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CLINICAL PATHWAY Cancer Care Operable Stage 2 Non-Small Cell Lung Cancer

CANCER CARE Pathway Templatepathways.christianacare.org/wp-content/...2-NSC-Lung-Cancer-Pathway.pdf · Scope of this Pathway This care pathway will serve adult patients who present

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Page 1: CANCER CARE Pathway Templatepathways.christianacare.org/wp-content/...2-NSC-Lung-Cancer-Pathway.pdf · Scope of this Pathway This care pathway will serve adult patients who present

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

Page 2: CANCER CARE Pathway Templatepathways.christianacare.org/wp-content/...2-NSC-Lung-Cancer-Pathway.pdf · Scope of this Pathway This care pathway will serve adult patients who present

O P E R A B L E S T A G E 2 N O N - S M A L L C E L L L U N G C A N C E R M A Y 2 , 2 0 1 6

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

Page 3: CANCER CARE Pathway Templatepathways.christianacare.org/wp-content/...2-NSC-Lung-Cancer-Pathway.pdf · Scope of this Pathway This care pathway will serve adult patients who present

O P E R A B L E S T A G E 2 N O N - S M A L L C E L L L U N G C A N C E R M A Y 2 , 2 0 1 6

Back to Table of Contents page 1

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]

Page 4: CANCER CARE Pathway Templatepathways.christianacare.org/wp-content/...2-NSC-Lung-Cancer-Pathway.pdf · Scope of this Pathway This care pathway will serve adult patients who present

O P E R A B L E S T A G E 2 N O N - S M A L L C E L L L U N G C A N C E R M A Y 2 , 2 0 1 6

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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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O P E R A B L E S T A G E 2 N O N - S M A L L C E L L L U N G C A N C E R M A Y 2 , 2 0 1 6

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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

Page 6: CANCER CARE Pathway Templatepathways.christianacare.org/wp-content/...2-NSC-Lung-Cancer-Pathway.pdf · Scope of this Pathway This care pathway will serve adult patients who present

O P E R A B L E S T A G E 2 N O N - S M A L L C E L L L U N G C A N C E R M A Y 2 , 2 0 1 6

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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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O P E R A B L E S T A G E 2 N O N - S M A L L C E L L L U N G C A N C E R M A Y 2 , 2 0 1 6

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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

Page 8: CANCER CARE Pathway Templatepathways.christianacare.org/wp-content/...2-NSC-Lung-Cancer-Pathway.pdf · Scope of this Pathway This care pathway will serve adult patients who present

O P E R A B L E S T A G E 2 N O N - S M A L L C E L L L U N G C A N C E R M A Y 2 , 2 0 1 6

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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

Page 9: CANCER CARE Pathway Templatepathways.christianacare.org/wp-content/...2-NSC-Lung-Cancer-Pathway.pdf · Scope of this Pathway This care pathway will serve adult patients who present

O P E R A B L E S T A G E 2 N O N - S M A L L C E L L L U N G C A N C E R M A Y 2 , 2 0 1 6

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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

Page 10: CANCER CARE Pathway Templatepathways.christianacare.org/wp-content/...2-NSC-Lung-Cancer-Pathway.pdf · Scope of this Pathway This care pathway will serve adult patients who present

O P E R A B L E S T A G E 2 N O N - S M A L L C E L L L U N G C A N C E R M A Y 2 , 2 0 1 6

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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

Page 11: CANCER CARE Pathway Templatepathways.christianacare.org/wp-content/...2-NSC-Lung-Cancer-Pathway.pdf · Scope of this Pathway This care pathway will serve adult patients who present

O P E R A B L E S T A G E 2 N O N - S M A L L C E L L L U N G C A N C E R M A Y 2 , 2 0 1 6

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CLINICAL EDUCATION MATERIALS

• National Cancer Institute

• Clinical Trials information

• National Comprehensive Cancer Network

Page 12: CANCER CARE Pathway Templatepathways.christianacare.org/wp-content/...2-NSC-Lung-Cancer-Pathway.pdf · Scope of this Pathway This care pathway will serve adult patients who present

©2016 Christiana Care Health Services, Inc.