Lung Cancer Diagnosis Pathway Map - Cancer Care Ontario
Lung Cancer Diagnosis 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.
Lung Cancer Diagnosis Pathway Map Pathway Map Preamble Version 2021.03 Page 2 of 7 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. Target Population Patients who present with signs or symptoms suspicious of lung cancer . 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, 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.* Pathway Map Legend Colour Guide Shape Guide Primary Care Intervention Palliative Care Decision or assessment point Pathology Organized Diagnostic Assessment Patient (disease) characteristics Surgery Exit pathway Line Guide Required Possible Consultation with specialist Radiation Oncology or Off page reference Medical Oncology R Referral Radiology Multidisciplinary Cancer Conference (MCC) Genetics Psychosocial Oncology (PSO) Respirologist 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 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 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. 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 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. 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).
Lung Cancer Diagnosis Pathway Map Suspicion Version 2021.03 Page 3 of 7 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. 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 Patient presenting with any of the following signs suspicious for cancer: Hemoptysis (single episode) New finger clubbing Suspicious lymphadenopathy (e.g. cervical, supraclavicular) Dysphagia Features of metastatic lung cancer (e.g. weight loss 5 kg, focal skeletal pain, headaches)1 Features suggestive of paraneoplastic syndromes1 or Patient presents with any of the following unexplained symptoms for 3 weeks (or sooner if patient has known risk factors)2: Cough Chest, rib or shoulder pain Weight loss/loss of appetite Abnormal chest sounds Dyspnea Hoarseness Thrombocytosis, anemia, and leukocytosis Horner s syndrome EBS #24-2 Visit to Health Care Provider R R Smoking Cessation Program Smoking cessation counselling & intervention where appropriate 1 A Chest Imaging CT (or chest xray) Cancer Imaging Guidelines Proceed to page 4 Underlying chronic respiratory problems presenting with unexplained changes in existing symptoms EBS #24-2 Patient presenting with any of the following: Stridor Massive hemoptysis New neurological signs suggestive of brain metastases or spinal cord compression including seizure EBS #24-2 Patient presenting with any of the following: Persistent non-massive hemoptysis (Multiple episodes of coughing blood or blood-streaked sputum) Superior vena cava syndrome/obstruction 3 EBS #24-2 Visit to emergency department These are emergency situations and the patient should be seen in the ER (if not presenting there) and referred emergently to specialist Follow-up with appropriate specialist No Imaging as appropriate Cancer Imaging Guidelines Treatment for presenting symptoms Lung cancer suspected? Yes R4 B Proceed to Page 4 R4 Patient presenting with abnormal imaging that reports suspicion of lung cancer (including screen detected cancers) EBS #24-2; EBS #15-10 Refer to the American College of Chest Physicians Clinical Practice Guideline, Chest, 132, 149-160 for features of a standardized evaluation for systematic metastases and a list of paraneoplastic syndromes associated with lung cancer. The following factors have been shown to increase the risk of lung cancer: current or previous smoking of tobacco in/through cigarettes, cigars, dry pipe or water pipe (bong, vaping), second hand exposure to tobacco smoke, lung Diseases (chronic obstructive pulmonary disease, asthma, pulmonary fibrosis), previous exposure to asbestos or other known carcinogens, occupational exposure to: dust or other microscopic particles, diesel engine emissions, or chlorinated solvents, personal or family history of cancer (especially lung, head & neck), infections (HPV 16/18 of the respiratory tract, previous pneumonia, HIV), other illnesses or health issues (silicosis, tuberculosis, lupus, rheumatoid arthritis, systemic sclerosis, diabetes, periodontal disease, blood lipid levels, increased abdominal obesity), occupations (miners, painters, iron and steel workers, bricklayers, welders), environmental (in-home burning of coal and/or biomass, unventilated cooking over high heat, air pollution, low socioeconomic status, high caffeine intake). 3 These patients should be accepted by the organized lung diagnostic assessment program if it can facilitate a diagnosis within one week. 4 An abnormal chest x-ray or an abnormal CT scan of chest suspicious of lung cancer is required with each organized lung diagnostic assessment program referral. A CT scan of the chest is not required for acceptance of an organized lung diagnostic assessment program referral if the chest x-ray is abnormal but a CT scan-chest is required prior to assessment at the program. Patient history should be mandatory as part of the referral and include, at a minimum: comorbidities, medications, allergies major health issues and symptoms that prompted the referral to the program. 2
Lung Cancer Diagnosis Pathway Map Initial Presentation and Imaging Version 2021.03 Page 4 of 7 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. 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 Consolidation or unexplained pleural effusion High suspicion of lung cancer (based on imaging and/or clinical judgement) A From Page 3 Treatment as appropriate R Follow-up chest x-ray (or CT chest) EBS #24-2 Organized Diagnostic Assessment4 Return to primary care provider for follow-up Resolved Results Nonresolving EBS #24-2 CT chest (If not previously done) Cancer Imaging Guidelines Results Begin staging test Suspected stage I,II,III – PET at PET Scans Ontario presentation to avoid Suspected stage IV – delay in consider CT abd, MRI staging brain, bone scan phase. Cancer Imaging Guidelines Suspected cancer Normal imaging results Return to primary care provider for follow-up Pleural effusion Thoracentesis B Results Normal imaging results From Page 3 Suspected pneumonia Low suspicion of lung cancer (based on imaging and/or clinical judgement) Suspected other infectious disease process (e.g. tuberculosis, atypical infections) R Chest x-ray Within one month after starting treatment Respirologist (or Tuberculosis Specialist) Other conditions (e.g. pulmonary embolus, trauma) R Respirologist (or Internist) Treatment as appropriate Evaluation of patients with high suspicion of lung cancer may be performed within structures facilitating organized diagnosti c assessment. Central mass or clinical N1, N2, N3 Proceed to Page 5 C D Pleural effusion Proceed to Page 6 Suspected stage IV Based on scans and/or patient history Proceed to Page 6 F G Proceed to Page 6 Status Follow-up with specialist (notify public health if TB is diagnosed) Not resolved and suspected lung cancer Not resolved and lung cancer not suspected Resolved Suspected chronic obstructive pulmonary disease (COPD) or other benign lung disease (e.g. sarcoidoisis) 4 Return to primary care provider for follow-up Positive for cancer Treatment with antibiotics (1 cycle) Proceed to Page 5 E Suspected cancer Results New or growing solitary peripheral mass or suspicious pulmonary nodule(s) without mediastinal or hilar lymphadenopathy Follow-up with specialist or return to primary care provider for follow-up Repeat chest x-ray Sputum culture Abnormal Results Normal Return to primary care provider for follow-up
Lung Cancer Diagnosis Pathway Map Diagnostic Procedures Version 2021.03 Page 5 of 7 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. 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 H C From Page 4 New or growing solitary peripheral mass or suspicious pulmonary nodule(s) without mediastinal or hilar lymphadenopathy Positive for cancer or suspicious PET/CT scan (If not previously done) PET Scans Ontario Needle biopsy not possible Results Interventional Radiology Cancer Imaging Guidelines Bronchoscopy not possible Cancer Imaging Guidelines Core Biopsy Or Fine Needle Biopsy Choice is based on the expertise of the radiologist and pathologist and the ability to obtain sufficient tissue for morphological diagnosis and molecular testing. Cancer Imaging Guidelines D From Page 4 Central mass or clinical N1, N2, N3 Mediastinoscopy EBS #17-6 Bronchoscopy5 Or Endobronchial ultrasound6 EBS #17-6 Endobronchial ultrasound If not previously done EBS #17-6 Negative but high level of clinical suspicion Cytology Cell block should be obtained And/Or Thoracic Surgery For diagnostic purposes Cytology7 Cell block should be obtained Pathology7,8 Negative and low level of clinical suspicion And/Or 7,8 Pathology Follow-up by family physician, specialist or pulmonary nodule clinic Follow-up CT As per Fleischner guidelines9 Change in result 6 And/Or Pathology7,8 Results Suspicious or negative but high level of clinical suspicion Return to primary care provider for follow-up Results Return to primary care provider for follow-up Stable I Positive for cancer Cytology7 Cell block should be obtained Proceed to Page 7 Results Negative for cancer If there is CT evidence of hilar and/or mediastinal lymphadenopathy May be performed by surgeon or respirologist Positive for cancer 7 Repeat biospy or other diagnostic testing As appropriate Thoracic Surgery For diagnostic purposes Cytology7 Cell block should be obtained Positive for cancer Proceed to Page 7 Results And/Or Pathology7,8 Or Interventional Radiology Negative for cancer Return to primary care provider for follow-up Change in result Negative and low level of clinical suspicion 5 Follow-up by specialist Results Depending on local resources, radial miniprobe navigational bronchoscopy with lung biopsy may be considered. If the endobronchial ultrasound transbronchial needle aspiration is negative but there is a high level of suspicion of lung cancer, a mediastinoscopy should be completed. 7 Results go to ordering and referring physician and family physician. 8 For more information about biomarkers, refer to the Lung Cancer Tissue Pathway. 9 Follow-up as per the Fleischner guidelines. For more information see Guidelines for Management of Small Pulmonary Nodules Detected on CT Scans: A Statement from the Fleischner Society. (2005). Radiology, 237, 395-400. 6 Stable for 3 -5 years Return to primary care provider for follow-up
Lung Cancer Diagnosis Pathway Map Diagnostic Procedures (cont'd) Version 2021.03 Page 6 of 7 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. 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 G Pleural effusion E F Thoracentesis Perform procedure promptly. Can be done for diagnosis or for symptom relief. Note: If malignant cells found, this condition makes the patient inoperable. Cancer Imaging Guidelines Tests on pleural fluid: Cytology (cell block should be obtained) Lactate dehydrogenase Protein concentration Glucose Amylase Cell count and differential Culture and sensitivity From Page 4 From page 4 J Proceed to Page 7 Cytology7 Cell block should be obtained And/Or Pathology7,8 Suspected stage IV Based on scans and/ or patient history Positive for cancer (Stage IV) Results Suspicious or negative but high level of clinical suspicion Repeat biospy, thoracentesis or other diagnostic testing As appropriate Thoracic Surgery For diagnostic purposes Obtain sufficient tissue sample for histological and molecular diagnosis via least invasive, most accessible and most likely to up-stage the patient Cancer Imaging Guidelines Cytology7 Cell block should be obtained And/Or Pathology7,8 Results go to ordering and referring physician and family physician. For more information about biomarkers, refer to the Lung Cancer Tissue Pathway. Return to primary care provider for follow up Change in result Follow up by specialist Results Stable 8 Results Negative for cancer Negative and low level of clinical suspicion 7 Positive for cancer Return to primary care provider for follow up
Lung Cancer Diagnosis Pathway Map Staging Version 2021.03 Page 7 of 7 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. 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 Tests to be completed (if not previously done) H I J PET/CT scan PET Scans Ontario Pathological Non-Small Cell Lung Cancer Diagnosis (NSCLC) Clinical Stage I Proceed to NSCLC Treatment Pathway Map (Page 3) Clinical Stage II or IIIA Clinical Stage II Proceed to NSCLC Treatment Pathway Map (Page 4) Clinical Stage III Proceed to NSCLC Treatment Pathway Map (Page 6) Invasive Mediastinal Staging EBS #17-6 Mediastinoscopy MRI brain For stage II, III, and IV. No MRI if patient is clinical stage I and asymptomatic Cancer Imaging Guidelines Results From Page 5 or 6 Clinical Stage IIIB or IIIC Or Endobronchial Ultrasound No CNS metastases Proceed to NSCLC Treatment Pathway Map (Page 7) CNS metastases Proceed to NSCLC Treatment Pathway Map (Page 8) Clinical Stage IV PET/CT scan (if not previously done) PET Scans Ontario Medical Oncologist Pathological Small Cell Lung Cancer Diagnosis (SCLC) R Radiation 10 Oncologist Thoracic Surgeon 10 Tests to be completed (if not previously done) Medical history, physical exam and blood work (If not done already) Clinical Stage I-III MRI brain CT if MRI is not available or contraindicated Cancer Imaging Guidelines CT chest and abdomen If not already performed or outdated Cancer Imaging Guidelines If emergency situation, symptomatic brain metastases, superior vena cava obstruction, spinal compression or stage I-III disease. Clinical Stage IV Bone scan If suspected metastasis, bone pain or abnormal calcium and alkaline phosphatase. Not indicated if PET/CT is negative Cancer Imaging Guidelines Bone scan If suspected metastasis, bone pain or abnormal calcium and alkaline phosphatase. Cancer Imaging Guidelines Proceed to SCLC Treatment Pathway Map (Page 3) Proceed to SCLC Treatment Pathway Map (Page 4)
Lung Cancer Diagnosis Pathway Map Version 2021.03. 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
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11/15/2011 4 Lung Cancer Facts Lung cancer accounts for more deaths than any other cancer in both men and women. Since 1987, more women have died each year from lung cancer than from breast cancer. Lung cancer causes more deaths than the next three common cancers combined (colon, breast, prostate). Smoking contributes to 80% and 90% of lung cancer deaths in
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Breast Cancer Screening & Diagnosis Pathway Map Pathway Glossary Version 2015.10 Page 3 of 10 The pathway map is intended to be used for informational purpos es 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 .
Lung cancer screening: the cost of inaction 2 Table of contents Executive summary 3 1 Introduction 7 2 Lung cancer: a public health priority 9 3 Earlier detection: the key to reducing the burden of lung cancer 12 4 LDCT screening for lung cancer: the next big opportunity in cancer detection 18 5 An investment in health system sustainability 21 6 Ensuring successful implementation of lung cancer
Non-small Cell Lung Cancer Treatment Pathway Map Version 2021.03. 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 .
hydrate (C–S–H), ettringite, and Ca(OH) 2 through a hydration reaction in which hydration heat is produced within the concrete because of an exothermic reaction. Since the thermal cracking of concrete reduces its internal force, watertightness, and durability, an appropriate measure is required to control the heat of hydration. The factors that influence the hydration heat of concrete .
