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.

Esophageal Cancer Treatment Pathway MapVersion 2019.05

Pathway Map Preamble Version yyyy.mm Page 2 of 12Confidential Draft

For Review OnlyPathway Map Preamble Version 2019.05 Page 2 of 12Esophageal Cancer Treatment 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.

Colour Guide

Primary Care

Palliative Care

Pathology

Diagnostic Assessment Program (DAP)

Surgery

Radiation Oncology

Medical Oncology

Radiology

Multidisciplinary Cancer Conference (MCC)

Psychosocial Oncology (PSO)

Neurosurgery

Endoscopy/Gastroenterology

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

X

X

© 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 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, is a government resource that helps patients find a family 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 health care provider , used throughout the pathway map, includes primary care providers and specialists, nurse practitioners, and emergency physicians.

Counseling and treatment for smoking cessation should be initiated early on in the pathway map and continued by care providers throughout the pathway map as necessary.

In order to minimize delays, processes may be carried out in parallel if disease management is not affected.

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: (1) 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, (2) 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

For more information on the systemic treatment QBP please refer to the Quality-Based Procedures Clinical Handbook for Systemic Treatment

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

Target Population Patients with a confirmed esophageal cancer diagnosis who have undergone the recommended diagnostic and staging procedures as

outlined in the Esophageal Cancer Diagnosis Pathway Map.

Health Care Connect,

MCC Tools

Surgery

EBS #19-3*

Person-Centered Care GuidelineEBS #19-2 Provider-Patient Communication*

Program Training & Consultation Centre – Hospital Based Resources

Clinical Stage IA Version 2019.05 Page 3 of 12Esophageal Cancer Treatment 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.

Not medically

operable or patient

refuses surgery

Medically

Resectable

From Diagnosis

Pathway Map

(Page 5) or

Barrett s

Esophagus

Pathway Map

(Pages 4 & 5)

Results

Adenocarcinoma

T1 | N0 | M0

Squamous

T1 | N0-1 | M0

AJCC Cancer Staging

Manual 8th edition

Stage I

pTis or pT1a

Incompletely

excised

Esophagectomy

EBS #17-1

pT1b

Proceed

to Follow-up

Care Pathway

Map

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

Consider integrating the palliative care approach early and across the cancer journey Click here for more information about palliative care

Status

Medical Oncologist

Radiation Oncologist

Gastroenterologist

Margins

&/or

Lymph

Nodes

Negative

Positive

Proceed

to Follow-up

Care Pathway

Map

MCC

Dietitian, PSO

Palliative Care

MCC

Endoscopic

Resection

(ER)

pTis or pT1a

Completely

excised

Proceed

to Follow-up

Care Pathway

Map

Status

Completely

excised

Incompletely

excised

Pathology

Pathology

Repeat Endoscopic

Resection (ER)

Pathology

Consider one or more of the

following:

Radiation therapy

Systemic therapy

Peer Review Progression

Proceed

to appropriate

page for

stage

Nutritional support

1High risk pathological features include: Lymphovascular invasion (LVI), poorly differentiated 2 Biopsy protocol: 4-quadrant biopsies (every 2cm) and biopsy of any visible nodules.3 Frequency may vary based on results and is determined by the treating physician.

R

R

Thoracic

Surgeon

DietitianSurgical Re-resection

EBS #17-1

Consider one or more of the

following:

Radiation therapy

Systemic therapy

Peer Review

Nutritional support

High Risk

Features?1

Esophagogastroduodeno-scopy (EGD)

Every 3 months until successful eradication of all

Barrett's metaplasia and dysplasia, followed by

EGD every 6 months for 1 year and then annually

Focal Tumour Ablation of remaining Barrett s

No

Yes Thoracic

SurgeonR

Endoscopic

Surveillance3

Esophagastro-

duodenoscopy

(EGD) +Biopsy2

Pathology

Proceed

to Barrett s

Esophagus

Pathway Map

(Page 4)

Clinical Stage IB and II Version 2019.05 Page 4 of 12Esophageal Cancer Treatment 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.

Medically

inoperable or

patient refuses

surgery

Adenocarcinoma

Stage II

T1 | N1 |M0 or

T2 | N0 |M0

Squamous

Stage II

T2 | N0-N1 |M0 or

T3 |N0 |M0

AJCC Cancer Staging

Manual 8th edition

Stage IB & II

From

Diagnosis

Pathway

Map

(Page 5)

Medically

operable and

resectable

Status

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

Consider integrating the palliative care approach early and across the cancer journey Click here for more information about palliative care

Medical

Oncologist

Thoracic

Surgeon

Radiation

Oncologist

Brachytherapy

Proceed to

Malignant

Dysphagia

Pathway Map

(Page 10) &/or

End of Life Care

Pathway Map

(Page 11)

Psychosocial oncology

and supportive care

Referral to appropriate

specialist if additional

support is required

End of life care planning

Palliative Care

Systemic Therapy

Dietitian

Medical Oncologist

Radiation Oncologist

Thoracic Surgeon

Gastroenterologist

Stent or Feeding tubeR

and/or

External Beam Radiation

Therapy

and/or

and/or

Esophag-

ectomy

EBS #17-1

Upper

esophageal

cancer4

Endoscopy

CT Chest Abdomen Pelvis

Persistent Thoracic

SurgeonR

Proceed to

Follow-up

Care

Pathway

Map

Definitive concurrent

chemoradiation

Radiation therapy

Systemic therapy

Peer Review

Medical

Oncologist

Radiation

Oncologist

Dietitian

Location

of cancer

Mid & Lower Third

Esophageal

or

Gastroesophageal

(GE) Junction 5

7 PET is preferred. 4 Upper Thoracic Esophagus: 20 to 25cm from upper central incisor teeth on esophagogastroduodenoscopy (EGD)5 Mid Thoracic Esophagus: 25 to 30cm from upper central incisor teeth on EGD.

Lower Thoracic Esophagus: 30 from upper central incisor teeth to 40cm/to the GE junction

Margins

&/or

Lymph

Nodes

Positive MCC

Pathology

Stage II Neo-

adjuvant

Therapy

EBS #2-11

Systemic

therapy

Chemo-

radiation

Radiation

therapy

Systemic

therapy

Peer Review

or

Surgical Re-resection

EBS #17-1

Consider one or more of the following:

Radiation therapy

Systemic therapy

Peer Review

Proceed to

Follow-up

Care

Pathway

Map

Complete

response

Treatment

Response

Assess treatment

response

Nutritional support

Nutritional support

R

R

Negative

MCC

Salvage

Esophagectomy

EBS #17-1

Systemic therapy

or

Brachytherapy

or

PET7

PET Recommendation

Report #4

CT Chest

Abdomen Pelvis

Assess treatment

response

OR

Dietitian

Clinical Stage III and IVA (squamous) Version 2019.05 Page 5 of 12Esophageal Cancer Treatment 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.

Adenocarcinoma

Squamous

MCC

Outcome

Medical

Oncologist

Radiation

Oncologist

Thoracic

Surgeon

Squamous

Stage III

T3| N1 |M0 or

T1-3| N2 |M0

Stage IVA

T4|N0-N3 | M0 or

Any T| N3| M0

AJCC Cancer Staging

Manual 8th edition

Stage III & IVA

6 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), 733-42.7 PET is preferred.

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

A

Status

Unresectable/

patient declines

surgery and good

performance

status

Salvage

Esophagectomy

EBS #17-1

Proceed

To Page 7

From

Diagnosis

Pathway

Map

(Page 5) Dietitian

Unresectable and

poor performance

status

Palliative

Care6Proceed

to End of Life

Care Pathway

Map

(Page 11)PSO

Palliative Brachytherapy

Palliative systemic therapyPsychosocial oncology and

supportive care

Referral to specialist if

additional support is required

End of life care planning

Palliative External Beam

Radiation Therapy

R

Concurrent Neoadjuvant

Chemoradiation

Radiation therapy

Systemic therapy

Peer Review Esophagectomy

EBS #17-1

Resectable/

Potentially

resectablePET7

(approximately 4 weeks post treatment)PET Recommendation Report #4

CT Chest Abdomen Pelvis

Reassessment of treatment response

If persistent or

reccurent

Complete

response

Proceed

to Follow-up

Care Pathway

Map

Nutritional support

Nutritional support

MCC

Proceed

To Page 6

And

Concurrent Definitive

Chemoradiation

Radiation therapy

Systemic therapy

Peer Review

Nutritional support

PET7

(approximately 4 weeks post treatment)PET Recommendation Report #4

CT Chest Abdomen Pelvis

Reassessment of treatment response

or Treatment

response

R

B

EBS #2-11

EBS #2-12

Clinical Stage III and IVA (adenocarcinoma) Version 2019.05 Page 6 of 12Esophageal Cancer Treatment 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.

Adenocarcinoma

Proceed

to Malignant

Dysphagia

Pathway Map

(Page 10) &/or

End of Life Care

Pathway Map

(Page 11)

Proceed

to Malignant

Dysphagia Pathway

Map (Page 10) or

Follow-up Care

Pathway Map

Status Unresectable/

patient declines

surgery and good

performance

status

Unresectable and

poor performance

status

Resectable/

Potentially

resectable

From

Page 5

6 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), 733-42.7 PET is preferred.

Salvage

Esophagectomy

EBS #17-1

Proceed

To Page 7

Palliative

Care6

PSO

Palliative Brachytherapy

Palliative systemic therapyPsychosocial oncology and

supportive care

Referral to specialist if

additional support is required

End of life care planning

Palliative External Beam

Radiation Therapy

Concurrent Neoadjuvant

Chemotherapy or

Chemoradiation

Radiation therapy

Systemic therapy

Peer Review Esophagectomy

EBS #17-1PET7

(approximately 4 weeks post treatment)PET Recommendation Report #4

CT Chest Abdomen Pelvis

Reassessment of treatment response

If persistent or

reccurent

Complete

response

Proceed

to Follow-up

Care Pathway

Map

Nutritional support

Nutritional support

And

Concurrent Definitive

chemoradiation

Radiation therapy

Systemic therapy

Peer Review

Nutritional support

PET7

(approximately 4 weeks post treatment)PET Recommendation Report #4

CT Chest Abdomen Pelvis

Reassessment of treatment response

or Treatment

response

R

Adenocarcinoma

Stage III

T2| N1 |M0 or

T3-T4a| N0-N1 |M0

Stage IVA

T1-4a|N2 | M0 or

T4b| N0-2| M0 or

Any T| N3| M0

AJCC Cancer Staging

Manual 8th edition

Stage III & IVA

B

CEBS #2-11

EBS #2-12

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

Clinical Stage III and IVA (continued) Version 2019.05 Page 7 of 12Esophageal Cancer Treatment 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.

Adenocarcinoma

Stage III

T2| N1 |M0 or

T3-T4a| N0-N1 |M0

Stage IVA

T1-4a|N2 | M0 or

T4b| N0-2| M0 or

Any T| N3| M0

Squamous

Stage III

T3| N1 |M0 or

T1-3| N2 |M0

Stage IVA

T4|N0-N3 | M0 or

Any T| N3| M0

AJCC Cancer Staging

Manual 8th edition

Stage III & IVA

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

Consider integrating the palliative care approach early and across the cancer journey. Click here for more information about palliative care

Proceed

to Follow-up

Care Pathway

Map

Margins

&/or

Lymph

Nodes

Negative

Positive

Consider one or

more of the

following:

Systemic therapy

From

Pages 5

& 6

MCC

Medical

Oncologist

Radiation

OncologistRadiation

Therapy

Pathology

Systemic therapy8

Thoracic

Surgeon Re-resection

EBS #17-1

8Adjuvant chemotherapy should be considered for patients who received neoadjuvant chemotherapy without concurrent radiation

RCT Chest Abdomen Pelvis

Reassessment of treatment

response

If persistent

Complete

response

Treatment

response

Proceed

to Follow-up

Care Pathway

Map

R

Proceed to

Malignant

Dysphagia

Pathway (Page 10)

&/or

End of Life Care

Pathway Map

(Page 11)

Palliative Care

Dietitian

Medical Oncologist

Radiation Oncologist

Brachytherapy

Psychosocial oncology

and supportive care

Referral to appropriate

specialist if additional

support is required

End of life care planning

Systemic Therapy

External Beam Radiation

Therapy

and/or

and/or

Manage Dysphagia (see

page 9 Malignant

Dysphagia Pathway)

Nutritional Support

A C

Clinical Stage IVB Version 2019.05 Page 8 of 12Esophageal Cancer Treatment 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.

Any T | Any N | M1

AJCC Cancer Staging

Manual 7th edition

Stage IVB

From

Diagnosis

Pathway

Map

(Page 5)

R

Proceed to

Malignant

Dysphagia

Pathway (Page 10)

&/or

End of Life Care

Pathway Map

(Page 11)

MCC9,10

9 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.

10 Review biomarker status

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

Consider integrating the palliative care approach early and across the cancer journey. Click here for more information about palliative care

Palliative Care

Dietitian

Medical Oncologist

Radiation Oncologist

Brachytherapy

Psychosocial oncology

and supportive care

Referral to appropriate

specialist if additional

support is required

End of life care planning

Systemic Therapy

External Beam Radiation

Therapy

and/or

and/or

Manage Dysphagia (see

page 9 Malignant

Dysphagia Pathway)

Nutritional Support

Recurrence Version 2019.05 Page 9 of 12Esophageal Cancer Treatment 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.

Local regional

recurrence with

nodal

involvement

Distant

recurrence

Appropriate treatment may

include one or more of the

following

Radiation therapy

Systemic therapy

Good

Poor

Surgical resection

EBS #17-1

Proceed to

End of Life

Care Pathway

Map (Page 11)

From

Esophageal

Cancer

Follow-up

Pathway

Map

Thoracic

Surgeon

Proceed

to Follow-up

Care Pathway

Map

Psychosocial oncology

and supportive care

Referral to appropriate

specialist if additional

support is required

End of life care planning

MCC10,11

Performance

Status

Type of

recurrence

10 Review biomarker status

11 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)

Peer Review

Focal Tumour

Ablation

Systemic therapy

Radiation therapy

Peer Review

Biopsy

Pathology

Palliative Care

PSO

Consistent surgical and

pathological confirmation

(if not previously done)

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

Consider integrating the palliative care approach early and across the cancer journey. Click here for more information about palliative care

End of life care planning

Systemic therapy

Radiation therapy

Peer Review

Local luminal

recurrence

MCC Medical

Oncologist

Radiation

Oncologist

Thoracic

Surgeon

Medical

Oncologist

Radiation

Oncologist

Palliative Care

R

R

R

R

Nutritional Support

Nutritional Support

Malignant Dysphagia Version 2019.05 Page 10 of 12Esophageal Cancer Treatment 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.

Result

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

Consider integrating the palliative care approach early and across the cancer journey. Click here for more information about palliative care

Proceed

To End of life

care (Page

11)

From

Treatment

Pathway

Map

Pages

4, 6, 7, 8

External Beam Radiation

therapy

Systemic Therapy

Stent or Feeding tubeEsophagogastroduodenoscopy

(EGD)

Pathology

Malignant

Stage IV or

unresectable Brachytherapy

Endoscopic therapies

Treatment options vary

based on centre resources:

Other:

Recurrent cancer after treatment Stage IV Esophageal cancer not amenable to

curative therapy

Thoracic Surgeon

DietitianR

Gastro-enterologist

Radiation Oncologist

Medical Oncologist

Palliative CareIn pain & symptom

management/psychosocial needs

End of Life Care Version 2019.05 Page 11 of 12Esophageal Cancer Treatment 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 2-4 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/

End of Life Care contd. Version 2019.05 Page 12 of 12Esophageal Cancer Treatment 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