endometrial cancer treatment & follow-up pathway map · endometrial cancer treatment &...

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.

Endometrial Cancer Treatment & Follow-Up Pathway MapDisease Pathway Management

Version 2018.12

Pathway Map Preamble Version yyyy.mm of 16

© 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 Preamble Version 2018.12 Page 2 of 16Endometrial Treatment & Follow Up 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.

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

Colour Guide

Primary Care

Palliative Care

Pathology

Gynecologic Oncology

Radiation Oncology

Medical Oncology

Radiology

Gynecology

Genetics

Multidisciplinary Cancer Conference (MCC)

Psychosocial Oncology (PSO)

Target Patient Population Women presenting with endometrial cancer

Pathway Map Considerations For more information about the optimal organization of gynecologic oncology services in Ontario refer to .

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 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 healthcare provider , used throughout the pathway map, includes primary care providers, specialists, midwives, nurse practitioners, gynecologists, emergency physicians or other healthcare providers

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:

- 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

- 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

EBS #4-11

Health Care Connect,

Person-Centered Care Guideline

EBS #19-2 Provider-Patient Communication*

MCC Tools

Surgery, Systemic Treatment, Radiation Treatment Wait Times prioritizations.

EBS #19-3*

* Note. EBS #19-2 and EBS#19-3 are 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.

https://www.cancercareontario.ca/en/guidelines-advice/types-of-cancer/446

http://www.ontario.ca/health-and-wellness/find-family-doctor-or-nurse-practitioner



https://www.cancercare.on.ca/toolbox/mcc_tools/

https://www.hqontario.ca/System-Performance/Wait-Times-for-Surgeries-and-Procedures

https://archive.cancercare.on.ca/ocs/wait-times/systemicwt/

https://archive.cancercare.on.ca/ocs/wait-times/radiationwt/


Clinical Stage I Version 2018.12 of 16Endometrial Cancer Treatment & Follow Up 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.

Primary Staging Surgery

Minimally Invasive Surgery is

best practice

Total Hysterectomy

Bilateral Salpingo-

oophorectomy

Possible Pelvic Lymph Node

Assessment Primary Staging Surgery

Minimally Invasive Surgery

is best practice

Total Hysterectomy

Bilateral Salpingo-

oophorectomy

Pelvic Lymph Node

Assessment

Possible Para-aortic Lymph

Node Dissection

Pathology16

Sexual Health

Discussion

Fertility

Discussion1

Yes

No

Meets Criteria

for Fertility

Sparing? 7

Appropriate

for primary

surgery?6


Minimal Invasive Surgery is best practice

Total Hysterectomy

Bilateral Salpingo-oophorectomy

Pelvic Lymph Node Assessment

Omentectomy

Possible Para-aortic Lymph Node Dissection

Serous,

Carcinosarcoma,

Clear cell,

Mixed histology

Endometrioid

Grade 1 or 2

Endometrioid

Grade 3

Proceed

to Page 8

Proceed

to Page 9

Proceed

to Page

12

Results

Proceed

to Page

6

1 Discussion to be individualized for each patient; however, may include the following: fertility options, hormone replacement therapy, referral for infertility consultation, etc.2 All tumours with MSH2/MSH6, MSH6, PMS2 and MLH1 (without hypermethylation) deficiency are candidates for genetic testing and should be referred for genetic counselling. 3 Endometrioid Grade 1: If grade I endometriod cancer diagnosed at a non- gynecologic oncology center (GOC), the pathology must be reviewed by a second pathologist. Both pathologists must be in agreement with diagnosis of grade I endometriod cancer; otherwise, referral of patient to a GOC is necessary.4 Endometriod Grade 2, 3 or High Risk Histology: Pathology review by a pathologist with an interest in gynecologic pathology at a gynecologic oncology center (GOC)5 The following should be taken into consideration: performance status, surgical resectability, and patient comorbidities6 Referral to gynecologist oncologist is optional for patients with grade 1 disease, however patients who are unfit for surgery or have a clinically enlarged cervix should be referred to a gynecologist oncologist7 Patients should undergo counseling that fertility sparing is for highly selected and motivated patients who meet strict crite ria for progestin therapy. Criteria for fertility sparing progestin therapy include: 1) Grade 1 endometrioid adenocarcinoma, 2) no myometrial invasion on MRI, 3) no metastatic disease, 4) no contraindications to

progesterone therapy, 5) desire for future fertility.11 High risk histology: serous, clear cell, carcinosarcoma, undifferentiated, mixed high grade16 All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.

R

CT Abdomen

Pelvis for Grade

3 or high risk

histology

Bloodwork

CA 125

Yes

NoObservation

Proceed

to Page 13

(Follow-

up)

Medical

Oncologist

Radiation

OncologistMCC

Radiation Therapy

Chemotherapy

Hormonal Therapy

From

Diagnosis

Pathway Map

(Page 4)

Gyneco-

logist

Gynecologic

Oncologist6

Pathology

Review3,16

R

R

Endometrioid

Grade 1

Refer to EBS #4-11

Endometrioid

Grade 2, 3, or High

Risk Histology 12

Refer to EBS #4-11 Appropriate

for primary

surgery?5

Yes

No Proceed

to Page 13

Medical

Oncologist

Radiation

OncologistMCC

Radiation

Therapy

Chemotherapy

Gynecologic

Oncologist

Pathology

Review4,16

Endometrioid

Grade 2

Endometrioid

Grade 3 or High

Risk Histology11

Genetics2

Genetics

Clinic

Genetics2

Genetics

Clinic

Genetics2

Genetics

Clinic

Preoperative

Work-Up

Ultrasound (if

not previously

done)

CT Chest

Chest X-Ray

A B

C

D

E

CT Abdomen

Pelvis for

Grade 2

OR

G

Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care

Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools

http://www.health.gov.on.ca/en/pro/programs/ohip/bulletins/4381/bul4381.aspx

https://www.cancercareontario.ca/en/guidelines-advice/cancer-continuum/treatment/multidisciplinary-cancer-conferences?redirect=true




https://www.cancercareontario.ca/en/cancer-treatments/palliative-care

https://www.cancercare.on.ca/toolbox/symptools/

Clinical Stage II Version 2018.12 of 16Endometrial Cancer Treatment & Follow Up 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.


Minimally Invasive Surgery is best

practice

Total Hysterectomy, recommend

radical hysterectomy


Cytology


Possible Para-aortic Lymph Node

Dissection Peritoneal washings

Omentecomy if high grade histology

R

Pathology16Yes

NoR

Results

From

Diagnosis

Pathway

Map

(Page 4)

3 Endometrioid Grade 1: If grade I endometriod cancer diagnosed at a non- gynecologic oncology center (GOC), the pathology must be reviewed by a second pathologist. Both pathologists must be in agreement with diagnosis of grade I endometriod cancer; otherwise, referral of patient to a GOC is necessary4 Endometriod Grade 2, 3 or High Risk Histology: Pathology review by a pathologist with an interest in gynecologic pathology at a gynecologic oncology center (GOC)5 The following should be taken into consideration: performance status, surgical resectability, and patient comorbidities10 Consider referral to a radiation centre with intracavitary brachytherapy cases 10 per year 16 All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.

Endometrioid

Serous,

Carcinosarcoma,

Clear cell and

Mixed Histology

Grade 1 or 2

Grade 3

Proceed

to Page 10

Proceed

to Page 11

Proceed

to Page 12

MCC

Appropriate

for primary

surgery?5

Radiation

Oncologist10

Medical

Oncologist

External Beam

Radiation Therapy

Chemotherapy

MCC

Surgery

Gynecologic

Oncologist

Pathology

Review3,4,16

Stage III/IV Proceed to

Page 5

Intracavitary

BrachytherapyProceed

to Page 13

CT Chest

MRI Pelvis

CT

Abdomen

Pelvis

CT Chest

Pelvic MRI

CT

Abdomen

Pelvis

H

I

J

L

M

and/or

EBS 4-11; EBS 21-2*

* Note. EBS 21-2 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.

Stage

Stage II

Sexual Health

Discussion









Clinical Stage III/IV Extrauterine Disease (Metastasis) Version 2018.12 of 16Endometrial Cancer Treatment & Follow Up 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.

Yes

No

Pathology16 Results

MCC Surgery

1 Discussion to be individualized for each patient; however, may include the following: fertility options, hormone replacement therapy, referral for infertility consultation, etc.2 All tumours with MSH2/MSH6, MSH6, PMS2 and MLH1 (without hypermethylation) deficiency are candidates for genetic testing and should be referred for genetic counselling. 3 Endometrioid Grade 1: If grade I endometriod cancer diagnosed at a non- gynecologic oncology center (GOC), the pathology must be reviewed by a second pathologist. Both pathologists must be in agreement with diagnosis of grade I endometriod cancer; otherwise, referral of patient to a GOC is necessary4 Endometriod Grade 2, 3 or High Risk Histology: Pathology review by a pathologist with an interest in gynecologic pathology at a gynecologic oncology center (GOC)5 The following should be taken into consideration: performance status, surgical resectability, and patient comorbidities16 All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.

Endometrioid

Grade 1 or 2

Grade 3

Proceed

to Page 10

Proceed

to Page 11

Appropriate

for primary

surgery?5

Radiation Therapy

Chemotherapy

Hormonal Therapy

R

Pathology

Review3,4,16

R

Primary Cytoreductive

Surgery

Total hysterectomy

Bilateral Salpingo-

oopherectomy

Cytoreductive

surgery

Fertility

Discussion1

Gynecologic

Oncologist

MCC

Radiation

Oncologist

Medical

Oncologist

From

Diagnosis

or

Treatment

(Page 4)

MCC

Proceed

to Page 12

Proceed

to Page 13

Genetics2

Genetics

Clinic

R

Genetics2

Genetics

ClinicCT Chest

CT

Abdomen

Pelvis

CT Chest

CT

Abdomen

Pelvis

N

O

P

R

M

Serous,

Carcinosarcoma,

Clear cell and Mixed

Histology








Endometrioid- Fertility Sparing Version 2018.12 of 16Endometrial Cancer Treatment & Follow Up 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.

From

Page 3R

Progestin

Therapy7,9Status

Complete

Response

Persistent

MRI Pelvis

Meets Criteria for Progestin Therapy?7

No

Yes

Surgical Staging

Minimal invasive surgery is

best practice Total hysterectomy

Bilateral Salpingo-

oophorectomy12

Stage I

Stage II

Pathology16 Results

Proceed

to Page 8

Proceed

to Page 10

2 All tumours with MSH2/MSH6, MSH6, PMS2 and MLH1 (without hypermethylation) deficiency are candidates for genetic testing and should be referred for genetic counselling. 3 Endometrioid Grade 1: If grade I endometriod cancer diagnosed at a non- gynecologic oncology center (GOC), the pathology must be reviewed by a second pathologist. Both pathologists must be in agreement with diagnosis of grade I endometriod cancer; otherwise, referral of patient to a GOC is necessary4 Endometriod Grade 2, 3 or High Risk Histology: Pathology review by a pathologist with an interest in gynecologic pathology at a gynecologic oncology center (GOC)7 Patients should undergo counseling that fertility sparing is for highly selected and motivated patients who meet strict crite ria for progestin therapy. Criteria for fertility sparing progestin therapy include: 1) Grade 1 endometrioid adenocarcinoma, 2) no myometrial invasion on MRI, 3) no metastatic disease, 4) no contraindications to

progesterone therapy, 5) desire for future fertility.8 Consider requesting IHC for mismatch repair9 Suggested progestin therapy includes medroxyprogesterone, megestrol acetate, and levonorgestrel IUD12 Consider omitting oophorectomy after thorough preoperative counselling with patient16 All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.

Progestin

Therapy7,9

Disease

Status

at 9-12

months?

Persistence or

Progressive

disease

Fertility Sparing

Treatment 7R

REI

(Reproductive

endocrinology and

infertility)

Dietitian

Proceed

to Page 7

MRI Pelvis

CT Abdomen

Pelvis

Bloodwork

CA 125

Gynecologic

Oncologist

Pathology

Review4,8,16

Biopsy

OR

Dilation and

Curettage

R

Gynecologist

Pathology

Review3,4,16

Genetics2

Genetics

Clinic

R

CT Chest

S

T

U

A

MRI Pelvis

Assessment every 3

months up to 9-12

monthsBiopsy

OR

Dilation and

Curettage

Pathology

Review3,4,16

MRI Pelvis

Assessment every 3

months up to 9-12

months

REI

(Reproductive

endocrinology and

infertility)





Endometrioid Fertility Sparing (contd) Version 2018.12 of 16Endometrial Cancer Treatment & Follow Up 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.

From

Page 6Status

Desire pregnancy

now

Desire pregnancy

later

Endometrial

Protection13

Complete

Hysterectomy

and Bilateral

Salpingo-

oopherectomy

Encourage

conception if

appropriate

Biopsy

Biopsy every 6

months

OR

abnormal bleeding

as per clinician

discretion

3 Endometrioid Grade 1: If grade I endometriod cancer diagnosed at a non- gynecologic oncology center (GOC), the pathology must be reviewed by a second pathologist. Both pathologists must be in

agreement with diagnosis of grade I endometriod cancer; otherwise, referral of patient to a GOC is necessary4 Endometriod Grade 2, 3 or High Risk Histology: Pathology review by a pathologist with an interest in gynecologic pathology at a gynecologic oncology center (GOC)12 Consider omitting oophorectomy after thorough preoperative counselling with patient13 IUD levonorgestrel, oral contraceptive pill, cyclical provera, or other progestational agents16 All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.

REI

(Reproductive

endocrinology and

infertility)

R

Proceed

to Page 13

Pathology

Review3,4,16

Child bearing

complete or

recurrent

endometrial cancer?

Yes

NoContinue Endometrial

Protection12

V

S

Results

Normal

Recurrent endometrial

cancer on biopsy

Surgical Staging

Minimal invasive surgery is

best practice Total hysterectomy

Bilateral Salpingo-

oophorectomy12

Stage I

Stage II

Pathology16 Results

Proceed

to Page 8

Proceed

to Page 10

W

X





Endometrial Grade 1 or 2, Stage I Version 2018.12 of 16Endometrial Cancer Treatment & Follow Up 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.

Proceed

to Page 11

Risk

Factors

Present14

Results

3 Endometrioid Grade 1: If grade I endometriod cancer diagnosed at a non- gynecologic oncology center (GOC), the pathology must be reviewed by a second pathologist. Both pathologists must be in agreement with diagnosis of grade I endometriod cancer; otherwise, referral of patient to a GOC is necessary4 Endometriod Grade 2, 3 or High Risk Histology: Pathology review by a pathologist with an interest in gynecologic pathology at a gynecologic oncology center (GOC)5 The following should be taken into consideration: performance status, surgical resectability, and patient comorbidities14 Risk factors include: age greater than 60 years based on Portec 1, positive lymphovascular invasion, deep myometrial invasion more than or equal to 50% 16All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.

Yes

NoVaginal

Brachytherapy

Observation

Vaginal

Brachytherapy Proceed

to Page 13External Beam

Radiation Therapy

From

Page

3,6,7

Grade 1 or

Grade 2

Y

Stage IA

Stage IB

Stage II

Stage III

Risk

Factors

Present14

Yes

No

Vaginal

Brachytherapy

Observation

Observation

Pathology16

Unstaged

CT Abdomen,

Pelvis

(If not previously

done)

No

Appropriate

for surgery?5

Yes

MCC

Gynecologic

Oncologist

Pathology

Review3,4,16

(If not

previously

done)

Radiation

Oncologist

Staging Surgery

Minimally Invasive Surgery is best practice

Consider Bilateral Salpingo-oophorectomy if

not removed

Possible PLN assessment for Grade 1

Additionally for Grade 2:


Staged

CTW

Status

I/O






Endometrioid Grade 3 Stage I Version 2018.12 of 16Endometrial Cancer Treatment & Follow Up 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.

MCC

Risk

Factors

Present14

Pathology

Review4,16

Radiation

Oncologist

From

Page 3Stage 1A

Status

Unstaged

No

Appropriate

for

surgery?5

4 Endometriod Grade 2, 3 or High Risk Histology: Pathology review by a pathologist with an interest in gynecologic pathology at a gynecologic oncology center (GOC)5 The following should be taken into consideration: performance status, surgical resectability, and patient comorbidities14 Risk factors include: age greater than 60 years based on Portec 1, positive lymphovascular invasion, deep myometrial invasion16 All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.

Stage 1B

Risk

Factors

Present14

Yes

No

Yes

No

Proceed

to Page 13

Staged

YesPathology16

Vaginal

Brachytherapy

Vaginal

Brachytherapy

Vaginal

Brachytherapy

Observation

Vaginal

Brachytherapy

External Beam

Radiation Therapy

External Beam

Radiation Therapy


Minimal Invasive Surgery is best practice



Omentectonmy

Para-aortic Lymph Node Dissection

Peritoneal washings

CT Abdomen,

Pelvis

(If not done

previously)

External Beam

Radiation Therapy

D

Results

Stage II- IVBProceed

to Page 11

Z

AA






Grade 1 or 2, Stage II - IVB Version 2018.12 of 16Endometrial Cancer Treatment & Follow Up 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.

From

Page 4-7

MCC

Pathology

Review4,16

Radiation

Oncologist

Medical

OncologistStatus

Unstaged

Staged

Appropriate

for surgery?5

Yes

No

Staging Surgery Pathology16

Stage II

Stage IIIA

Stage IIIB

Stage IIIC

Stage IVA

Stage IVB

Pelvic Radiation Therapy

Vaginal Brachytherapy

Tumour Directed Radiation

Therapy

Chemotherapy

Hormonal Therapy

Tumour Directed Radiation

Therapy

Chemotherapy

Hormonal Therapy

Clinical Trials

Proceed

to Page 13

CT Abdomen,

Pelvis

(If not done

previously)

BB

H

N

U

4 Endometriod Grade 2, 3 or High Risk Histology: Pathology review by a pathologist with an interest in gynecologic pathology at a gynecologic oncology center (GOC)5 The following should be taken into consideration: performance status, surgical resectability, and patient comorbidities16 All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.

Results

X


Chemotherapy


Concurrent Chemotherapy

Chemotherapy

Pelvic +/- Tumour Directed

Radiation Therapy







Grade 3, Stage II - IVB Version 2018.12 of 16Endometrial Cancer Treatment & Follow Up 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.

From

Page

4,5,9

MCC

Pathology

Review4,16

Radiation

Oncologist

Medical

OncologistStatus

Unstaged

Staged

Appropriate

for surgery?5

Yes

No

Staging Surgery Pathology16

Stage II

Stage IIIA

Stage IIIB

Stage IIIC

Stage IVA

Stage IVB




Radiation Therapy

Chemotherapy

Clinical Trials

Proceed

to Page 13

CT Chest,

Abdomen, Pelvis

(If not done

previously)

CC

I

O

4 Endometriod Grade 2, 3 or High Risk Histology: Pathology review by a pathologist with an interest in gynecologic pathology at a gynecologic oncology center (GOC)5 The following should be taken into consideration: performance status, surgical resectability, and patient comorbidities16 All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.

Chemotherapy

Results

AA


Chemotherapy



Chemotherapy


Radiation Therapy







Serous, Carcinosarcoma, Clear Cell and Mixed

HistologyVersion 2018.12 of 16Endometrial Cancer Treatment & Follow Up Pathway Map

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.

Gynecologic

Oncologist

Stage IA/IB

Stage II

Stage IIIA

Stage IIIB

Stage IVA

From

Pages

3, 4, 5

Stage IVB

Status

IA

Staged

Unstaged

CT imaging

(if not done

previously)

Appropriate

for

surgery?5

No

Yes

Staging Surgery


Para-aortic Lymph Node

Dissection

Pathology16

Radiation

Oncologist

Medical

Oncologist

Radiation

Oncologist

Medical

Oncologist Proceed

to Page 13

Radiation

Oncologist

Medical

Oncologist

Stage IIIC

Radiation

Oncologist

Medical

Oncologist

Results

Radiation

Oncologist

Medical

Oncologist

DD

E

J

P

5 The following should be taken into consideration: performance status, surgical resectability, and patient comorbidities

16 All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.

Results

IB


Chemotherapy

Pelvic +/- Tumour Directed Radiation Therapy


Chemotherapy



Chemotherapy



Radiation

OncologistMedical

Oncologist

Chemotherapy



Chemotherapy



Radiation

Oncologist

Medical

Oncologist


Chemotherapy

Chemotherapy


Clinical Trial





Follow-up Care (All Sub-Types) Version 2018.12 of 16Endometrial Cancer Treatment & Follow Up 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.

Follow-up Frequency

Every 3-6 months within the first two

years and then every six months for the

next three years

Gynecologic

Oncologist

From

Pages

3-5,7-12

Physical and Pelvic-rectal

examination

Gynecologist

(Grade 1, stage

1 endometrioid)

No evidence of recurrence

for 3-5 years

Suspicion for recurrence

Recurrence

Non-Cancer Related

Not suggestive of

recurrence

Late Effects of

Treatment

Refer to

Appropriate

Specialist

Refer to

Appropriate

Specialist

Refer to

Primary Care

Provider

Distant Metastases

Proceed

to Page 14

Medical

Oncologist

Radiation

Oncologist

Refer to EBS #4-9

Refer to EBS #4-9

OR

OR

OR

Imaging as

Appropriate

EE

B

G

L

R

V

Personal and family medical

history

Primary care

provider15

OR

15 Appropriate for low risk stage 1a with no adjuvant therapy

Y

Z

BB

CC

DD

Status

Results

Refer to

Primary Care

Provider (if

not done prior

to 5 years)







Persistent, Recurrent, Metastatic and Carcinosarcoma

(All Sub-Types) Version 2018.12 of 16Endometrial Cancer Treatment & Follow Up Pathway Map

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.

Pathology

Review4,16

Repeat

Biopsy

CT Abdomen,

Pelvis

MRI Pelvis

Imaging as

Appropriate

From

Page 13

4 Endometriod Grade 2, 3 or High Risk Histology: Pathology review by a pathologist with an interest in gynecologic pathology at a gynecologic oncology center (GOC).16 All endometrial cancers in women <70 years old should have reflex MMR IHC to screen for Lynch syndrome. If MLH1 deficient, reflex hypermethylation should be performed.

Medical

Oncologist

Radiation

Oncologist

Gynecologic

Oncologist

MCC

Palliative Care

Proceed

to

End-of-Life

(Page 15)

Chemotherapy

EBS #4-3

Clinical Trials

EBS #4-3

Psychosocial oncology and

palliative care

Referral to appropriate specialist

if additional support is required

End of life care planning

Progression

Appropriate therapy may include one or

more of the following:

Radiation therapy

Surgery

PSO

EE

CT Chest








End of Life Care Version 2018.12 of 16Endometrial Cancer Treatment & Follow Up 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 to 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/



http://ocp.cancercare.on.ca/common/pages/UserFile.aspx?fileId=298466

https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=285263#page=4

http://ocp.cancercare.on.ca/common/pages/UserFile.aspx?fileId=298466

http://www.goldstandardsframework.org.uk/



End of Life Care cont. Version 2018.12 of 16Endometrial Cancer Treatment & Follow Up 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





endometrial cancer treatment & follow-up pathway map · endometrial cancer treatment &...

Documents