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

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 Surgical resection Ensure bronchoscopy and mediastinoscopy are completed EBS #17-1 Concurrent preoperative therapy Stage IIB T1a-c, T2a, b N0 M0 Or T3 N0 M0 Potentially resectable and medically operable superior sulcus tumour AJCC Cancer Staging Manual 8th edition Radiation Oncologist MRI thoracic inlet To confirm operability MCC R Operable Medical Oncologist Radiation therapy Systemic therapy Peer Review Status Radiation therapy Systemic therapy Peer Review B From Page 3 Margins negative Pathologica l stage II1 K From Page 8 or From Diagnosis Pathway Map (Page 7) Thoracic Surgeon Status Resectable and medically operable nonsuperior sulcus tumour Surgical resection EBS #17-1 Pathology1 Results 1 Thoracic Surgeon Reassesment D Resectable Not resectable Proceed to page 6 Proceed to Follow-up Care Pathway Map (Page 3) Adjuvant systemic therapy GL-7-A-2016-3 Medical Oncologist MCC Margins positive Pathological stage IIIA1 Unresectable or medically inoperable R Surgical Re-resection To achieve negative margins Pathology1 Radiation Oncologist R Medical Oncologist R Medical Oncologist MCC For more information about biomarkers, refer to the Lung Cancer Tissue Pathway R Medical Oncologist Thoracic Surgeon Intervention al Radiologist Or Stereotactic body radiation therapy EBS #7-21 Peer Review Adjuvant systemic therapy GL-7-A-2016-3 Sequence may vary Radiation therapy Systemic therapy Peer Review Radical radiation therapy2 Peer Review Radiation Oncologist Proceed to Page 5 Concurrent or sequential depending on performance status Not operable Thoracic Surgeon C 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 Positive Nodes Adjuvant systemic therapy GL-7-A-2016-3 Negative Nodes Adjuvant systemic therapy GL-7-A-2016-3 Margins negative C From Page 4 Pathology1 MCC Results Margins positive 1 For more information about biomarkers, refer to the Lung Cancer Tissue Pathway Radiation Oncologist Medical Oncologist Thoracic Surgeon Proceed to Follow-up Care Pathway Map (Page 3) Individualized treatment plan based on previous interventions and treatments

Non-small Cell Lung Cancer Treatment Pathway Map Clinical stage IIIA and IIIB Version 2021.03 Page 6 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 Note. EBS #7-12 is currently listed as For Education and Information Purposes . Stage III Stage IIIA T1a–c, T2a,b N2 M0 Or T3 N1 M0 Or T4 N0, N1 M0 A D From page 3 or 4 Pathological stage IIIA (resected clinical stage I or II) MCC EF Concurrent chemoradiation preoperative therapy Stage IIIB T1a–c, T2a,b N3 M0 Or T3, T4 N2 M0 Resectable stage IIIA and medically operable5 Stage IIIC T3, T4 N3 M0 Medical Oncologist R Radiation therapy Peer Review Systemic therapy GL-7-A-2016-3 Stage IV CT Chest Abdomen for restaging MCC Proceed to Page 7 or 8 Positive lymph nodes Surgical resection EBS #17-1 1 Systemic therapy GL-7-A-2016-3 Adjuvant systemic therapy GL-7-A-2016-3 Results Pathology Negative lymph nodes Or AJCC Cancer Staging Manual 8th edition Radiation Oncologist MCC Outcome Proceed to Follow-up Care Pathway Map (Page 3) Concurrent chemoradiation L From Page 8 or From Diagnosis Pathway Map (Page 7) Good performance status (ECOG 0-1 or PPS 80-100) and minimal weight loss Symptom Management Guides-to-practice Medical Oncologist Managing 3 Physician R Radiation Oncologist MCC MCC Outcome Unresectable stage IIIA, stage IIIB or medically inoperable EBS #7-3; EBS #7-10 Immunotherapy EBS #7-10 Concurrent chemoradiation Or if patient unsuitable, sequential chemoradiation Or radiation alone if patient is unsuitable for chemotherapy Radiation therapy Systemic therapy EBS #7-3 Cisplatin-based & Peer Review EBS #7-3; EBS #7-10 Borderline performance status or moderate weight loss Symptom Management Guides-to-practice Thoracic Surgeon Radical radiation therapy EBS #7-3 & Peer Review Systemic therapy Cisplatin-based Performance status Palliative systemic therapy Poor performance status (ECOG 2 or PPS 60) and significant weight loss Symptom Management Guides-to-practice Pa lliative Ca re 4 Or Palliative radiation therapy EBS #7-12 EBS #7-3 Psychosocial oncology and supportive care Referral to specialist if additional support is required PSO For more information about biomarkers, refer to the Lung Cancer Tissue Pathway End of life care planning Explore second and third 3 Managing physician may be a surgeon, respirologist or radiation oncologist. line therapies as appropriate 4 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. 5 Includes T3 N1 M0, T4 N0 or N1 M0, T1/T2 N2 only if single station intracapsular N2 1 Proceed to End of Life Care Pathway Map (Page 10)

Non-small Cell Lung Cancer Treatment Pathway Map Stage IV (No CNS Metastases) Version 2021.03 Page 7 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 IV Good/moderate performance status (ECOG 0 to 2 or PPS 60100) and/or localized symptomatic disease No CNS Metastases Stage IV Any T Any N M1 Radiation therapy Systemic therapy EBS #7-10 Stage IVA Any T Any N M1a, b Stage IVB Any T Any N M1c AJCC Cancer Staging Manual 8th edition From Diagnosis Pathway Map (Page 7) Managing Physician6 Severe localized disease amenable to radiation or Focal Tumour Ablation Medical Oncologist Radiation Oncologist 7, 8 MCC R Interventional Radiologist Focal Tumour Ablation Summary of Recommendations Systemic therapy EBS #7-10 Palliative radiation therapy Poor performance status ECOG 3 PPS 40-50 Focal Tumour Ablation Summary of Recommendations Consider targeted therapy if mutation positive ECOG 4 PPS 10-30 Thoracentesis Symptomatic pleural effusion OR Pleurodesis OR Systemic therapy EBS #7-10 Pleural tunneled catheter 6 Patient is usually managed by a medical oncologist. 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. 8 Review biomarker status 7 Therapy with palliative intent May include chemotherapy, radiation, surgery, etc. Psychosocial oncology and supportive care Referral to appropriate specialist if additional support is required End of life care planning E G I From Page 6 or 8 or 9 Radiation therapy Performance status and disease characteristics Pa lliative Ca re PSO Focal Tumour Ablation Summary of Recommendations Proceed to End of Life Care Pathway Map (Page 10)

Non-small Cell Lung Cancer Treatment Pathway Map Stage IV (CNS Metastases) Version 2021.03 Page 8 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 IV CNS Metastases Stage IV Any T Any N M1 Palliative Care Very limited life expectancy PSO Stage IVA Any T Any N M1a, b Psychosocial oncology and supportive care Referral to appropriate specialist if additional support is required Proceed to End of Life Care Pathway Map (Page 10) End of life care planning G Stage IVB Any T Any N M1c AJCC Cancer Staging Manual 8th edition From Diagnosis Pathway Map (Page 7) Managing Physician5 MCC6 Neurosurgeon Status F H From Page 6 or 9 Proceed to Page 7 Other metastases Brain metastases8 Radiation Oncologist 9 R Palliative Care MCC CNS or similar multidisciplinary discussion Resection of metastatic brain lesion(s) (If resectable) Stereotactic radiosurgery or whole brain if high burden of intracranial disease Peer Review Status J PSO Stage IA or Stage IB Proceed to Page 3 Stage IIA or Stage IIB Proceed to Page 4 Stage IIIA or Stage IIIB Proceed to Page 6 Medical Oncologist No other metastases and suitable for curative intent treatment PET Scan Radiation Oncologist Stage of tumour in the lung K Thoracic Surgeon 6 Patient is usually managed by a medical oncologist. 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. 9 If small and asymptomatic brain metastases, consider deferring radiation therapy and initiating systemic therapy. These patients require close surveillance that should include surveillance of physical and emotional symptoms. 10 Radiation oncologist with CNS expertise or one who treats brain metastases 7 L

Non-small Cell Lung Cancer Treatment Pathway Map Recurrence Version 2021.03 Page 9 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 Appropriate treatment may include one or more of the following Radiation therapy Peer Review Systemic therapy EBS# 7-10 Good Surgical resection Pathological Confirmation (if not previously done) Local regional recurrence Focal Tumour Ablation Summary of Recommendations Performance Status Biopsy Pathology Pa lliative Ca re From Lung Cancer Follow-up Pathway Map (page 3) Poor Managing Physician 7,10 MCC Type of recurrence PSO H Yes CNS metastasis Proceed to page 8 I No 8 Proceed to page 7 Review biomarker status 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) 11 Psychosocial oncology and supportive care Referral to appropriate specialist if additional support is required End of life care planning Systemic therapy EBS# 7-10 Radiation therapy Distant recurrence Proceed to Follow-up Care Pathway Map (Page 3) Peer Review Proceed to End of Life Care Pathway Map (Page 10)

Non-small Cell Lung Cancer Treatment Pathway Map End of Life Care Version 2021.03 Page 10 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 End of Life Care Key conversations to revisit Goals of Care and to discuss and document key treatment decisions 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 Explore the patient s views on medications, tests, resuscitation, intensive care and preferred location of death If a patient makes any treatment decisions relevant to their current condition (i.e., provides consent), these decisions can be incorporated into their Plan of Treatment Review Goals of Care and patient preferences regularly, particularly when there is a change in clinical status Screen, Assess, Plan, Manage and Follow Up Pathway Map Target Population: Individuals with cancer approaching the last 3 months of life and their families. While this section of the pathway is focused on the care delivered at the end of life, palliative care should be initiated much earlier in the illness trajectory. In particular, providers can introduce a palliative approach to care as early as the time of diagnosis. Triggers that suggest patients are nearing the last few months and weeks of life ECOG/PatientECOG/PRFS 4 OR PPS 50 Declining performance status/functional ability End of Life Care planning and implementation Collaboration and consultation between specialistlevel care teams and primary care teams Conversations to determine where care should be provided and who will be responsible for providing the care Screen for specific end of life psychosocial issues Assess and address patient and families' loss, grief and bereavement needs including anticipatory grief, past trauma or losses, preparing children (young children, adolescents, young adults), guardianship of children, death anxiety Provide appropriate guidance, support and information to families, caregivers, and others, based on awareness of culture and needs, and make referrals to available resources and/or specialized services to address identified needs as required Identify family members at risk for abnormal/complicated grieving and connect them proactively with bereavement resources Identify patients who could benefit from specialized palliative care services (consultation or transfer) As patient and family/caregiver needs increase and/or change over time consult with palliative care specialists and/or other providers with additional expertise, as required. Transfer care only if/when needs become more extensive or complex than the current team can handle Discuss referral with the patient and their family/caregiver Proactively develop and implement a plan for expected death Explore place-of-death preferences and the resources required (e.g., home, hospice, palliative care unit, long term care or nursing home) to as

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 .