Esophageal Cancer Treatment Pathway Map · Esophageal Cancer Treatment Pathway Map Clinical Stage...
Transcript of Esophageal Cancer Treatment Pathway Map · Esophageal Cancer Treatment Pathway Map Clinical Stage...
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.
Esophageal Cancer Treatment Pathway MapVersion 2019.05
Pathway Map Preamble Version yyyy.mm Page 2 of 12Confidential Draft
For Review OnlyPathway Map Preamble Version 2019.05 Page 2 of 12Esophageal Cancer Treatment Pathway Map
Pathway Map Disclaimer This pathway map is a resource that provides an overview of the treatment that an individual in the Ontario cancer system
may receive.
The pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or
be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject
to clinical judgment and actual practice patterns may not follow the proposed steps set out in the pathway map . In the
situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has
any questions regarding the information set out in the pathway map. The information in the pathway map does not create a
physician-patient relationship between Cancer Care Ontario (CCO) and the reader.
While care has been taken in the preparation of the information contained in the pathway map, such information is provided
on an as-is basis, without any representation, warranty, or condition, whether express, or implied, statutory or otherwise,
as to the information s quality, accuracy, currency, completeness, or reliability.
CCO and the pathway map s content providers (including the physicians who contributed to the information in the pathway
map) shall have no liability, whether direct, indirect, consequential, contingent, special, or incidental, related to or arising
from the information in the pathway map or its use thereof, whether based on breach of contract or tort (including
negligence), and even if advised of the possibility thereof. Anyone using the information in the pathway map does so at his
or her own risk, and by using such information, agrees to indemnify CCO and its content providers from any and all liability ,
loss, damages, costs and expenses (including legal fees and expenses) arising from such person s use of the information in
the pathway map.
This pathway map may not reflect all the available scientific research and is not intended as an exhaustive resource. CCO
and its content providers assume no responsibility for omissions or incomplete information in this pathway map. It is
possible that other relevant scientific findings may have been reported since completion of this pathway map. This pathway
map may be superseded by an updated pathway map on the same topic.
Colour Guide
Primary Care
Palliative Care
Pathology
Diagnostic Assessment Program (DAP)
Surgery
Radiation Oncology
Medical Oncology
Radiology
Multidisciplinary Cancer Conference (MCC)
Psychosocial Oncology (PSO)
Neurosurgery
Endoscopy/Gastroenterology
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
X
X
© 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 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 map. For patients who do not have a primary care provider, is a government resource that helps patients find a family doctor or nurse practitioner.
Throughout the pathway map, a shared decision-making model should be implemented to enable and encourage patients to play an active role in the management of their care. For more information see and
Hyperlinks are used throughout the pathway map to provide information about relevant CCO tools, resources and guidance documents.
The term health care provider , used throughout the pathway map, includes primary care providers and specialists, nurse practitioners, and emergency physicians.
Counseling and treatment for smoking cessation should be initiated early on in the pathway map and continued by care providers throughout the pathway map as necessary.
In order to minimize delays, processes may be carried out in parallel if disease management is not affected.
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: (1) 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, (2) 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
* Note. EBS #19-2 and 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.
Target Population Patients with a confirmed esophageal cancer diagnosis who have undergone the recommended diagnostic and staging procedures as
outlined in the Esophageal Cancer Diagnosis Pathway Map.
Health Care Connect,
MCC Tools
Surgery
EBS #19-3*
Person-Centered Care GuidelineEBS #19-2 Provider-Patient Communication*
Program Training & Consultation Centre – Hospital Based Resources
Clinical Stage IA Version 2019.05 Page 3 of 12Esophageal Cancer Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in 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.
Not medically
operable or patient
refuses surgery
Medically
Resectable
From Diagnosis
Pathway Map
(Page 5) or
Barrett s
Esophagus
Pathway Map
(Pages 4 & 5)
Results
Adenocarcinoma
T1 | N0 | M0
Squamous
T1 | N0-1 | M0
AJCC Cancer Staging
Manual 8th edition
Stage I
pTis or pT1a
Incompletely
excised
Esophagectomy
EBS #17-1
pT1b
Proceed
to Follow-up
Care Pathway
Map
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Consider integrating the palliative care approach early and across the cancer journey Click here for more information about palliative care
Status
Medical Oncologist
Radiation Oncologist
Gastroenterologist
Margins
&/or
Lymph
Nodes
Negative
Positive
Proceed
to Follow-up
Care Pathway
Map
MCC
Dietitian, PSO
Palliative Care
MCC
Endoscopic
Resection
(ER)
pTis or pT1a
Completely
excised
Proceed
to Follow-up
Care Pathway
Map
Status
Completely
excised
Incompletely
excised
Pathology
Pathology
Repeat Endoscopic
Resection (ER)
Pathology
Consider one or more of the
following:
Radiation therapy
Systemic therapy
Peer Review Progression
Proceed
to appropriate
page for
stage
Nutritional support
1High risk pathological features include: Lymphovascular invasion (LVI), poorly differentiated 2 Biopsy protocol: 4-quadrant biopsies (every 2cm) and biopsy of any visible nodules.3 Frequency may vary based on results and is determined by the treating physician.
R
R
Thoracic
Surgeon
DietitianSurgical Re-resection
EBS #17-1
Consider one or more of the
following:
Radiation therapy
Systemic therapy
Peer Review
Nutritional support
High Risk
Features?1
Esophagogastroduodeno-scopy (EGD)
Every 3 months until successful eradication of all
Barrett's metaplasia and dysplasia, followed by
EGD every 6 months for 1 year and then annually
Focal Tumour Ablation of remaining Barrett s
No
Yes Thoracic
SurgeonR
Endoscopic
Surveillance3
Esophagastro-
duodenoscopy
(EGD) +Biopsy2
Pathology
Proceed
to Barrett s
Esophagus
Pathway Map
(Page 4)
Clinical Stage IB and II Version 2019.05 Page 4 of 12Esophageal Cancer Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in 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.
Medically
inoperable or
patient refuses
surgery
Adenocarcinoma
Stage II
T1 | N1 |M0 or
T2 | N0 |M0
Squamous
Stage II
T2 | N0-N1 |M0 or
T3 |N0 |M0
AJCC Cancer Staging
Manual 8th edition
Stage IB & II
From
Diagnosis
Pathway
Map
(Page 5)
Medically
operable and
resectable
Status
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Consider integrating the palliative care approach early and across the cancer journey Click here for more information about palliative care
Medical
Oncologist
Thoracic
Surgeon
Radiation
Oncologist
Brachytherapy
Proceed to
Malignant
Dysphagia
Pathway Map
(Page 10) &/or
End of Life Care
Pathway Map
(Page 11)
Psychosocial oncology
and supportive care
Referral to appropriate
specialist if additional
support is required
End of life care planning
Palliative Care
Systemic Therapy
Dietitian
Medical Oncologist
Radiation Oncologist
Thoracic Surgeon
Gastroenterologist
Stent or Feeding tubeR
and/or
External Beam Radiation
Therapy
and/or
and/or
Esophag-
ectomy
EBS #17-1
Upper
esophageal
cancer4
Endoscopy
CT Chest Abdomen Pelvis
Persistent Thoracic
SurgeonR
Proceed to
Follow-up
Care
Pathway
Map
Definitive concurrent
chemoradiation
Radiation therapy
Systemic therapy
Peer Review
Medical
Oncologist
Radiation
Oncologist
Dietitian
Location
of cancer
Mid & Lower Third
Esophageal
or
Gastroesophageal
(GE) Junction 5
7 PET is preferred. 4 Upper Thoracic Esophagus: 20 to 25cm from upper central incisor teeth on esophagogastroduodenoscopy (EGD)5 Mid Thoracic Esophagus: 25 to 30cm from upper central incisor teeth on EGD.
Lower Thoracic Esophagus: 30 from upper central incisor teeth to 40cm/to the GE junction
Margins
&/or
Lymph
Nodes
Positive MCC
Pathology
Stage II Neo-
adjuvant
Therapy
EBS #2-11
Systemic
therapy
Chemo-
radiation
Radiation
therapy
Systemic
therapy
Peer Review
or
Surgical Re-resection
EBS #17-1
Consider one or more of the following:
Radiation therapy
Systemic therapy
Peer Review
Proceed to
Follow-up
Care
Pathway
Map
Complete
response
Treatment
Response
Assess treatment
response
Nutritional support
Nutritional support
R
R
Negative
MCC
Salvage
Esophagectomy
EBS #17-1
Systemic therapy
or
Brachytherapy
or
PET7
PET Recommendation
Report #4
CT Chest
Abdomen Pelvis
Assess treatment
response
OR
Dietitian
Clinical Stage III and IVA (squamous) Version 2019.05 Page 5 of 12Esophageal Cancer Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in 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.
Adenocarcinoma
Squamous
MCC
Outcome
Medical
Oncologist
Radiation
Oncologist
Thoracic
Surgeon
Squamous
Stage III
T3| N1 |M0 or
T1-3| N2 |M0
Stage IVA
T4|N0-N3 | M0 or
Any T| N3| M0
AJCC Cancer Staging
Manual 8th edition
Stage III & IVA
6 For more information about early palliative care for
advanced cancer refer to Zimmermann et al., (2014)
Early palliative care for patients with advanced cancer:
a cluster-randomized controlled trial. Lancet,
383(9930), 1721-30 and Temel et al. (2010). Early
palliative care for patients with metastatic NSCLC. The
New England Journal Of Medicine, 363(8), 733-42.7 PET is preferred.
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
A
Status
Unresectable/
patient declines
surgery and good
performance
status
Salvage
Esophagectomy
EBS #17-1
Proceed
To Page 7
From
Diagnosis
Pathway
Map
(Page 5) Dietitian
Unresectable and
poor performance
status
Palliative
Care6Proceed
to End of Life
Care Pathway
Map
(Page 11)PSO
Palliative Brachytherapy
Palliative systemic therapyPsychosocial oncology and
supportive care
Referral to specialist if
additional support is required
End of life care planning
Palliative External Beam
Radiation Therapy
R
Concurrent Neoadjuvant
Chemoradiation
Radiation therapy
Systemic therapy
Peer Review Esophagectomy
EBS #17-1
Resectable/
Potentially
resectablePET7
(approximately 4 weeks post treatment)PET Recommendation Report #4
CT Chest Abdomen Pelvis
Reassessment of treatment response
If persistent or
reccurent
Complete
response
Proceed
to Follow-up
Care Pathway
Map
Nutritional support
Nutritional support
MCC
Proceed
To Page 6
And
Concurrent Definitive
Chemoradiation
Radiation therapy
Systemic therapy
Peer Review
Nutritional support
PET7
(approximately 4 weeks post treatment)PET Recommendation Report #4
CT Chest Abdomen Pelvis
Reassessment of treatment response
or Treatment
response
R
B
EBS #2-11
EBS #2-12
Clinical Stage III and IVA (adenocarcinoma) Version 2019.05 Page 6 of 12Esophageal Cancer Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in 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.
Adenocarcinoma
Proceed
to Malignant
Dysphagia
Pathway Map
(Page 10) &/or
End of Life Care
Pathway Map
(Page 11)
Proceed
to Malignant
Dysphagia Pathway
Map (Page 10) or
Follow-up Care
Pathway Map
Status Unresectable/
patient declines
surgery and good
performance
status
Unresectable and
poor performance
status
Resectable/
Potentially
resectable
From
Page 5
6 For more information about early palliative care for advanced cancer refer to Zimmermann et al ., (2014) Early palliative care for patients with advanced cancer: a cluster-randomized controlled trial. Lancet, 383(9930), 1721-30 and Temel et al. (2010). Early
palliative care for patients with metastatic NSCLC. The New England Journal Of Medicine, 363(8), 733-42.7 PET is preferred.
Salvage
Esophagectomy
EBS #17-1
Proceed
To Page 7
Palliative
Care6
PSO
Palliative Brachytherapy
Palliative systemic therapyPsychosocial oncology and
supportive care
Referral to specialist if
additional support is required
End of life care planning
Palliative External Beam
Radiation Therapy
Concurrent Neoadjuvant
Chemotherapy or
Chemoradiation
Radiation therapy
Systemic therapy
Peer Review Esophagectomy
EBS #17-1PET7
(approximately 4 weeks post treatment)PET Recommendation Report #4
CT Chest Abdomen Pelvis
Reassessment of treatment response
If persistent or
reccurent
Complete
response
Proceed
to Follow-up
Care Pathway
Map
Nutritional support
Nutritional support
And
Concurrent Definitive
chemoradiation
Radiation therapy
Systemic therapy
Peer Review
Nutritional support
PET7
(approximately 4 weeks post treatment)PET Recommendation Report #4
CT Chest Abdomen Pelvis
Reassessment of treatment response
or Treatment
response
R
Adenocarcinoma
Stage III
T2| N1 |M0 or
T3-T4a| N0-N1 |M0
Stage IVA
T1-4a|N2 | M0 or
T4b| N0-2| M0 or
Any T| N3| M0
AJCC Cancer Staging
Manual 8th edition
Stage III & IVA
B
CEBS #2-11
EBS #2-12
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Clinical Stage III and IVA (continued) Version 2019.05 Page 7 of 12Esophageal Cancer Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in 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.
Adenocarcinoma
Stage III
T2| N1 |M0 or
T3-T4a| N0-N1 |M0
Stage IVA
T1-4a|N2 | M0 or
T4b| N0-2| M0 or
Any T| N3| M0
Squamous
Stage III
T3| N1 |M0 or
T1-3| N2 |M0
Stage IVA
T4|N0-N3 | M0 or
Any T| N3| M0
AJCC Cancer Staging
Manual 8th edition
Stage III & IVA
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Consider integrating the palliative care approach early and across the cancer journey. Click here for more information about palliative care
Proceed
to Follow-up
Care Pathway
Map
Margins
&/or
Lymph
Nodes
Negative
Positive
Consider one or
more of the
following:
Systemic therapy
From
Pages 5
& 6
MCC
Medical
Oncologist
Radiation
OncologistRadiation
Therapy
Pathology
Systemic therapy8
Thoracic
Surgeon Re-resection
EBS #17-1
8Adjuvant chemotherapy should be considered for patients who received neoadjuvant chemotherapy without concurrent radiation
RCT Chest Abdomen Pelvis
Reassessment of treatment
response
If persistent
Complete
response
Treatment
response
Proceed
to Follow-up
Care Pathway
Map
R
Proceed to
Malignant
Dysphagia
Pathway (Page 10)
&/or
End of Life Care
Pathway Map
(Page 11)
Palliative Care
Dietitian
Medical Oncologist
Radiation Oncologist
Brachytherapy
Psychosocial oncology
and supportive care
Referral to appropriate
specialist if additional
support is required
End of life care planning
Systemic Therapy
External Beam Radiation
Therapy
and/or
and/or
Manage Dysphagia (see
page 9 Malignant
Dysphagia Pathway)
Nutritional Support
A C
Clinical Stage IVB Version 2019.05 Page 8 of 12Esophageal Cancer Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in 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.
Any T | Any N | M1
AJCC Cancer Staging
Manual 7th edition
Stage IVB
From
Diagnosis
Pathway
Map
(Page 5)
R
Proceed to
Malignant
Dysphagia
Pathway (Page 10)
&/or
End of Life Care
Pathway Map
(Page 11)
MCC9,10
9 Key factors to consider in treatment decision include performance status, weight loss, disease symptoms, co-morbidities, sites of metastatic disease, molecular testing, patient wishes and understanding, and emotional status.
10 Review biomarker status
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Consider integrating the palliative care approach early and across the cancer journey. Click here for more information about palliative care
Palliative Care
Dietitian
Medical Oncologist
Radiation Oncologist
Brachytherapy
Psychosocial oncology
and supportive care
Referral to appropriate
specialist if additional
support is required
End of life care planning
Systemic Therapy
External Beam Radiation
Therapy
and/or
and/or
Manage Dysphagia (see
page 9 Malignant
Dysphagia Pathway)
Nutritional Support
Recurrence Version 2019.05 Page 9 of 12Esophageal Cancer Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in 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.
Local regional
recurrence with
nodal
involvement
Distant
recurrence
Appropriate treatment may
include one or more of the
following
Radiation therapy
Systemic therapy
Good
Poor
Surgical resection
EBS #17-1
Proceed to
End of Life
Care Pathway
Map (Page 11)
From
Esophageal
Cancer
Follow-up
Pathway
Map
Thoracic
Surgeon
Proceed
to Follow-up
Care Pathway
Map
Psychosocial oncology
and supportive care
Referral to appropriate
specialist if additional
support is required
End of life care planning
MCC10,11
Performance
Status
Type of
recurrence
10 Review biomarker status
11 Subsequent treatment depends on: performance status, time to relapse, age, patient wishes (if long disease-free interval, recurrent tumor may be sensitive to initial chemotherapy)
Peer Review
Focal Tumour
Ablation
Systemic therapy
Radiation therapy
Peer Review
Biopsy
Pathology
Palliative Care
PSO
Consistent surgical and
pathological confirmation
(if not previously done)
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Consider integrating the palliative care approach early and across the cancer journey. Click here for more information about palliative care
End of life care planning
Systemic therapy
Radiation therapy
Peer Review
Local luminal
recurrence
MCC Medical
Oncologist
Radiation
Oncologist
Thoracic
Surgeon
Medical
Oncologist
Radiation
Oncologist
Palliative Care
R
R
R
R
Nutritional Support
Nutritional Support
Malignant Dysphagia Version 2019.05 Page 10 of 12Esophageal Cancer Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in 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.
Result
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Consider integrating the palliative care approach early and across the cancer journey. Click here for more information about palliative care
Proceed
To End of life
care (Page
11)
From
Treatment
Pathway
Map
Pages
4, 6, 7, 8
External Beam Radiation
therapy
Systemic Therapy
Stent or Feeding tubeEsophagogastroduodenoscopy
(EGD)
Pathology
Malignant
Stage IV or
unresectable Brachytherapy
Endoscopic therapies
Treatment options vary
based on centre resources:
Other:
Recurrent cancer after treatment Stage IV Esophageal cancer not amenable to
curative therapy
Thoracic Surgeon
DietitianR
Gastro-enterologist
Radiation Oncologist
Medical Oncologist
Palliative CareIn pain & symptom
management/psychosocial needs
End of Life Care Version 2019.05 Page 11 of 12Esophageal Cancer Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in 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 2-4 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/
End of Life Care contd. Version 2019.05 Page 12 of 12Esophageal Cancer Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in 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