hpv-negative oropharyngeal squamous cell carcinoma … · 2019-10-22 · stage i/ii version 2019.09...

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.

HPV-Negative Oropharyngeal Squamous Cell Carcinoma

Treatment Pathway MapVersion 2019.09

Pathway Map Preamble Version yyyy.mm of 13Confidential 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 2019.09 Page 2 of 13

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

Palliative Care

Pathology

Surgery

Radiation Oncology

Medical Oncology

Radiology

Multidisciplinary Cancer Conference (MCC)

Psychosocial Oncology (PSO)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/Provider Interaction

Referral

Wait time indicator time point

Pathway Map Legend

W

R

X

X

HPV-Negative Oropharyngeal Squamous

Cell Carcinoma Treatment Pathway Map

Pathway Map Considerations 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. 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, 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 .

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

The term health care provider , used throughout the pathway, includes primary care providers and specialists, nurse practitioners, otolaryngologists, speech language pathologists, registered dietitians, and emergency physicians.

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. PSO support may include social worker and psychiatric support. Psychiatric support may be provided by a Psychologist, a Psychiatrist or by a Primary Care Provider. For more information, visit

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.

The following should be considered when weighing the treatment options described in this pathway 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

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

Counseling and treatment for smoking cessation should be initiated early on in the pathway and continued by care providers throughout the pathway as necessary.

Organizational Guidance for the Care of Patients with Head and Neck Cancer in Ontario recommendations apply across this pathway and establish the minimum requirements to maintain a head and neck disease site program. For more information visit:

MCC Tools

Surgery, Systemic Treatment, Radiation Treatment Wait Times prioritizations.

EBS #19-3

Health Care Connect,

Person-Centered Care Guideline

* Note. EBS #19-3 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.

Program Training & Consultation Centre – Hospital Based Resources

Quality-Based Procedures Clinical Handbook for Systemic Treatment

GL 5-3ORG

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

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

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

https://www.ptcc-cfc.on.ca/cms/one.aspx?portalId=97833&pageId=352445

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

https://www.cancercareontario.ca/en/guidelines-advice/types-of-cancer/58936

Stage I/II Version 2019.09 of 13


Cell Carcinoma 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 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.

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

Treatment

Decision

Tumor originates from midlineor

Lateral origin with medial extension

Lateralized tonsillar cancer or

Very small palate and lateral pharyngeal wall

MCC or

MDT

Dental

Oncologist

Speech

Language

Pathologist

Registered

Dietitian

From

Diagnosis

Pathway

Map (Page

5)

Bilateral Neck Radiation Therapy

Peer Review

Ipsilateral Neck Radiation

TherapyPeer Review

Audiologist

Smoking

Cessation

Program

Nursing1

Radiation

Therapy

Surgery7

Indications include:

Contraindications for

radiation therapy,

Patient choice,

Previous radiation,

Amenable to transoral

resection without free flap

reconstruction

Pathology

Indications

for Post-

operative

Therapy4

Yes

No

Surgical Management of

Primary and Neck

(Nodal levels II-IV and those

with clinical or radiographic

evidence disease)

Radiation Therapy4

Concurrent

Chemotherapy5

EBS 5-11

Peer Review

Disease

Characteris-

tics

Social

Worker

PSO Support

Primary

Care

Provider2

Dental Evaluation

Nutrition, speech

and swallowing

evaluation/therapy,

and dysphagia

prevention

Psychosocial

Intervention

May include:

Financial:

disability, drug

benefits

Transportation

Placement

Medication

management

Counselling

regarding

diagnosis,

appearance

changes & HPV

Blood Work

Audiometry

R

Proceed

to Page 10

GL 5-3ORG

A

During Treatment

Ototoxicity Management

If patient is on chemotherapy

On Treatment Review

To include:

Radiation Medicine Clinician

Oncology Nurse

Patients should also have

access to:

Clinical Nurse Specialist /

Nurse Practitioner

Registered Dietitian

Speech Language Pathologist

Dental Oncology

Social Worker

Medical

OncologistR

Smoking cessation

counselling &

intervention where

appropriate

Note. EBS #5-11 is currently listed as In Review .

Proceed

to Page 11

BGL 5-3ORG

Stage I

T1 | N0 | M0

Stage II

T2 | N0 | M0

AJCC Cancer Staging

Manual 8th edition

UICC The TNM

Classification of

Malignant Tumours,

8th Edition

Stage I/II

1 All patients should have access to specialized oncology nurse, clinical nurse specialist or nurse practitioner to manage the complex physical, social and psychological health needs that arise during treatment and in early follow-up post treatment2 Some patients may require on-going direct care with their Primary Care Provider during treatment.3 Surgery may be an option for some patients. Patients should be included in trials investigating Transoral Robotic Surgery (TORS) where available.4 Indications for post-operative radiotherapy: Deep margins <5mm OR one or more of the following at the primary site: peri-neural invasion, lymph-vascular invasion OR lymph node involvement ( 2 lymph nodes, any lymph node >3 cm (N2+), nodal level IV-V LN positive, extracapsular extension (ECE)). 5 Indications for concurrent chemotherapy: positive margins or extracapsular extension (ECE).

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

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


http://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=299876







Stage III Version 2019.09 of 13





From

Diagnosis

Pathway

Map (Page

5)

Treatment

Decision

Radiation

Therapy

Surgery3



radiation therapy,

Patient choice,

Previous radiation,

Amenable to transoral

resection without free

flap reconstruction

Pathology

Indications

for Post-

Operative

Therapy4

Yes

Surgical Management of

Primary and Neck

(Nodal levels II-IV and those

with clinical or radiographic

evidence disease)

Proceed

to Page 10

Radiation Therapy

Peer ReviewDuring Treatment


If patient is on

chemotherapy

R

Age

70

Age

Age

>70

Concurrent

Chemotherapy

EBS 5-11

Radiation

TherapyPeer Review

Dental Evaluation

Nutrition, speech

and swallowing

evaluation/therapy,

and dysphagia

prevention

Psychosocial

Intervention

May include:

Financial:

disability, drug

benefits

Transportation

Placement

Counselling

regarding

diagnosis,

appearance

changes & HPV

Blood Work

Audiometry

Feeding Tube

Placement

NoProceed

to Page 11

Radiation

Therapy

Peer

Review

Concurrent Therapy

Targeted Therapy ChemotherapyOr

EBS 5-11

C

D

On Treatment Review

To include:

Radiation Medicine

Clinician

Oncology Nurse

Patients should also

have access to:

Clinical Nurse

Specialist / Nurse

Practitioner


Speech Language

Pathologist

Dental Oncology

Social Worker

Concurrent Therapy5

Targeted Therapy

Only consider if

age >70

Chemotherapy5Or

EBS 5-11

Radiation Therapy4

Peer Review

Node

negative

Nodal

status Node

positiveMCC or

MDT

Dental

Oncologist

Speech

Language

Pathologist

Registered

Dietitian

Social

Worker

PSO

Support

Audiologist

Smoking

Cessation

Program

Nursing1

Primary

Care

Provider2

Medical

Oncologist

Smoking cessation

counselling &

intervention where

appropriate

Note. EBS #5-11 is currently listed as In Review .

GL 5-3ORG

GL 5-3ORG

T3 | N0 | M0

T1-3 | N1 | M0

AJCC Cancer Staging

Manual 8th edition

UICC The TNM

Classification of Malignant

Tumours, 8th Edition

Stage III


















Stage IV A-B Version 2019.09 of 13




Age

Age 70

Age >70



Proceed

to Page 10

MCC or

MDT

Dental

Oncologist

Speech

Language

Pathologist

Registered

Dietitian

Social

Worker

PSO

Support

Audiologist

Smoking

Cessation

Program

Nursing1

Primary

Care

Provider2

From

Diagnosis

Pathway

Map (Page

5)

R

Radiation Therapy

Concurrent

Chemotherapy

Peer Review

Radiation Therapy

Concurrent Therapy

Targeted Therapy ChemotherapyOr

Peer Review

Dental Evaluation

Nutrition, speech

and swallowing

evaluation/therapy,

and dysphagia

prevention

Psychosocial

Intervention

May include:

Financial:

disability, drug

benefits

Transportation

Placement

Counselling

regarding

diagnosis,

appearance

changes & HPV

Blood Work

Audiometry

Feeding Tube

Placement

Treatment

Decision

Radiation

Therapy6 E

Medical

Oncologist

Smoking cessation

counselling &

intervention where

appropriate

EBS 5-11

EBS 5-11

Surgery3



radiation therapy,

Patient choice,

Previous radiation

PathologyIndications for

Post-Operative

Therapy4

YesSurgical Management

of Primary and Neck

(Nodal levels II-IV and

those with clinical or

radiographic evidence

disease)

NoProceed

to Page 11

Radiation Therapy4

Concurrent

Chemotherapy5

Peer Review

pT4a,

Gross bone

invasion

F

During Treatment



On Treatment Review

To include:

Radiation Medicine

Clinician

Oncology Nurse

Patients should also

have access to:

Clinical Nurse

Specialist / Nurse

Practitioner


Speech Language

Pathologist

Dental Oncology

Social Worker

GL 5-3ORG

GL 5-3ORG

Stage IVA

T4a | N0-1 | M0

T1-4a | N2 | M0

Stage IVB

T4b | any N | M0

Any T | N3 | M0

AJCC Cancer Staging Manual 8th

edition

UICC The TNM Classification of

Malignant Tumours, 8th Edition

Stage IVA-B Cancer

EBS 5-11












Stage IV C Metastatic Disease Version 2019.09 of 13



From

Page 7

R

Medical

Oncologist

Palliative Care

From

Diagnosis

Pathway

(Page 5)



MCC or

MDT

Dental

Oncologist

Speech

Language

Pathologist

Registered

Dietitian

Social

Worker

PSO Support

Audiologist

Smoking

Cessation

Program

Nursing1

Oligometastatic

disease

Disseminated

metastases

Fit for

systemic

therapy?

Yes

Systemic Therapy6

(e.g. Targeted therapy

or chemotherapy)

Proceed

to Page11

Consider aggressive local therapies

SurgeryAnd/Or

Extent of

Disease

Proceed

to Page 11

Observation

May be an option for

asymptomatic,

minimal bulk disease

Progression

Dental Evaluation

Nutrition, speech and

swallowing evaluation/

therapy, and dysphagia

prevention

In the recurrent and metastatic

scenario, patients may require

any and all of the same

supportive care as patients

undergoing primary treatment

Psychosocial Intervention

May include:

Financial: disability, drug

benefits

Transportation

Placement

Counselling regarding

diagnosis, appearance

changes & HPV

Blood Work

Audiometry

Feeding Tube Placement

Any T | Any N | M1

AJCC Cancer

Staging Manual 8th

edition

UICC The TNM

Classification of

Malignant Tumours,

8th Edition

Stage IV C/

Metastatic

Disease

Proceed to

End of Life

Care

Pathway Map

(page 12)

Appropriate therapy may include one or

more of the following:

Palliative Systemic Therapy6

(e.g. Targeted therapy or

chemotherapy)

Psychosocial oncology and

palliative care

Referral to appropriate specialist if

additional support is required

End of life care planning

Palliative Surgery

(e.g. CNS, local-regional)No

Clinical Trials

Palliative Radiation Therapy

Peer Review

G

H

K

Recurrence or

Progression

GL 5-3ORG

GL 5-3ORG

GL 5-3ORG

Systemic

TherapyAnd/Or

1 All patients should have access to specialized oncology nurse, clinical nurse specialist or nurse practitioner to manage the complex physical, social and psychological health needs that

arise during treatment and in early follow-up post treatment6 Platinum-containing agents (single or multi-agent) alone or in combination with other agents; other systemic therapy options may also exist including targeted therapies such as Nivolumab

as indicated. Consider referral to Head & Neck centre.

Radiation

Therapy

Peer Review




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






Recurrence Version 2019.09 of 13



Local

Recurrence

Regional

Recurrence

Metastatic

From

Page 9 R

Medical

Oncologist

Proceed

to Page 9

Proceed

to Page 6

R



MCC or

MDT

Dental

Oncologist

Speech

Language

Pathologist

Registered

Dietitian

Social

Worker

PSO Support

Audiologist

Smoking

Cessation

Program

Nursing1

Palliative Care

Dental Evaluation

Nutrition, speech and

swallowing evaluation/

therapy, and dysphagia

prevention

In the recurrent and metastatic scenario, patients may require any and all of the

same supportive care as patients undergoing primary

treatment

Psychosocial

Intervention

May include:

Financial: disability,

drug benefits

Transportation

Placement

Counselling regarding

diagnosis, appearance

changes & HPV

Blood Work

Audiometry

Feeding Tube

Placement

J

K

R

1 All patients should have access to specialized oncology nurse, clinical nurse specialist or nurse practitioner to manage the complex physical, social and psychological health needs that arise during treatment and in early follow-up post treatment.

Surgical

Oncologist

Radiation

Oncologist

Proceed

to Page 8

I

Type of

recurrence

Tissue Biopsy

Locoregional

Imaging:

CT Head & Neck

or

MRI Nasopharynx

and Oropharynx

CT Thorax

Restaging, if not

previously done

CT Abdomen

PETPET Scans Ontario

GL 5-3ORG




https://www.ccohealth.ca/en/what-we-do/general-health/pet-scans-ontario


Local Recurrence Version 2019.09 of 13



Local

Recurrence

Previous

Radiation

Treatment?

Yes

No

From

Page 7

Surgical

Assessment

Yes

No

Proceed

to Page11



Salvage Surgery

Salvage Re-irradiation Therapy

Palliative

Systemic TherapyPalliative Care

And/

Or

Palliative therapies, which may include:

And/

Or


Peer Review

Proceed to

End of Life

Care

Pathway Map

(page 12)

Pathology

Indications for

Post-operative

Therapy8, 9

Yes

No

Post-operative

re-irradiation therapy8

Concurrent

Chemotherapy9

Salvage

Surgery7 Proceed

to Page 11Pathology

Indications for

Post-operative

Therapy4

Yes

No

Post-operative

radiation therapy

Concurrent

Chemotherapy5

Peer Review

Progression

Proceed to

End of Life

Care

Pathway Map

(page 12)

Progression

Radiation Therapy with

Curative Intent

Concurrent

Chemotherapy

Peer Review

Resectable?

Palliative

Systemic

Therapy

Palliative

Care

And/

Or


And/

Or

Palliative

Radiation Therapy

Peer Review

Peer Review

Peer Review

L

M

I

4 Indications for post-operative radiotherapy: Deep margins <5mm OR one or more of the following at the primary site: peri-neural invasion, lymph-vascular invasion OR lymph node involvement ( 2 lymph nodes, any lymph node >3 cm (N2+), level IV-V LN positive, extracapsular extension (ECE)). 5 Indications for concurrent chemotherapy: positive margins or extracapsular extension (ECE).7 Surgery may be an option for some patients if procedure can be completed in conservatively/transorally. Patients should be

included in trials investigating Transoral Robotic Surgery (TORS) where available.8 Post-operative re-irradiation to be considered for very high risk scenarios in appropriate patients after careful discussion with the surgeon and patient on the risk vs. benefits of re-irradiation. 9 Appropriateness of concurrent chemotherapy with re-irradiation should be considered on an individual basis after discussion with a multidisciplinary team.

Resectable?

Yes

No

Concurrent

Chemotherapy9

Re-irradiation with or without concurrent systemic treatment 8,9

Surgical

Assessment

Treatment

intent?

Palliative

Curative

Treatment

intent?

Palliative

Curative

During Treatment



On Treatment ReviewTo include: Radiation Medicine Clinician Oncology NursePatients should also have access to: Clinical Nurse Specialist / Nurse

Practitioner Registered Dietitian Speech Language Pathologist Dental Oncology Social Worker

During Treatment





GL 5-3ORG

GL 5-3ORG

EBS 5-11

EBS 5-11

















Regional Recurrence Version 2019.09 of 13



Regional

Recurrence

Previous

Radiation

Treatment to

the Neck?

Yes

No

From

Page 9

Surgical

Assessment

Yes

No

Proceed

to Page 11



Salvage Neck Dissection

Salvage Re-irradiation Therapy

Palliative Systemic

TreatmentPalliative Care

And/

Or


And/

Or


Peer Review

Pathology

Indications

for Post-

operative

Therapy8, 9

Yes

No

Post-operative


Concurrent

Chemotherapy9

Neck

Dissection7

Proceed

to Page 11

Pathology

Indications for

Post-operative

Therapy4

Yes

No

Post-operative

radiation therapy

Concurrent

Chemotherapy5

Peer Review

Progression

Proceed to

End of Life

Care

Pathway Map

(page 12)

Progression

Radiation Therapy with

Curative Intent

Concurrent

Chemotherapy

Peer Review

Resectable?

ChemotherapyPalliative

Care

And/

Or


And/

Or

Re-irradiation

Therapy

Peer Review

Peer Review

Peer Review

N

O

J

4 Indications for post-operative radiotherapy: Deep margins <5mm OR one or more of the following at the primary site: peri-neural invasion, lymph-vascular invasion OR lymph node involvement ( 2 lymph nodes, any lymph node >3 cm (N2+), level IV-V LN positive, extracapsular extension (ECE)). 5 Indications for concurrent chemotherapy: positive margins or extracapsular extension (ECE).7 Surgery may be an option for some patients if procedure can be completed in conservatively/transorally. Patients

should be included in trials investigating Transoral Robotic Surgery (TORS) where available.8 Post-operative re-irradiation to be considered for very high risk scenarios in appropriate patients after careful discussion with the surgeon and patient on the risk vs. benefits of re-irradiation. 9 Appropriateness of concurrent chemotherapy with re-irradiation should be considered on an individual basis after discussion with a multidisciplinary team.

Resectable?

Yes

No

Concurrent

Chemotherapy9

Re-irradiation with or without concurrent systemic treatment 9

Surgical

Assessment

During Treatment





Treatment

intent?

Curative

Palliative

Treatment

intent?

Curative

Palliative

During Treatment





Proceed to

End of Life

Care

Pathway Map

(page 12)

GL 5-3ORG

GL 5-3ORG

EBS 5-11

EBS 5-11

















Post-Chemoradiotherapy Response Evaluation Version 2019.09 of 13



Proceed

to Page 11


Neck Dissection

(Nodal levels II-IV and those with clinical

or radiographic evidence of disease)

From

Pages 3-8

Post Treatment

Dental

Evaluation

(4-8 weeks post

radiation)

Assessment

and

management of

treatment-

related

symptoms and

side effects

A C E

Management of treatment-related symptoms and side effects

Lymphedema or stiffness of

the neck or shoulders

Physiotherapist

or Lymphedema

Clinic

R

If any of the following

persist post-treatment:

Dysphagia

Nutritional risk

Changes in voice or

communication status

Persistent weight loss

Presence of or high

risk for trismus

post-treatment

Speech

Language

Pathologist

Dental

Oncologist

R

R

Speech

Language

Pathologist

Registered

Dietitian

And/Or

Psychosocial

DistressR PSO SupportSocial Work

No

Evidence of

residual disease

or adverse

features12?

Locoregional

Imaging:

CT Head & Neck

or

MRI Nasopharynx

and Oropharynx10

10-12 weeks post-

treatment

Pathology

Indications

for Post-

operative

Therapy

Yes

No

Yes

Location

Local

Regional

Local and

Regional

Biopsy Pathology

Proceed

to Page 11

Result

Positive for viable

residual disease

Negative for viable

residual disease

PET11

Yes

No

Resectable?

Salvage Surgical

Management of Primary

Yes

No

Resectable?

Post-operative


Systemic Therapy9

Individualized Plan

Peer Review

Yes

Resectable?

Salvage

Surgical

Management

of Primary

and Neck

Biopsy of primary

tumour with or

without lymph

node biopsy

Pathology Result

Positive for viable

residual disease

Negative for viable

residual disease

No

Re-irradiation therapy

Systemic Therapy9

Individualized Plan

Peer Review

Palliative Care

Proceed

to End of

Life Care

Pathway

Map (page

12)

Progression

Re-irradiation therapy

Systemic Therapy9

Individualized Plan

Peer Review

Palliative Care

Proceed

to End of

Life Care

Pathway

Map (page

12)

Progression

Systemic Therapy9

Individualized Plan

Palliative Care

Proceed

to End of

Life Care

Pathway

Map (page

12)

Progression

Proceed

to Page 11

MCC or

MDT

Re-irradiation therapyPeer Review

Q

P

GL 5-3ORG

GL 5-3ORG

GL 5-3ORG

8 Post-operative re-irradiation to be considered for very high risk scenarios in appropriate patients after careful discussion with the surgeon and patient on the risk vs. benefits of re-irradiation. 9 Appropriateness of concurrent chemotherapy with re-irradiation should be considered on an individual basis after discussion with a multidisciplinary team.10 Same modality should be used as baseline imaging11 Restaging after chemoradiotherapy treatment to assess patients with N1-N3 squamous-cell carcinoma of the H&N, if patients have residual neck nodes 1.5cm on re-staging CT performed 10-12 weeks post therapy for HPV positive disease.12 Adverse features include central necrosis and extracapsular extension.















Follow-Up Version 2019.09 of 13



Recurrence or

Progression

Proceed

to Page 7


From

Pages 3-8

Return to

primary care

provider for

follow-up

Management of treatment-related symptoms and side effects

Follow-Up

Every 3 months for year 1,

Every 4 months for year 2,

Every 6 months for year 3-5

Dental Assessment

In previously irradiated patients, extractions must be performed

by dental oncologists or dentists experienced in head and neck

cancers due to risk of osteoradionecrosis

Imaging

Frequency determined as

indicated by clinical suspicion

of recurrent disease

Physical Examination

Including indirect inspection

or fibre-optic nasendoscopy

Audiology or ophthalmology assessment

Blood Work

May include Complete Blood

Count (CBC) and Thyroid

Stimulating Hormone (TSH)

History

Including swallowing function

and pain

Assessment and management of treatment-related

symptoms and side effects

Lymphedema or

stiffness of the neck

or shoulders

Physiotherapist

or Lymphedema

Clinic

R

If any of the following

persist post-treatment:

Dysphagia

Nutritional risk

Changes in voice or

communication status

Persistent weight loss

Trismus is noted

or persists post

treatment

Speech

Language

Pathologist

Dental

Oncologist

R

R

Speech

Language

Pathologist

Registered

Dietitian

And/Or

B D FG H LM N OP Q

R

Psychosocial

DistressR PSO SupportSocial Work

Result

No Recurrence

or

Progression

10 Same modality should be used as baseline imaging



End of Life Care Version 2019.09 of 13



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 2-4 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 2019.09 of 13



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

hpv-negative oropharyngeal squamous cell carcinoma … · 2019-10-22 · stage i/ii version 2019.09...

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