CANCER CARE Pathway...
Transcript of CANCER CARE Pathway...
C L I N I C A L P A T H W A Y
Cancer Care
Operable Stage 2 Non-Small Cell Lung Cancer
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Operable Stage 2 Non-Small Cell Lung Cancer Table of Contents (tap to jump to page)
INTRODUCTION 1
Scope of this Pathway 1
Pathway Contacts 1
CLINICAL PATHWAY 3
PATHWAY ALGORITHMS 4
Algorithm 1: Screening and Followup 4 Algorithm 2: Initial Evaluation 5 Algorithm 3: Pre-Staging/Pre-Op Workup 6 Algorithm 4: Surgical 7 Algorithm 5: Non-Surgical 7 Algorithm 6: Post-Op Management 8 Algorithm 7: Followup/Monitoring 9
CLINICAL EDUCATION MATERIALS 10
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INTRODUCTION
This clinical pathway supports optimal care of patients experiencing Stage II Lung Cancer by standardizing the process of clinical care based on available best evidence, and by reducing the risk of harm that may occur due to unnecessary variations in clinical care.
Scope of this Pathway This care pathway will serve adult patients who present for acute care with the primary diagnosis of operable stage 2 non-small cell lung cancer.
Pathway Contacts The content of this pathway is developed and maintained by the Cancer Care service line of Christiana Care Health System. Questions or feedback about the content may be directed to:
Administrative Lead: Tammy Brown, RN, Clinical Director phone: 302-623-4710 e-mail: [email protected] Physician Lead: Jamil Khatri, M.D. phone: 302-731-7728 e-mail: [email protected]
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CLINICAL PATHWAY
In Delaware and the United States, lung cancer is the most frequently diagnosed form of cancer, and it’s the most common cause of death from cancer. The Helen F. Graham Cancer Center & Research Institute sees about 35 patients with stage 2 non-small cell lung cancer each year. Among the pathway’s goals are decreasing the number of imaging procedures from diagnosis through survivorship and reducing the cost of care by standardizing chemotherapy protocols.
Any physician can refer an inpatient or outpatient to the Thoracic Multidisciplinary Center or any of the multidisciplinary centers at the Helen F. Graham Cancer Center & Research Institute for a treatment/diagnostic plan or for a second opinion. Patients may also self-refer by calling 302-623-4500.
Other services include: smoking cessation, psychology, social work, nutrition, specialty rehabilitation, library, and Simply You.
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PATHWAY ALGORITHMS ALGORITHM 1: SCREENING AND FOLLOWUP
CCHS Lung Cancer Screening And Follow-up Pathway(NCCN Guideline Evidence Based) 09/10/2015
Pre-
Scr
eeni
ng
Phase
Lung Screening NN receives referral
Patient or PCP calls
Screening Questions by NN
Patient Meets Criteria
YES
NO
Imaging
PerformLDCT
LDCT Positive or Incidental Finding?
NO
YES
Patient is seen in Lung Nodule MDC with
Pulmonologist, Thoracic Surgeon & Lung NN
- Offer smoking cessation materials Quit Line#- Referring Physician Notified patient is not eligible
- NN Contacts Patient for consent process- Schedules for Lung Screening MDC- NP Discusses benefits, risks confirms eligibility- Order LDCT if not already obtained from PCP-Pt meets with smoking cessation coach at MDC or referral made
- NN communicates with PCP via phone/email- NN calls patient with negative result- Patient to have next screening in one year
- Positive result (+lung nodules: Follow Fleischner Society Recommendation- NN communicates Abnormal Finding with PCP- NN refers patient to Lung Nodule MDCMDC coordinator calls patient to schedule appointment
Scan Needed in 3 or 6 months?
Lung NN to coordinate
appointment
Yes
Patient need Surgery?
No
Lung NN to coordinate with
Thoracic Surgeon Office
Yes
Non-pulmonary finding per
team?
Lung NN to relay to PCP patient or NN to
continue with surveillance annually
Yes
No
InitialEvaluation
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ALGORITHM 2: INITIAL EVALUATION
CCHS Abnormal Chest X-Ray Pathway(NCCN Guideline Evidence Based) 10/19/2015
Initi
al E
valu
atio
n
Phase
PositiveCXR
Imaging
Allergy, Renal Dys,
Uncontrolled Diabetes
No
Yes
CT Positive?
See Follow-up Guidelines or Ref
to PCPNO
YES
Imaging
Non-ContrastChest CT Scan
Imaging
ContrastChest CT Scan
Start
Negative
Pre-Staging Follow-up
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ALGORITHM 3: PRE-STAGING/PRE-OP WORKUP
CCHS Operable Stage II Non- Small Cell Lung Cancer PathwayAbnormal CT Chest Workup/Initial Evaluation(NCCN Guideline Evidence Based) 10/20/2015
Pre-
Stag
ing/
Pre-
Op
Wor
kup
Page 2
CT Scan within 30 days?
Imaging
Preferred PET CT
Imaging
PETW Fusion
YES
NO
Pathologic Mediastinal Staging with Endobronchial Ultrasound(EBUS)
OrMediastinoscopy
OR Surgery,
Mediastinotomy, EUS or CT guided BX
Pulmonary FunctionTests/DLCO
Within 6 months
SevereCOPD
LabArterial Blood
Gas TestingYES Pulmonary Consult
Suggested
ASA CLASS IIIOR
ASA CLASS IV Cardiac ClearanceYes
InitialEvaluation
MRIContra-
Indicated?
Pre Discussion of risk/benefitAdvance DirectivesGoals of CarePatient Preference Risk of Procedures, etc.
-T2bN0-T1aN1-T1bN1-T2aN1-T2bN1T3N0
-T1a-T1b-T2a
-T3N1- N2, :N3
T4
Stage II
Stage IOff Pathway)
Stage III(Off Pathway)
Low or HighSuspicion
Follow-UpLow
High
High
Imaging
Brain MRI+Gad
Imaging
CT Scan+ Cont
No
Yes
Positive Results from
Previous Procedures?
Yes
SurgicalCandidate?
Age, preference, ComorbiditiesRisk&Benefits?
Non-SurgicalNo
Yes
SurgicalNo Cleared forSurgery? Yes
Surgery Recommended? Yes
No
No
No
NoBiospy
Non-Small CellLung?
Biospy Non-Small Cell
Lung?Biopsy Yes
Off PathwayNo
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ALGORITHM 4: SURGICAL
CCHS Resectable and Operable Stage II Non- Small Cell Lung Cancer Pathway(NCCN Guideline Evidence Based) 10/19/2015
Surg
ical
Phase
SurgicalCBC, BMP
Within 3 monthsECG/EKG
Within 1 months
Pre Discussion of risk/benefitAdvance DirectivesGoals of CarePatient Preference Risk of Procedures, etc**Clinical Trials
Consider inductionchemo
AncefAllergy?
AncefNo
Clinda (PreOp)Yes
Perform VATS(Preferred)
Or Open Thoracotomy
TumorPathology
ALGORITHM 5: NON-SURGICAL
CCHS Resectable but Inoperable Stage II Non- Small Cell Lung Cancer Pathway(NCCN Guideline Evidence Based) 10/19/2015
Non
-Sur
gica
l
Phase
Non-Surgical
N0Or N1
Definitive XRTConsider SABRT
Definitive ChemoXRT
(Like Stage III)N1
N0
Consider Adjuvant Chemo for High RiskMay Include poorly differentiated tumors, atypical cascinoids, vascular invasion, wedge resection, tumors > 4cm, visceral pleural involvement, incomplete lymph node staging.
Adjuvant Treatment
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ALGORITHM 6: POST-OP MANAGEMENT
Title
Post
-Op
Mgm
t
Phase
Tumor Margin
CCHS Operable Stage II Non- Small Cell Lung Cancer Pathway Adjuvant Treatment(NCCN Guideline Evidence Based) 10/19/2015
Is Performance status =0,1,2
No No adjuvant treatment
Yes
Pathology Findings?
R0
Re- Resection
Adjuvant ChemoWithin 12 weeks of
Surgery** Consider Clinical
Trial
Squamous orNonSquamous
Neuropathy orRenal Issues or
No issuesSquamous
NonSquamous
GeurzarCarbo/Geuzar
Carbo/TaxolRenal Issues
Cisplatin/DocetaxelNo Issues
Neuropathy
Neuropathy orRenal Issues or
No issues
Carbo/Alimta?
Carbo/TaxolRenal Issues
Cisplatin/AlimtaNo Issues
Neuropathy
Followup
XRT( 54-60 Gy)
Chemo ->XRTR1?
Rc- Resection + Chemo
Chemo XRT
R2?
TumorPathology
Adjuvant Treatment
R0 = no residual tumorR1 = microscopic residual tumorR2 = macroscopic residual tumor
PathologyHistology, GradeMargin, Lymph NodesMolecular Studies/Mutation Testing for Clinical Trial
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ALGORITHM 7: FOLLOWUP/MONITORING
CCHS Operable Stage II Non- Small Cell Lung Cancer PathwayFollow-up/Surveillance (NCCN Guideline Evidence Based) 10/19/2015
Mon
itorin
gFo
llow
-Up
Phase
Follow up visits
• MD visit q 3-6 months for 2 yrs, then q 6-12 months for 3 more years, then may follow with Primary Care Physician (PCP)
• CT scan q 6 months for two years and then yearly for a total of five years.
• No routine PET scans
• Coordinate visits between medical oncologist and surgeon.
Smoking, cessation healthy life style
MD Visit Every3-6 Months
MD VisitEvery 6-12 Months
> 2 years since Start of
TreatmentCT Scan every
6 months
NO
YES > 3 years since TreatmentCT Scan
Every year
NO
Refer to Primary Care Physician(PCP)
Continue followUp with MD? NO
YES
-Coordinate with primary care physician for monitoring of general health 6 months post surgery (after chemotherapy complete)
-Refer back to PCP after 5 years unless ongoing hematologic/oncologic issues
FollowupFollowupMD Visit Every
3-6 Months
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CLINICAL EDUCATION MATERIALS
• National Cancer Institute
• Clinical Trials information
• National Comprehensive Cancer Network
©2016 Christiana Care Health Services, Inc.