Ovarian Cancer Diagnosis Pathway Map Version 2020.01 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.
Ovarian Cancer Diagnosis Pathway Map Pathway Map Preamble Target Population The pathway map reflects the clinical management of women with signs or symptoms suspicious for epithelial ovarian cancer These women are in need of diagnostic work-up Version yyyy.mm 2020.01 Page 2 of 5 Pathway Map Legend Shape Guide Colour Guide Intervention Primary Care Decision or assessment point Palliative Care Patient (disease) characteristics Pathology For additional information about the optimal organization of gynecologic oncology services in Ontario refer to EBS #4-11 The term healthcare provider , used throughout the pathway map, includes primary care providers and specialists, e.g. family doctors, nurse practitioners, gynecologists, midwives and emergency physicians. 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 Radiation Oncology Hyperlinks are used throughout the pathway map to provide information about relevant Ontario Health (Cancer Care Ontario) tools, resources and guidance documents. 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* or Medical Oncology Radiology Gynecology Off-page reference Patient/Provider interaction R Referral W Wait time indicator time point Multidisciplinary Cancer Conference (MCC) Line Guide Required EBS #19-2 Provider-Patient Communication* Exit pathway X X Pathway Map Considerations Consultation with specialist Gynecologic Oncology Possible 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. 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 recommendations will no longer be maintained but may still be useful for academic or other information purposes. 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). * 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
Ovarian Cancer Diagnosis Pathway Map Initial Presentation and Investigations Version 2020.01 Page 3 of 5 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 t he 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 Patient presents with suspicious findings from incidental imaging or Patient presents with one or more of the following signs/symptoms: Suspicious or palpable pelvic or abdominal mass Abnormal vaginal bleeding Increased abdominal size Ascites Difficulty eating (early satiety, nausea) Persistent and/or unexplained: Pelvic or abdominal pain Gastrointestinal symptoms (e.g. bloating) Urinary symptoms (urgency or frequency) Visit to or test ordered by a Healthcare Provider Focused History to include: Family history of cancer (paternal & maternal) BRCA status Clinical menopausal status 1 Directed Physical Examination Pelvic Examination Including speculum and bimanua/pelvirectal examinations, and examination of external genitalia R Gynecologist Transvaginal And Other imaging Pelvic /or if indicated Ultrasound Refer to EBS #4-15 Patient with prior pathology report suggestive of a diagnosis of Epithelial Ovarian Cancer (EOC) Tumours or Serous Tubal Intraepithelial Carcinoma (STIC) Suspicious Ovarian Mass R R Ultrasound features: presence of multilocularity, bilaterality, solid component(s), ascites or evidence of metastases Blood Tests to Include: CA-125 (required for RMI) Renal Function Complete Blood Count (CBC) Other Blood Tests Only If Indicated: CEA CA 19-9 Other tumour markers (e.g., AFP, LDH, HCG) Gynecologic Oncologist R or RMI See box lower left R Gynecologist Proceed to Page 4 B RMI 200 and suspicious R Gynecologic Oncologist Proceed to Page 5 CT Chest CT Abdomen Pelvis Biopsy Cytology Non gynecologic cancer Refer to Appropriate Specialist Appropriate Specialist2 Gynecologic Oncologist The classification of post-menopausal is a woman who has not had her period for more than 1 year or a woman over 50 who has had a hysterectomy 2 Consider a referral to a medical oncologist, hepato-pancreato-biliary surgeon, and/or gastroenterologist as appropriate 1 A Gynecologist RMI 200 and clinically not suspicious Peritoneal carcinomatosis with or without an ovarian mass U 1 if ultrasound has 0 or 1 features present U 4 if ultrasound has 2 or more features present Absolute serum measurement (U/mL) Refer to Appropriate Specialist Results Refer to EBS #4-15 M 1 for premenopausal women M 4 for postmenopausal women1 Abnormality requiring follow-up by a Specialist RMI 200 Risk of Malignancy Index (RMI) U x M x CA 125 M (Menopausal status) CA 125 (Cancer antigen 125) Return to Primary Care Provider for follow-up Imaging (If not previously performed) Gastrointestinal (GI) Evaluation as needed U (Ultrasound) No Abnormality Blood Test to Include: CA-125 May Also Include: CEA CA 19-9 Other tumour makers (e.g., AFP, LDH, HCG) Results Advanced Stage EOC Proceed to Appropriate Histologic Treatment Pathway Map (Page 6)
Ovarian Cancer Diagnosis Pathway Map Initial Presentation and Investigations CONTD Version 2020.01 Page 4 of 5 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 t he 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 Return to Primary Care Provider for follow-up Return to Primary Care Provider for follow-up Benign RMI 200 Expert Opinion4 Continue Follow-up with Gynecologist R Epithelial Ovarian Cancer A From Page 3 Repeat if 8 weeks since last RMI calculation3 Transvaginal Pelvic Ultrasound D From Page 5 Surgical Procedure Refer to EBS #4-15 Pathologist 5 Results Gynecologic Oncologist Proceed to Appropriate Histologic Treatment Pathway Map (Page 4) Proceed to Borderline Epithelial Ovarian Tumour Treatment Pathway Map Borderline epithelial ovarian tumour R Gynecologic Oncologist Other gynecological cancer R Gynecologic Oncologist RMI Blood Test may Include: CA-125 Treatment and follow-up as appropriate Refer to Appropriate Specialist Non-gynecological cancer C RMI 200 There is a lack of guidance indicating the appropriate time interval as to when ultrasound and RMI assessment should be repeated If appropriate, seek a second opinion from a gynecological oncologist 5 BRCA reflex testing should be performed on tumours from all newly diagnosed patients with high grade serous ovarian, fallopian tube or primary peritoneal cancer, to determine eligibility for the drug olaparib 3 4 R Gynecologic Oncologist Proceed to Page 5
Ovarian Cancer Diagnosis Pathway Map Diagnosis and Clinical Radiological Staging Version 2020.01 Page 5 of 5 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 t he 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 D B C Low Suspicion or Non-malignant From Page 3 &4 Assessment Transvaginal Pelvic Ultrasound Refer to EBS #4-15 Other imaging if indicated Refer to EBS #4-15 Suspicion Gynecologist Follow up with Gynecologic Oncologist Work-up Blood Test to Include: CA-125 Renal Function Complete Blood Count (CBC) R Proceed to Page 4 Return to Primary Care Provider for follow-up Return to Primary Care Provider for follow-up Results Refer to EBS #4-15 Other blood tests only if indicated: CEA CA 19-9 Other tumour markers as indicated (e.g., AFP, LDH, HCG) High Suspicion Proceed to Appropriate Histologic Treatment Pathway Map (Page 3)
Ovarian Cancer Diagnosis Pathway Map Pathway Map Preamble Version yyyyVersion 2020.mm Page .01 Page 2 of 5 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.
Ovarian cancer is the seventh most common cancer among women. There are three types of ovarian cancer: epithelial ovarian cancer, germ cell cancer, and stromal cell cancer. Equally rare, stromal cell cancer starts in the cells that produce female hormones and hold the ovarian tissues together. Familial breast-ovarian cancer
Ovarian cancer Contents Overview Section 1 Ovarian Cancer Section 2 Epidemiology Section 3 Treatment References i. Types of ovarian cancer The vast majority (over 90%) of ovarian tumours arise from the uncontrolled growth and replication of epithelial cells which form the surface of the ovary.
ovarian cancer is a heterogeneous disease which includes multiple histological subtypes including endometrioid, clear cell and mucinous histologies. However, high grade serous ovarian cancer (HGSOC) 1is the most common epithelial ovarian cancer . Despite heterogeneity in cancer subtypes, all ovarian cancer cells preferentially metastasize to .
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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 .
Epithelial ovarian cancer Ovarian cancer is the most lethal of the gynecological malignancies, with 150,917 deaths globally in 2012. The disease is most common in Northern 625 women were diagnosed with ovarian cancer in 2011, corresponding to the disease. Woman in all ages can be affected, but ovarian cancer is un-common before the age of 30 [2].
Architectural Graphic Standards , American Institute of Architects, Mar 30, 2007, Architecture, 1080 pages. Since 1932, the ten editions of Architectural Graphic Standards have been referred to as the "architect's bible." From site excavation to structures to roofs, this book is the. Basic construction blueprint reading , Mark W. Huth, 1980, Architecture, 131 pages. Discusses the use of .