet strict crite ria for progestin therapy. Criteria for fertility sparing progestin therapy include: 1) Grade 1 endometrioid adenocarcinoma, 2) no myometrial invasion on MRI, 3) no metastatic disease, 4) no contraindications to
progesterone therapy, 5) desire for future fertility.11 High risk histology: serous, clear cell, carcinosarcoma, undifferentiated, mixed high grade16 All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.
R
CT Abdomen
Pelvis for Grade
3 or high risk
histology
Bloodwork
CA 125
Yes
NoObservation
Proceed
to Page 13
(Follow-
up)
Medical
Oncologist
Radiation
OncologistMCC
Radiation Therapy
Chemotherapy
Hormonal Therapy
From
Diagnosis
Pathway Map
(Page 4)
Gyneco-
logist
Gynecologic
Oncologist6
Pathology
Review3,16
R
R
Endometrioid
Grade 1
Refer to EBS #4-11
Endometrioid
Grade 2, 3, or High
Risk Histology 12
Refer to EBS #4-11 Appropriate
for primary
surgery?5
Yes
No Proceed
to Page 13
Medical
Oncologist
Radiation
OncologistMCC
Radiation
Therapy
Chemotherapy
Gynecologic
Oncologist
Pathology
Review4,16
Endometrioid
Grade 2
Endometrioid
Grade 3 or High
Risk Histology11
Genetics2
Genetics
Clinic
Genetics2
Genetics
Clinic
Genetics2
Genetics
Clinic
Preoperative
Work-Up
Ultrasound (if
not previously
done)
CT Chest
Chest X-Ray
A B
C
D
E
CT Abdomen
Pelvis for
Grade 2
OR
G
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Clinical Stage II Version 2018.12 Page 4 of 16Endometrial Cancer Treatment & Follow Up 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 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.
Primary Staging Surgery
Minimally Invasive Surgery is best
practice
Total Hysterectomy, recommend
radical hysterectomy
Bilateral Salpingo-oophorectomy
Cytology
Pelvic Lymph Node Assessment
Possible Para-aortic Lymph Node
Dissection Peritoneal washings
Omentecomy if high grade histology
R
Pathology16Yes
NoR
Results
From
Diagnosis
Pathway
Map
(Page 4)
3 Endometrioid Grade 1: If grade I endometriod cancer diagnosed at a non- gynecologic oncology center (GOC), the pathology must be reviewed by a second pathologist. Both pathologists must be in agreement with diagnosis of grade I endometriod cancer; otherwise, referral of patient to a GOC is necessary4 Endometriod Grade 2, 3 or High Risk Histology: Pathology review by a pathologist with an interest in gynecologic pathology at a gynecologic oncology center (GOC)5 The following should be taken into consideration: performance status, surgical resectability, and patient comorbidities10 Consider referral to a radiation centre with intracavitary brachytherapy cases 10 per year 16 All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.
Endometrioid
Serous,
Carcinosarcoma,
Clear cell and
Mixed Histology
Grade 1 or 2
Grade 3
Proceed
to Page 10
Proceed
to Page 11
Proceed
to Page 12
MCC
Appropriate
for primary
surgery?5
Radiation
Oncologist10
Medical
Oncologist
External Beam
Radiation Therapy
Chemotherapy
MCC
Surgery
Gynecologic
Oncologist
Pathology
Review3,4,16
Stage III/IV Proceed to
Page 5
Intracavitary
BrachytherapyProceed
to Page 13
CT Chest
MRI Pelvis
CT
Abdomen
Pelvis
CT Chest
Pelvic MRI
CT
Abdomen
Pelvis
H
I
J
L
M
and/or
EBS 4-11; EBS 21-2*
* Note. EBS 21-2 is older than 3 years and is currently listed as For Education and Information Purposes . This means that the recommendations will no longer be maintained but may still be useful for academic or other information purposes.
Stage
Stage II
Sexual Health
Discussion
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Clinical Stage III/IV Extrauterine Disease (Metastasis) Version 2018.12 Page 5 of 16Endometrial Cancer Treatment & Follow Up 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 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.
Yes
No
Pathology16 Results
MCC Surgery
1 Discussion to be individualized for each patient; however, may include the following: fertility options, hormone replacement therapy, referral for infertility consultation, etc.2 All tumours with MSH2/MSH6, MSH6, PMS2 and MLH1 (without hypermethylation) deficiency are candidates for genetic testing and should be referred for genetic counselling. 3 Endometrioid Grade 1: If grade I endometriod cancer diagnosed at a non- gynecologic oncology center (GOC), the pathology must be reviewed by a second pathologist. Both pathologists must be in agreement with diagnosis of grade I endometriod cancer; otherwise, referral of patient to a GOC is necessary4 Endometriod Grade 2, 3 or High Risk Histology: Pathology review by a pathologist with an interest in gynecologic pathology at a gynecologic oncology center (GOC)5 The following should be taken into consideration: performance status, surgical resectability, and patient comorbidities16 All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.
Endometrioid
Grade 1 or 2
Grade 3
Proceed
to Page 10
Proceed
to Page 11
Appropriate
for primary
surgery?5
Radiation Therapy
Chemotherapy
Hormonal Therapy
R
Pathology
Review3,4,16
R
Primary Cytoreductive
Surgery
Total hysterectomy
Bilateral Salpingo-
oopherectomy
Cytoreductive
surgery
Fertility
Discussion1
Gynecologic
Oncologist
MCC
Radiation
Oncologist
Medical
Oncologist
From
Diagnosis
or
Treatment
(Page 4)
MCC
Proceed
to Page 12
Proceed
to Page 13
Genetics2
Genetics
Clinic
R
Genetics2
Genetics
ClinicCT Chest
CT
Abdomen
Pelvis
CT Chest
CT
Abdomen
Pelvis
N
O
P
R
M
Serous,
Carcinosarcoma,
Clear cell and Mixed
Histology
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Endometrioid- Fertility Sparing Version 2018.12 Page 6 of 16Endometrial Cancer Treatment & Follow Up 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 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.
From
Page 3R
Progestin
Therapy7,9Status
Complete
Response
Persistent
MRI Pelvis
Meets Criteria for Progestin Therapy?7
No
Yes
Surgical Staging
Minimal invasive surgery is
best practice Total hysterectomy
Bilateral Salpingo-
oophorectomy12
Stage I
Stage II
Pathology16 Results
Proceed
to Page 8
Proceed
to Page 10
2 All tumours with MSH2/MSH6, MSH6, PMS2 and MLH1 (without hypermethylation) deficiency are candidates for genetic testing and should be referred for genetic counselling. 3 Endometrioid Grade 1: If grade I endometriod cancer diagnosed at a non- gynecologic oncology center (GOC), the pathology must be reviewed by a second pathologist. Both pathologists must be in agreement with diagnosis of grade I endometriod cancer; otherwise, referral of patient to a GOC is necessary4 Endometriod Grade 2, 3 or High Risk Histology: Pathology review by a pathologist with an interest in gynecologic pathology at a gynecologic oncology center (GOC)7 Patients should undergo counseling that fertility sparing is for highly selected and motivated patients who meet strict crite ria for progestin therapy. Criteria for fertility sparing progestin therapy include: 1) Grade 1 endometrioid adenocarcinoma, 2) no myometrial invasion on MRI, 3) no metastatic disease, 4) no contraindications to
progesterone therapy, 5) desire for future fertility.8 Consider requesting IHC for mismatch repair9 Suggested progestin therapy includes medroxyprogesterone, megestrol acetate, and levonorgestrel IUD12 Consider omitting oophorectomy after thorough preoperative counselling with patient16 All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.
Progestin
Therapy7,9
Disease
Status
at 9-12
months?
Persistence or
Progressive
disease
Fertility Sparing
Treatment 7R
REI
(Reproductive
endocrinology and
infertility)
Dietitian
Proceed
to Page 7
MRI Pelvis
CT Abdomen
Pelvis
Bloodwork
CA 125
Gynecologic
Oncologist
Pathology
Review4,8,16
Biopsy
OR
Dilation and
Curettage
R
Gynecologist
Pathology
Review3,4,16
Genetics2
Genetics
Clinic
R
CT Chest
S
T
U
A
MRI Pelvis
Assessment every 3
months up to 9-12
monthsBiopsy
OR
Dilation and
Curettage
Pathology
Review3,4,16
MRI Pelvis
Assessment every 3
months up to 9-12
months
REI
(Reproductive
endocrinology and
infertility)
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Endometrioid Fertility Sparing (contd) Version 2018.12 Page 7 of 16Endometrial Cancer Treatment & Follow Up 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 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.
From
Page 6Status
Desire pregnancy
now
Desire pregnancy
later
Endometrial
Protection13
Complete
Hysterectomy
and Bilateral
Salpingo-
oopherectomy
Encourage
conception if
appropriate
Biopsy
Biopsy every 6
months
OR
abnormal bleeding
as per clinician
discretion
3 Endometrioid Grade 1: If grade I endometriod cancer diagnosed at a non- gynecologic oncology center (GOC), the pathology must be reviewed by a second pathologist. Both pathologists must be in
agreement with diagnosis of grade I endometriod cancer; otherwise, referral of patient to a GOC is necessary4 Endometriod Grade 2, 3 or High Risk Histology: Pathology review by a pathologist with an interest in gynecologic pathology at a gynecologic oncology center (GOC)12 Consider omitting oophorectomy after thorough preoperative counselling with patient13 IUD levonorgestrel, oral contraceptive pill, cyclical provera, or other progestational agents16 All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.
REI
(Reproductive
endocrinology and
infertility)
R
Proceed
to Page 13
Pathology
Review3,4,16
Child bearing
complete or
recurrent
endometrial cancer?
Yes
NoContinue Endometrial
Protection12
V
S
Results
Normal
Recurrent endometrial
cancer on biopsy
Surgical Staging
Minimal invasive surgery is
best practice Total hysterectomy
Bilateral Salpingo-
oophorectomy12
Stage I
Stage II
Pathology16 Results
Proceed
to Page 8
Proceed
to Page 10
W
X
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Endometrial Grade 1 or 2, Stage I Version 2018.12 Page 8 of 16Endometrial Cancer Treatment & Follow Up 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 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.
Proceed
to Page 11
Risk
Factors
Present14
Results
3 Endometrioid Grade 1: If grade I endometriod cancer diagnosed at a non- gynecologic oncology center (GOC), the pathology must be reviewed by a second pathologist. Both pathologists must be in agreement with diagnosis of grade I endometriod cancer; otherwise, referral of patient to a GOC is necessary4 Endometriod Grade 2, 3 or High Risk Histology: Pathology review by a pathologist with an interest in gynecologic pathology at a gynecologic oncology center (GOC)5 The following should be taken into consideration: performance status, surgical resectability, and patient comorbidities14 Risk factors include: age greater than 60 years based on Portec 1, positive lymphovascular invasion, deep myometrial invasion more than or equal to 50% 16All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.
Yes
NoVaginal
Brachytherapy
Observation
Vaginal
Brachytherapy Proceed
to Page 13External Beam
Radiation Therapy
From
Page
3,6,7
Grade 1 or
Grade 2
Y
Stage IA
Stage IB
Stage II
Stage III
Risk
Factors
Present14
Yes
No
Vaginal
Brachytherapy
Observation
Observation
Pathology16
Unstaged
CT Abdomen,
Pelvis
(If not previously
done)
No
Appropriate
for surgery?5
Yes
MCC
Gynecologic
Oncologist
Pathology
Review3,4,16
(If not
previously
done)
Radiation
Oncologist
Staging Surgery
Minimally Invasive Surgery is best practice
Consider Bilateral Salpingo-oophorectomy if
not removed
Possible PLN assessment for Grade 1
Additionally for Grade 2:
Pelvic Lymph Node Assessment
Staged
CTW
Status
I/O
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Endometrioid Grade 3 Stage I Version 2018.12 Page 9 of 16Endometrial Cancer Treatment & Follow Up 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 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.
MCC
Risk
Factors
Present14
Pathology
Review4,16
Radiation
Oncologist
From
Page 3Stage 1A
Status
Unstaged
No
Appropriate
for
surgery?5
4 Endometriod Grade 2, 3 or High Risk Histology: Pathology review by a pathologist with an interest in gynecologic pathology at a gynecologic oncology center (GOC)5 The following should be taken into consideration: performance status, surgical resectability, and patient comorbidities14 Risk factors include: age greater than 60 years based on Portec 1, positive lymphovascular invasion, deep myometrial invasion16 All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.
Stage 1B
Risk
Factors
Present14
Yes
No
Yes
No
Proceed
to Page 13
Staged
YesPathology16
Vaginal
Brachytherapy
Vaginal
Brachytherapy
Vaginal
Brachytherapy
Observation
Vaginal
Brachytherapy
External Beam
Radiation Therapy
External Beam
Radiation Therapy
Primary Staging Surgery
Minimal Invasive Surgery is best practice
Bilateral Salpingo-oophorectomy
Pelvic Lymph Node Assessment
Omentectonmy
Para-aortic Lymph Node Dissection
Peritoneal washings
CT Abdomen,
Pelvis
(If not done
previously)
External Beam
Radiation Therapy
D
Results
Stage II- IVBProceed
to Page 11
Z
AA
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Grade 1 or 2, Stage II - IVB Version 2018.12 Page 10 of 16Endometrial Cancer Treatment & Follow Up 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 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.
From
Page 4-7
MCC
Pathology
Review4,16
Radiation
Oncologist
Medical
OncologistStatus
Unstaged
Staged
Appropriate
for surgery?5
Yes
No
Staging Surgery Pathology16
Stage II
Stage IIIA
Stage IIIB
Stage IIIC
Stage IVA
Stage IVB
Pelvic Radiation Therapy
Vaginal Brachytherapy
Tumour Directed Radiation
Therapy
Chemotherapy
Hormonal Therapy
Tumour Directed Radiation
Therapy
Chemotherapy
Hormonal Therapy
Clinical Trials
Proceed
to Page 13
CT Abdomen,
Pelvis
(If not done
previously)
BB
H
N
U
4 Endometriod Grade 2, 3 or High Risk Histology: Pathology review by a pathologist with an interest in gynecologic pathology at a gynecologic oncology center (GOC)5 The following should be taken into consideration: performance status, surgical resectability, and patient comorbidities16 All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.
Results
X
Vaginal Brachytherapy
Chemotherapy
Pelvic Radiation Therapy
Concurrent Chemotherapy
Chemotherapy
Pelvic +/- Tumour Directed
Radiation Therapy
Concurrent Chemotherapy
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Grade 3, Stage II - IVB Version 2018.12 Page 11 of 16Endometrial Cancer Treatment & Follow Up 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 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.
From
Page
4,5,9
MCC
Pathology
Review4,16
Radiation
Oncologist
Medical
OncologistStatus
Unstaged
Staged
Appropriate
for surgery?5
Yes
No
Staging Surgery Pathology16
Stage II
Stage IIIA
Stage IIIB
Stage IIIC
Stage IVA
Stage IVB
Pelvic Radiation Therapy
Vaginal Brachytherapy
Pelvic +/- Tumour Directed
Radiation Therapy
Chemotherapy
Clinical Trials
Proceed
to Page 13
CT Chest,
Abdomen, Pelvis
(If not done
previously)
CC
I
O
4 Endometriod Grade 2, 3 or High Risk Histology: Pathology review by a pathologist with an interest in gynecologic pathology at a gynecologic oncology center (GOC)5 The following should be taken into consideration: performance status, surgical resectability, and patient comorbidities16 All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.
Chemotherapy
Results
AA
Vaginal Brachytherapy
Chemotherapy
Pelvic Radiation Therapy
Concurrent Chemotherapy
Chemotherapy
Pelvic +/- Tumour Directed
Radiation Therapy
Concurrent Chemotherapy
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Serous, Carcinosarcoma, Clear Cell and Mixed
HistologyVersion 2018.12 Page 12 of 16Endometrial Cancer Treatment & Follow Up 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 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.
Gynecologic
Oncologist
Stage IA/IB
Stage II
Stage IIIA
Stage IIIB
Stage IVA
From
Pages
3, 4, 5
Stage IVB
Status
IA
Staged
Unstaged
CT imaging
(if not done
previously)
Appropriate
for
surgery?5
No
Yes
Staging Surgery
Pelvic Lymph Node Assessment
Para-aortic Lymph Node
Dissection
Pathology16
Radiation
Oncologist
Medical
Oncologist
Radiation
Oncologist
Medical
Oncologist Proceed
to Page 13
Radiation
Oncologist
Medical
Oncologist
Stage IIIC
Radiation
Oncologist
Medical
Oncologist
Results
Radiation
Oncologist
Medical
Oncologist
DD
E
J
P
5 The following should be taken into consideration: performance status, surgical resectability, and patient comorbidities
16 All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.
Results
IB
Vaginal Brachytherapy
Chemotherapy
Pelvic +/- Tumour Directed Radiation Therapy
Concurrent Chemotherapy
Chemotherapy
Pelvic Radiation Therapy
Concurrent Chemotherapy
Chemotherapy
Pelvic Radiation Therapy
Vaginal Brachytherapy
Radiation
OncologistMedical
Oncologist
Chemotherapy
Pelvic Radiation Therapy
Vaginal Brachytherapy
Chemotherapy
Pelvic Radiation Therapy
Vaginal Brachytherapy
Radiation
Oncologist
Medical
Oncologist
Pelvic +/- Tumour Directed Radiation Therapy
Chemotherapy
Chemotherapy
Pelvic +/- Tumour Directed Radiation Therapy
Clinical Trial
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Follow-up Care (All Sub-Types) Version 2018.12 Page 13 of 16Endometrial Cancer Treatment & Follow Up 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 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.
Follow-up Frequency
Every 3-6 months within the first two
years and then every six months for the
next three years
Gynecologic
Oncologist
From
Pages
3-5,7-12
Physical and Pelvic-rectal
examination
Gynecologist
(Grade 1, stage
1 endometrioid)
No evidence of recurrence
for 3-5 years
Suspicion for recurrence
Recurrence
Non-Cancer Related
Not suggestive of
recurrence
Late Effects of
Treatment
Refer to
Appropriate
Specialist
Refer to
Appropriate
Specialist
Refer to
Primary Care
Provider
Distant Metastases
Proceed
to Page 14
Medical
Oncologist
Radiation
Oncologist
Refer to EBS #4-9
Refer to EBS #4-9
OR
OR
OR
Imaging as
Appropriate
EE
B
G
L
R
V
Personal and family medical
history
Primary care
provider15
OR
15 Appropriate for low risk stage 1a with no adjuvant therapy
Y
Z
BB
CC
DD
Status
Results
Refer to
Primary Care
Provider (if
not done prior
to 5 years)
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Persistent, Recurrent, Metastatic and Carcinosarcoma
(All Sub-Types) Version 2018.12 Page 14 of 16Endometrial Cancer Treatment & Follow Up 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 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.
Pathology
Review4,16
Repeat
Biopsy
CT Abdomen,
Pelvis
MRI Pelvis
Imaging as
Appropriate
From
Page 13
4 Endometriod Grade 2, 3 or High Risk Histology: Pathology review by a pathologist with an interest in gynecologic pathology at a gynecologic oncology center (GOC).16 All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.
Medical
Oncologist
Radiation
Oncologist
Gynecologic
Oncologist
MCC
Palliative Care
Proceed
to
End-of-Life
(Page 15)
Chemotherapy
EBS #4-3
Clinical Trials
EBS #4-3
Psychosocial oncology and
palliative care
Referral to appropriate specialist
if additional support is required
End of life care planning
Progression
Appropriate therapy may include one or
more of the following:
Radiation therapy
Surgery
PSO
EE
CT Chest
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
End of Life Care Version 2018.12 Page 15 of 16Endometrial Cancer Treatment & Follow Up 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 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.
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 Home and Community Care early (not just for last 2 to 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 http://www.goldstandardsframework.org.uk/
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
End of Life Care cont. Version 2018.12 Page 16 of 16Endometrial Cancer Treatment & Follow Up 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 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.
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
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
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools