Non-small Cell Lung Cancer Treatment Pathway Map - Cancer Care Ontario

Non-small Cell Lung Cancer Treatment Pathway Map

Version 2021.03

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 Ontario Health (Cancer Care Ontario) and the reader.

Non-small Cell Lung Cancer Treatment Pathway Map

Pathway Map Preamble

Version 2021.03 Page 2 of 10

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 suchregard. 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 Ontario Health (Cancer Care Ontario) and the reader.

Pathway Map Legend

Target Population

Colour Guide

Shape Guide

Line Guide

Patients with a confirmed non-small cell lung cancer diagnosis who have undergone the recommended diagnostic and

staging procedures as outlined in the Lung Cancer Diagnosis Pathway Map .

Primary Care Palliative Care

Intervention Decision or assessment point

Required Possible

Pathway Map Considerations

Any disease site-specific information that applies throughout the pathway map can go at the top of the Considerations . The

following text is boilerplate and should be mostly uniform across all pathway maps, though there may be some variation.

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, Health Care Connect 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 Person-Centered Care Guideline and EBS #19-2 Provider-Patient Communication.*

Hyperlinks are used throughout the pathway map to provide information about relevant Ontario Health (Cancer Care

Ontario) tools, resources and guidance documents.

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

family doctors, nurse practitioners, and emergency physicians.

Multidisciplinary Cancer Conferences (MCCs) may be considered for all phases of the pathway map. For more information

on Multidisciplinary Cancer Conferences, visit MCC Tools.

For more information on wait time prioritization, visit Surgery. 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 EBS #19-3.*

Pathology Organized Diagnostic Assessment Surgery

Radiation Oncology

Medical Oncology

Radiology Multidisciplinary Cancer Conference (MCC) Genetics

Patient (disease) characteristics Consultation with specialist Exit pathway or Off page reference R Referral

Psychosocial Oncology (PSO)

Neurosurgeon

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 rec eive .

The pathway map is inten ded to be used for informational purposes only. The pathway map is not intended to c onstitute 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 Ontario Health (Cancer Care Ontario) and the reader.

While care has been taken in the preparation of the information contained in the pathway map, such inf ormation 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.

Ontario Health (Cancer Care Ontario) 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 Ontario Health (Cancer Care Ontario) 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.

* Note. EBS #19-2 and EBS #19-3 are older than 3 years and are 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.

This pathway map may not reflect all the available scientific research and is not intended as an exhaustive resource. Ontario Health (Cancer Care Ontario) and its content providers assume no responsibility for omissions or incomplete information in this pathway map. It is possible that other relevant sc ientific findings may have been reported since c ompletion of this pathway map. This pathway map may be superseded by an updated pathway map on the same topic.

? Ontario Health (Cancer Care Ontario) 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 Ontario Health (Cancer Care Ontario).

Non-small Cell Lung Cancer Treatment Pathway Map

Clinical stage IA and IB

Version 2021.03 Page 3 of 10

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 suchregard. 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 Ontario Health (Cancer Care Ontario) 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

Stage I

Stage IA T1 | N0 | M0

Stage IAI T1mi, a | N0 | M0

Stage IAII T1b | N0 | M0

Stage IAIII T1c | N0 | M0

Stage IB T2a | N0 | M0

AJCC Cancer Staging Manual 8th edition

Resectable and medically

operable

Tumour unresectable at the

time of surgery

MCC

Pathological stage IIIA

Surgical resection EBS #17-1

Patholog y1

Results

Patholog ic al stage II

Pathological stage I

J From

Page 8 Or From

Diagnosis Pathway

Map (Page 7)

Thoracic Surgeon

Status

Resectable and medically operable

Unresectable

or medically

inoperable or

MCC

R

patient declines

surgery

1 For more information about biomarkers, refer to the Lung Cancer Tissue Pathway 2 Tumour ablation may be considered if not eligible for other treatment

Radiation Oncologist

Thoracic Surgeon (If not

previously seen or for additional opinion)

Interventional Radiologist

A

Proceed to Page 6

B

Proceed to page 4

MCC

Margins negative Stage IA

Margins

negative,

R

Stage IB

Margins positive, All stage I

Resectable

Medical Oncologist

Systemic Therapy GL-7-A-2016-3

Surgical

Re-resection

To achieve

Pathology1 R

negative margins

EBS #17-1

Medical Oncolog ist

Systemic Therapy Considered only

for stage IB GL-7-A-2016-3

Thoracic Surgeon reassesment

Not resectable

R

Radical radiation therapy2

Or Curative intent (Stereotactic body

radiation therapy or standard fractionation radiotherapy) Peer Review Or EBS #7-21

Focal Tumour Ablation2

Summary of Recommendations

Radiation Oncologist

Medical Oncologist

Sequence dependent on performance status

Radiation Therapy

Peer Review

Systemic Therapy Considered only for

stage 1B GL-7-A-2016-3

Proceed to stage appropriate treatment pathway map

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

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

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

Non-small Cell Lung Cancer Treatment Pathway Map

Clinical stage IIA and IIB

Version 2021.03 Page 4 of 10

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 suchregard. 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 Ontario Health (Cancer Care Ontario) 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

Stage II

Stage IIA T2b | N0 | M0

Stage IIB T1a-c, T2a, b | N0| M0 Or

T3 | N0 | M0

AJCC Cancer Staging Manual 8th edition

K

From Page 8 or From Diagnosis

Pathway Map (Page 7)

Thoracic Surgeon

Status

Potentially resectable and

medically operable superior

sulcus tumour

MRI thoracic inlet

To confirm operability

MCC

B

From Page 3

Resectable and medically operable nonsuperior sulcus

tumour

Surgical resection EBS #17-1

Patholog y1

Radiation Oncologist

R

Medical Oncologist

Thoracic Surgeon

Status

Operable

Not operable

Concurrent preoperative therapy

Radiation therapy Peer Review

Systemic therapy

Concurrent or sequential depending on performance status

Radiation therapy Peer Review

Systemic therapy

Surgical resection Ensure

bronchoscopy and mediastinoscopy are

completed EBS #17-1

Pathologica l stage II1

Results Pathological stage IIIA1

Margins negative

R

Medical Oncologist

Adjuvant systemic therapy

GL-7-A-2016-3

MCC

Margins positive

D

Proceed to page 6

Thoracic Surgeon Reasses-

ment

Resectable

Surgical Re-resection To achieve

negative margins

Patholog y1

Not resectable

R

Radiation Oncologist

Medical Oncologist

Adjuvant

R

Medical Oncolog ist

systemic therapy

GL-7-A-2016-3

Sequence may vary

Radiation therapy Peer Review

Systemic therapy

C

Proceed to Page 5

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

Unresectable or

medically

MCC

inoperable

R

Radiation Medical Thoracic Oncologist Oncologist Surgeon

Intervention al Radiologist

1 For more information about biomarkers, refer to the Lung Cancer Tissue Pathway

Radical radiation therapy2 Peer Review

Or

Stereotactic body radiation

therapy

Peer Review

EBS #7-21

Systemic therapy

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

Non-small Cell Lung Cancer Treatment Pathway Map

Clinical stage IIA and IIB contd

Version 2021.03 Page 5 of 10

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 suchregard. 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 Ontario Health (Cancer Care Ontario) 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

C

From Page 4

Patholog y1

MCC

Results

Margins negative

Margins positive

Positive Nodes

Adjuvant systemic therapy

GL-7-A-2016-3

Negative Nodes

Adjuvant systemic therapy

GL-7-A-2016-3

Radiation Medical Thoracic Oncologist Oncologist Surgeon

Individualized treatment plan

based on previous interventions and treatments

1 For more information about biomarkers, refer to the Lung Cancer Tissue Pathway

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

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