Clinical Pathways for the Medical Management · the patient and family members. Lastly, it is emphasized that the clinical pathways shown here only provide a general guideline to

Clinical Pathways for the Medical Management of the Top 10 Solid Malignant Tumors

in the Philippines 2015

Clinical Pathways Task Force

Dr. Jose S. Garcia, Jr. Chair

Dr. Jhade Lotus P. Peneyra

Co-chair

Dr. Maximino G. Bello III Dr. Gloria R. Cristal-Luna Dr. Roselle B. De Guzman Dr. Jay T. Datukan Dr. Carlos Dy Dr. Divina B. Esteban Dr. Therese Narcisa Q. Fajardo Dr. Cherelina S. Ferreras Dr. Marigold M. Ferrolino Dr. Christina G. Galvez Dr. Domingo E. Ganzon Dr. Agnes E. Gorospe Dr. Katherine V. Hernandez Dr. Anita G. Lacuesta-Jesena Dr. Juanita Lu Lim

Dr. Conrado J. Lola Dr. Cherry M. Marquez Dr. Felina R. Masadao-Adefuin Dr. Corazon A. Ngelangel Dr. Annielyn Beryl A. Ong-Cornel Dr. Ma. Laura S. Pedraza Dr. Paul Francis B. Pua Dr. Mary Claire V. Soliman Dr. Heinrik MJ S. Strebel Dr. Edwin S. Tan Dr. Beatrice J. Tiangco Dr. Maria A. Warren Dr. Angeline T. Yeo Dr. Ellie May B. Villegas Dr. Antonio H. Villalon

Edited by Dr. Ivan Noel G. Olegario

Governing Council 2014-2015

Dr. Anita G. Lacuesta-Jesena President

Dr. Mary Claire V. Soliman

Vice President

Dr. Felina R. Masadao-Adefuin Secretary

Dr. Necy S. Juat

Treasurer

Dr. Buenaventura C. Ramos, Jr. Dr. Joseph D. Parra Dr. Leo Y. Marbella

Dr. Cherry M. Marquez Dr. Jose S. Garcia, Jr.

Council Members

Dr. Ellie May B. Villegas Immediate Past President

Secretariat Erlyn J. Banal

Eddielyn D. Igloso Renz Mharie C. Pereyra

PHILIPPINE SOCIETY OF MEDICAL ONCOLOGYPHILIPPINE SOCIETY OF MEDICAL ONCOLOGY

Clinical Pathways for the Medical Management of the Top 10 Solid Malignant Tumors in the Philippines 2015

TABLE OF CONTENTS

Messages ……………………………………………………………. 5 Introduction …………………………………………….………... 6 Multidisciplinary team approach …………………… 7 Breast cancer ………………………………………................. 8 Lung cancer …………………..………………………………….. 12 Lung cancer (non-small cell) …………………………….. 12 Lung cancer (small cell) ….………………………………. 20 Colorectal cancer ………………………………………… 21 Hepatocellular carcinoma ………………………………… 24 Cervical cancer ……………………………………….……… 27 Prostate cancer ……………………………….……….………… 30 Lymphoma ……………………..…………………………… 34 Lymphoma: Hodgkin’s lymphoma …………………… 34 Lymphoma: Diffuse large B-cell lymphoma ...…… 41 Ovarian cancer ………………………………………………… 45 Gastric cancer ……………………………………………………. 47 Nasopharyngeal cancer ………………………………………. 50

INTRODUCTION

Cancer remains a major killer among Filipinos, ranking third after heart disease and vascular diseases, with a mortality rate of 52 cases per 100,000 Filipinos. Among the various solid malignant tumors, the 10 most common are (in descending order of incidence): (1) Breast Cancer; (2) Lung Cancer; (3) Colorectal Cancer; (4) Liver Cancer; (5) Cervical Cancer; (6) Prostate Cancer; (7) Lymphoma; (8) Ovarian Cancer; (9) Gastric Cancer; and (10) Nasopharyngeal Cancer. To provide some guidance on the medical management of these 10 solid malignant tumors, the Philippine Society of Medical Oncology, the country’s certifying body for medical oncology specialists, developed these clinical pathways. These pathways outline the patient journey through the health system, together with his/her attending physicians, from suspicion, to diagnosis, to treatment. It is hoped that these clinical pathways would help improve the quality of care given to Filipino cancer patients. These pathways may also be used as a guide by health-regulatory agencies in developing and implementing policies and programs regarding the proper management of these 10 cancers. Cancer outcomes can be significantly improved by early detection and evidence-based treatment. Furthermore, effective cancer treatment requires the active involvement of several medical professionals: medical oncologists, surgical oncologists, radiation oncologists, gynecological oncologists, radiologists, interventional radiologists, pain management specialists, nutritionists, physiatrists, psychiatrists, psychologists, and palliative care specialists, among others. These clinical pathways focus on the medical management of cancer. However, the pathways also emphasize the importance of involving the different specialties, in a structured manner, during the multidisciplinary team meeting. Decision-making should be a collaboration between the team members and the patient and family members. Lastly, it is emphasized that the clinical pathways shown here only provide a general guideline to patient management. Physicians are encouraged to individualize treatment according to the unique patient characteristics, the patient’s values and preferences, and the health care setting.

6

The Multidisciplinary Team Approach

The management of cancer should be multidisciplinary-interdisciplinary, with each discipline respecting the specialty expertise of the other, all for the benefit of the cancer patient. This is with the consideration of the current state of cancer management. The three primary disciplines in the treatment of cancer include: 1. Surgical oncology. The surgical oncologist is a master of surgical techniques used in the biopsy, debulking, or excision of malignant tumors.

2. Radiation oncology. The radiation oncologist is the expert in planning and use of radiation therapy, such as the use of external radiation and brachytherapy.

3. Medical oncology. The medical oncologist trained in internal medicine, and further trained in medical oncology. He is an expert in the use of systemic therapy, such as chemotherapy, hormonal therapy, and/or targeted therapy. He is also knowledgeable in the prevention, recognition and treatment of complications of these medications, that inevitably occur in the use of these potentially lethal drugs. The medical oncologist should educate the patient on medical options appropriate for the specific cancer type and stage, taking into consideration the patient’s functional status, concomitant illnesses, personal values and financial status.

7

Patient suspected with breast cancer

• History and physical examination• Complete blood count with platelet; liver function tests; alkaline phosphatase• 2D echocardiography and electrocardiogram• Prothrombin time, partial thromboplastin time, when necessary• Mammography or breast ultrasound, when necessary1

• Breast MRI (optional)

Biopsy2 and pathology review

Diagnosis of breast cancer

Breast panelEstrogen receptor (ER), progesterone receptor (PR), HER2-neu

Staging• Bone scan3

• CT scan or ultrasound of the abdomen and pelvis4

• Chest x-ray or CT scan• Cranial CT or MRI (optional)

Stage 05 to IIIa Stage IIIb to IV

Refer to Surgical Oncology and Radiation

Oncology for opinion

Refer to Surgical Oncology and Radiation Oncology if necessary

Go to Systemic therapy (adjuvant) for Stage I to

IIIa

Go to Systemic therapy for Advanced Stage

BREAST CANCER

Clinical Pathway

Consider enrollment into clinical trialsMultidisciplinary team meeting

8

Stage I to IIIa6,7

ER/PR (+) HER2 (+)

ER/PR (+)HER2 (-)

ER/PR (-)HER2 (+)

ER/PR (-)HER2 (-)

Chemotherapy8-11

with concomitant or sequential

HER2 targeted therapy11

Hormonal therapy13

Chemotherapy8-11

Chemotherapy8-11

with concomitant or sequential

HER2 targeted therapy12

Chemotherapy8-

11

Advanced breast cancer15-17

HER2 (+) HER2 (-)

Hormonal therapy13

Chemotherapy10,11,19 with concomitant or sequential HER2 targeted therapy20

Chemotherapy10,1

1,19 or mTORinhibitor21

ER/PR (+) with no life-threatening metastasis

ER/PR (+) with life-threatening metastasis ER/PR (-)

At least stable disease Refractory18

Continue hormonal therapy12

Follow-up14

Follow-up14

Systemic Therapy for Advanced Breast Cancer

BREAST CANCER

Systemic Therapy (Adjuvant) for Stage I to IIIa Breast Cancer

9

10

NOTES:1. Women aged less than 40 years have dense breast tissue and may benefit more frombreast ultrasound. Those aged 40 years and above may undergo mammography.

2. Core or open biopsy is generally preferred to allow sufficient tissue to be removed foradequate histopathologic diagnosis. The histopathology report should include the followinginformation:

a. Type of operation performedb. Histologic type of breast carcinomac. Extent of ductal carcinoma in situ (if applicable)d. Size of largest invasive componente. Number of positive lymph nodes/number of lymph nodes examinedf. Differentiationg. Margins of resectionh. Lymph vessel, vascular, and perineural invationi. Estrogen and progesterone receptorj. Her2neu status by immunohistochemistry

3. If with localized symptoms, elevated alkaline phosphatase, or T3N1M0, total bone scan isindicated.

4. If with abdominal symptoms or physical findings, elevated alkaline phosphatase, orabnormal liver function tests, CT scan or ultrasound of the abdomen and pelvis is indicated.

5. Patients with lobar carcinoma in situ should receive counselling on risk reduction.Hormone therapy should be given for patients with hormone-receptor positive ductalcarcinoma in situ.

6. Preoperative chemotherapy for large clinical stage IIA, IIB, and T3N1M0 tumors shouldbe considered for women who meet the criteria for breast conserving therapy. In caseswhere breast conserving therapy is not possible, preoperative chemotherapy remains anoption for patients deemed to benefit from the therapy.

7. Drug management (chemotherapy, hormonal therapy or targeted therapy in the adjuvantto palliative setting) is the responsibility of the medical oncologist who does the planning,administratioon and monitoring of drug therapeutic and safety effects.

8. Please refer also to the Z-package of PhilHealth.

9. Adjuvant chemotherapy options include anthracyclines (doxorubicin, epirubicin,pegylated liposomal doxorubicin); taxanes (paclitaxel, docetaxel, albumin nano-particlebound paclitaxel); anti-metabolites (5-fluorouracil, capecitabine, gemcitabine, methotrexate);vinca alkaloids (vincristine and vinorelbine); and alkylating agents (cisplatin, carboplatin,cyclophosphamide). These drugs are used in combination based on regimens outlined ininternational guidelines.

10. Treatment of neutropenia includes granulocyte colony-stimulating factor. Treatment ofanemia includes erythropoietin.

BREAST CANCER

11

NOTES:11. Anti-emetic drugs such as tropisetron, ramosetron, ondansetron, palonosetron may begiven for nausea and vomiting.

12. Adjuvant or neoadjuvant HER2-targeted therapy includes trastuzumab, lapatinib, orpertuzumab.

13.Adjuvant hormonal therapy includes tamoxifen, aromatase inhibitors (anastrozole,letrozole, exemestane), and fulvestrant.

14. Routine surveillance includes: 1) history and physical examination q3-6 months for thefirst 3 years, q6-12 months for years 4 and 5, and annually therafter; 2) annualmammography beginning 6 months after radiation therapy; 3) monthly breast self-examination; and 4) annual pelvic examination. Optional investigations include bloodcounts, liver function tests, chest x-ray, total body bone scan, liver ultrasound, CT scan,breast MRI, bone densitometry, electrocardiogram, 2D echocardiogram, and high-sensitivitytroponin I/T.

15. Metastatic sites for breast cancer are usually the regional lymph nodes, skin, lungs,liver, bone, brain, etc. Stage IV breast cancer can be those with a) “operable-like” breastmass but with distant metastasis wherein simple mastectomy followed by radiotherapy oftarget breast and regional lymph node sites and symptomatic lymph node sites pluschemotherapy/hormonal therapy, OR wherein radiotherapy to target breast lesion/othersymptomatic metastatic sites plus chemotherapy/hormone therapy can be done; or b)“inoperable-like” breast mass (adherent, ulcerated, etc.) with distant metastasis, whereintoilette mastectomy can be done with chemotherapy/hormonal therapy or radiotherapy, orbest supportive care. Surgery, rdiotherapy and systemic therapy in stage IV diseases are allpalliative in intent, although several patients can respond very well to systemic therapy withor without radiotherapy and have significantly long disease progression interval.

16. Best supportive care includes management of nutrition, pain, infection, psychologicalwell-being, nursing, rehabilitative care, and other pertinent quality-of-life patient care.

17. Bisphosphonates such as zoledronic acid, incadronic acid, pamidronate or ibandronicacid should be given for bone metastases. These are given in addition to chemotherapy orhormonal therapy for palliative purposes or to prevent skeletal-related events andpathologic fractures in patients on adjuvant aromatase inhibitors. Denosumab may also beused in preventing these skeletal-related events.

18. Hormone refractory refers to progressive disease after 2 months of hormonal therapy.

19. Agents listed in adjuvant chemotherapy may be used in metastatic breast cancer, withthe addition of the anti-mitotic agent, eribulin. Eribulin may be given in patients previouslytreated with chemotherapy, specifically an anthracycline and a taxane, unless the patient isnot suitable for these treatments.

20. HER2-targeted therapy for metastatic breast cancer includes lapatinib or trastuzumab +pertuzumab (1st line) and trastuzumab emtansine (TDM1) (2nd line).

21. Everolimus may be given in combination with an aromatase inhibitor in ER/PR (+),HER2 (-) patients previously treated with hormonal therapy.

BREAST CANCER

LUNG CANCER: NON-SMALL CELL LUNG CANCER

NSCLC suspect

• History and Physical Examination• CT/PET scan, OR CT scan of the chest with contrast to include liver and adrenals + Bone

scan + MRI of the brain with contrast or CT of the brain with contrast• Bronchoscopy if the mass is central and within the airways in location OR CT guided

biopsy if the mass is peripheral• Mediastinal lymph node evaluation if present on imaging (mediastinoscopy OR CT

guided biopsy)• Pathological assessment

o H and E staino May do thyroid transcription factor 1 (TTF1), carcinoembryonic antigen (CEA)

calretinin, cytokeratin (CK), high-molecular-weight (HMW) hyaluronano If unsure if lesion is a metastatic lesion, may do CK7, CK20, HMW screening panelo If adenocarcinoma, check for EGFR mutation and then ALK testing o If squamous carcinoma, may check for EGFR mutation if never smoker or light smokero Consider EGFR mutation and ALK testing for mixed histology tumors (e.g.,

adenosquamous) and for small specimens.

No mediastinal lymph nodes (LN)

(+) mediastinal LN(N2) Stage IIIB Stage IV

Definitive chemo-RT

Go to Treatment of Stage IV NSCLC

Go to Treatment of N2 disease NSCLC Stage I and II

Medically unresectable

Pulmonary function testing

Definitive radiotherapy

Medically resectable

Surgery with LN dissection

Go to Adjuvant Therapy for N0/N1 NSCLC

Superior sulcus tumor/invasion of proximal airway or chest wall or mediastinum/separate

pulmonary nodule

Go to Treatment of specific subsets

Clinical Pathway

12

Adjuvant Therapy for N0/N1 NSCLC

(-) Margins of resection

Stage 1A Stage IB/IIA (no nodes)

Stage IIA/IIB (N1 nodes)

Observe Chemotherapy1

(+) Margins of resection

Notes:1. Chemotherapy includes cisplatin, carboplatin, vinorelbine, etoposide, vinblastine,

gemcitabine, paclitaxel, docetaxel, and pemetrexed.


Stage IIIA

Observe, or chemotherapy1

for high-risk patients

Chemotherapy1; or chemo-RT2 if patient is found to have N2

disease

Stage IA Stage IB/IIA Stage IIB Stage IIIA

Re-resection or RT

Re-resection or RT; +/-

chemotherapy1

Re-resection + chemotherapy1; OR chemo-RT2

Chemo-RT2

13

Adjuvant Therapy for N0/N1 NSCLC

Superior sulcus tumor Separate pulmonary nodule (T3N0, T4N0)

Notes:1. Chemotherapy includes cisplatin, carboplatin, vinorelbine, etoposide, vinblastine,

gemcitabine, paclitaxel, docetaxel, and pemetrexed.2. Chemo-RT may be administered concurrently, or if the patient is not able to tolerate

concurrent chemo-RT, sequential chemo-RT may be given.


Surgery

Invasion of proximal airway/chest wall/

mediastinum

Not resectable Resectable Not

resectable Resectable

Surgery Concurrent chemo-RT1 Surgery Concurrent

chemo-RT1

Surgery if resectable

N2 disease after surgery

N0/N1 after surgery

Chemotherapy1

(+) margins (-) margins

Chemotherapy1 Concurrent chemo-RT1

14

Treatment of specific subsets

Concurrent chemo-RTOR

Induction chemotherapy

Treatment of N2 disease NSCLC (N3 nodes negative, M0)


No progression With progression

Surgery if resectable, then chemotherapy, and RT if

not yet given Local

progressionSystemic

progression

RT Chemotherapy

Locoregional recurrence Treatment

Endobronchial obstruction laser/stent/other surgeryExternal beam radiation therapy (EBRT) or brachytherapy

Resectable recurrence ReresectionEBRT

Mediastinal lymph node Concurrent chemoRT (if no prior RT)Systemic therapy (if with prior RT)

Superior vena cava (SVC) obstruction

concurrent chemo RT (if none prior)EBRTSVC stent

Severe hemoptysis EBRT or brachytherapySurgery

In any of the above: if no evidence of disseminated disease: observation or systemic therapyif with disseminated disease: systemic therapy for metastatic disease

EGFR tyrosine kinase inhibitors may be considered for patients with locally advanceddisease with medical contraindication to surgery or those who refuse surgery.

Treatment for Locoregional Recurrence

15

Treatment of N2 disease NSCLC (N3 nodes negative, M0)


Treatment of Stage IV NSCLC (M1)

M1 disease: Pleural or pericardial effusion

Distant metastasis

Thoracentesis or pericardiocentesis; +/-

thoracoscopy if thoracentesis indeterminate

Local therapy (pleurodesis/catheter drainage/pericardial

window

Palliative RT for diffuse brain metastases, bone metastases, or localized

symptoms

M1b: Limited sites

Pathologic mediastinal LN evaluation; bronchoscopy; brain

CT or MRI; PET/CT scan

Systemic therapy

Brain Adrenals

Refer to surgery and RT

T1-2, N0-1; T3 N0: Surgical

resection

Pathologic diagnosis by needle

or resection

Local therapy (adrenal) if lung lesion is curable

16

Treatment of Stage IV NSCLC (M1)

AdenocarcinomaLarge cell carcinoma

Squamous cellNSCLC not otherwise specified

EGFR mutation testing positive ALK testing positive EGFR and ALK

negative or unknown

Chemotherapy. Refer to First-line Chemotherapy and Subsequent Therapies for

Non-squamous cell CA and First-line Chemotherapy and

Subsequent Therapies for Squamous Cell CA.

LUNG CANCER: NON-SMALL CELL LUNG CANCERSystemic therapy for metastatic NSCLC

Crizotinib until progression

Gefitinib or erlotinib or

afatinib until progression

• Chemotherapy on progression. • Consider doing a biopsy on progression.• Consider enrollment in clinical trial if available.

Symptomatic:• Consider local therapy for symptomatic isolated lesions• Consider RT for multiple brain lesions• Consider chemotherapy for multiple systemic lesions

17

AdenocarcinomaLarge cell carcinoma

NSCLC not otherwise specified*EGFR mutation negative + ALK negative

Performance status 0 to 2


LUNG CANCER: NON-SMALL CELL LUNG CANCERFirst-line Chemotherapy and Subsequent

Therapies for Non-squamous Cell CA

Doublet chemotherapy

+/- bevacizumab

Best supportive care

Evaluate tumor response via CT

scan

Progression Response or stable disease

PS 3-4: Gefitinibor erlotinib if not yet given; else, best supportive

care

PS 0-2: Docetaxelor pemetrexed or

gefitinib or erlotinib

4 to 6 cycles total


scan


Subsequent therapy

Maintenance treatment1OR

Observe then proceed to Subsequent therapy

Notes: 1. Maintenance treatment may be bevacizumab, pemetrexed, bevacizumab+pemetrexed, gemcitabine, gefitinib, or erlotinib.

18

Squamous cell CA



LUNG CANCER: NON-SMALL CELL LUNG CANCERFirst-line Chemotherapy and Subsequent

Therapies for Squamous Cell CA

Doublet chemotherapy



scan


PS 3-4: Gefitinibor erlotinib if not yet given; else, best supportive

care

PS 0-2: Docetaxelor gemcitabine or afatinib, gefitinib

or erlotinib

4 to 6 cycles total


scan


Subsequent therapy

Maintenance treatment1OR

Observe then proceed to Subsequent therapy

Notes: 1. Maintenance treatment may be gemcitabine, docetaxel, afatinib, gefitinib, or erlotinib.

19

LUNG CANCER: SMALL CELL LUNG CANCER

SCLC suspect

• History and Physical Examination• Pathologic review• Complete blood count, sodium, potassium, glucose,

creatine, lactic acid dehydrogenase, calcium• Liver function tests• CT scan of the chest and upper abdomen• CT scan or MRI of the brain• Bone scan• ECG if with history of heart disease• Echocardiogram if doxorubicin is planned

Limited stage

Clinical Pathway

Extensive stage

Concurrent Chemo-RT

First-line chemotherapy

Complete or partial response

• Prophylactic cranial irradiation

• Observe for progression

• Smoking cessation

Progression

Notes: 1. First line chemotherapy includes etoposide, cisplatin, or carboplatin 2. Subsequent chemotherapy includes topotecan, cyclophosphamide, adriamycin and vincristine

Subsequent Chemotherapy

20

COLORECTAL CANCER

Clinical Pathway

Patient suspected with colon cancer

History and physical examination

If stage III and high-risk3

stage II, add adjuvant chemotherapy4.

Patient suspected with rectal cancer

Colonoscopy and biopsyFlexible sigmoidoscopy

or colonoscopy and biopsy

If (+) cancer:• Consider enrolment into clinical trials• Multidisciplinary team meeting• Metastatic work-up1

• Carcinoembryonic antigen (CEA)• Molecular profiling2

Localized colon

cancer

Metastatic colon

cancer

Localized rectal

cancerMetastatic rectal cancer

Surgery

Go to Treatment of metastatic colon cancer

Go to Treatment of localized

rectal cancer

Individualized treatment planning:• For resectable

metastasis, chemotherapy or chemoradiation, then consider surgery

• For unresectable metastasis, consider chemotherapy with or without prior localized treatment (e.g., diverting ostomy/resection/stenting)

21

COLORECTAL CANCER

Treatment of metastatic colon cancer

Patient with metastatic colon cancer

Resectable Borderline resectable Unresectable

Chemotherapy5 and targeted therapy.6 Give IV bisphosphonates if bone metastases is present.

Curative surgeryReassess if resectable

If resectable

Patient with localized rectal cancer

T1/2, N0 T3N0 or Any T, N+ T4, any N

SurgeryPre-operative

chemotherapy7

and radiotherapy

Treatment of localized rectal cancer

Surgery

Adjuvant chemotherapy7 and

radiotherapy

Surgery

22

COLORECTAL CANCER

Follow-up for patients with colorectal cancer

Notes:1. Metastatic work-up includes bone scan; CT scan of the chest, whole abdomen, and

pelvis; complete blood count; and serum creatinine, alanine aminotransferase, alkaline phosphatase, and calcium.

2. Molecular profiling includes KRAS, BRAF, microsatellite instability, and, for high-risk patients, KI-67 antigen.

3. High-risk patients include those with obstruction, perforation, poor differentiation, aneuploidy, high S-phase, and deleted chromosome18q.

4. Adjuvant chemotherapy for stage II-III colon cancer includes 5-fluorouracil, leucovorin,capecitabine, and oxaliplatin.

5. Chemotherapy for metastatic colon cancer includes oxaliplatin, 5-fluorouracil, leucovorin, capecitabine, and irinotecan.

6. Targeted therapy for colorectal cancer includes cetuximab or panitumumab for wild-type KRAS or codon 13 mutation; and bevazucimab or regorafenib for angiogenesis inhibition.

7. Neo/adjuvant chemotherapy for T3N0 or node-positive rectal cancer includes 5-fluorouracil, leucovorin, capecitabine, and oxaliplatin.

8. Treatment of neutropenia includes granulocyte colony-stimulating factor. Treatment of anemia may include erythropoietin.

Test Frequency

Physical examination • Every 4 months for first 3 years• Every 6 months on 4th and 5th year• Annually thereafter

Complete blood count8Liver ultrasound

Every 2 to 3 months

Carcinoembryonic antigen Every 2 to 3 months, stop after 5 years

Colonoscopy or double-contrast barium enema

At 6 months to 1 year, then every 3 years

Chest x-ray Yearly

CT scan As indicated

23

HEPATOCELLULAR CARCINOMA

Initial assessment

Patient suspected with hepatocellular carcinoma (HCC): Liver nodule

History and physical examinationHepatobiliary ultrasound

< 1cm diameter

Repeat ultrasound after 3 months

StableGrowing or changing in character

4-phase multi-detector CT scan or

Dynamic contrast enhanced MRIor

Other contrast-enhanced CT or MRI

Investigate according to

sizeYES

Arterial hypervascularity AND venous or delayed phase washout?

1+ cm diameter

NO

HCC1 Biopsy1

24


Management pathway as adapted from the Barcelona Clinic Liver Cancer Staging System

HCC

Stage 0• Performance status

test (PST) 0• Child Pugh A

Stage A-C• PST 0-2• Child Pugh A-B

Stage D• PST >2• Child Pugh C

• Consider enrollment into clinical trials

• Multidisciplinary team meeting

Surgical resection

Liver transplant

Percutaneous ethanol injection or

radiofrequency ablation

Work-up: Alpha-feto protein, liver function tests, complete blood counts, creatinine, protime

Transarterialchemo-

embolization2

Targeted therapies3

Symptomatic treatment

Palliative chemotherapy4

Stage 0Single HCC < 2cm

Single HCC

Normal portal pressure or

bilirubin

Early stage or 3 nodules <3cm,

PS 0

Portal invasion, N1, M1, PS 1-2

Multinodular,PS 2

3 nodules <3 cm

High portal pressure or

bilirubin

Associated disease?

YES NO

25


Follow-up for patients with HCC

Notes:1. Histologic confirmation is not necessary for the diagnosis of HCC, but may be useful in lesions with atypical vascular pattern (PSO, 2012). A biopsy may be risky in HCC patients, as HCC is generally hypervascular, and patients typically have abnormal bleeding parameters.2. Agents for transarterial chemoembolization includes lipiodol, doxorubicin, epirubicin, 5-fluorouracil, mitomycin, cisplatin .3. Targeted therapies for HCC includes sorafenib and sunitinib.4. Chemotherapy for HCC includes liposomal doxorubicin and capecitabine.5. Treatment of neutropenia includes granulocyte colony-stimulating factor. Treatment of anemia may include erythropoietin.

Test Frequency

Liver ultrasound

Every 2 to 3 monthsLiver function tests

Complete blood count

Creatinine

Protime

26

Patient with abnormal Pap smear

Repeat Pap smear every 3 to 6 months

CERVICAL CANCER

Patient with abnormal Pap smear

Low-grade squamous

intraepithelial lesion

Atypical squamous cell

ofundetermined significance

Atypical glandular cell

ofundetermined significance

Carcinoma

Colposcopy + biopsy1 +endocervical curettage

Invasive carcinoma

Carcinoma in situ (CIN) I CIN II CIN III

Normal

Abnormal

Observe or cryotherapy

Follow-upPap smear

andcolposcopy q 3-6 months;

annually after 2 normal results

Cryotherapy Cone biopsy1 or loop electrosurgical

excision procedure (LEEP)

CIN IICIN III or

carcinoma in situ

More invasive carcinoma

Definitive treatment (see subsequent algorithms)

Close follow-upsurveillance

Total hysterectomy (TH) +bilateral salpyngo-oophorectomy

(BS)

Desirous of pregnancy

Completed reproductive function

27

Patient suspected with cervical cancer

History and physical examinationComplete blood count with platelet

Cervical biopsy1 and pathologic review

Diagnosis of cervical cancer

Staging• Pelvic and abdominal CT scan• Liver and kidney function tests• Chest x-ray or CT scan• Bone scan

CERVICAL CANCER

Clinical Pathway

Consider enrollment into clinical trialsMultidisciplinary team meeting

For all stages: Refer to gynecological and radiation oncology services.

Stage IA to IB1 and selected IIA1 (early-stage disease and

smaller lesions)

Stage IVB

Follow-up Chemotherapy2 andindividualized RT

Concurrent chemo-RT2

Stage IB2 to IVA

28

CERVICAL CANCER

Follow-up of patients with cervical cancer

NOTES1. Cone biopsy is indicated if the cervical biopsy is insufficient to define invasiveness

or if accurate assessment of microinvasive disease is necessary.

2. Chemotherapy for cervical cancer may include cisplatin, vinblastine, venorelbine,gemcitabine, bleomycin, ifosfamide, paclitaxel, tepotecan or irinotecan.

3. The use of ifosfamide requires the concurrent use of intravenous mesna.Treatment of neutropenia includes granulocyte colony-stimulating factor.Treatment of anemia may include erythropoietin.

Procedure Interval/comments

Physical examination Every 3 months for 2 yearsEvery 6 months for years 3 to 5Annual thereafter

Pap smear Every 3 months for 2 yearsEvery 6 months for years 3 to 5Annual thereafter

Chest x-ray Annually or as indicated

CT scan (or MRI or positronemission scan, optional)

Annual for the first 3 years

Hormone therapy Maintenance therapy for alleviating menopausal symptoms

29

PROSTATE CANCER

Initial Assessment

Patient suspected with prostate cancer

History and physical examinationDigital rectal examination (DRE)

Negative DRE

Prostate Specific Antigen (PSA) test

PSA <2.5 ng/mL

PSA 2.5-4ng/mL

PSA 4.1-10ng/mL

% Free PSA

Normal: Above cut-off1 Cut-off or lower2

Transurethral ultrasound

(TRUS)-guided biopsy

Annual DRE and PSA evaluation

Positive DRE

30

PROSTATE CANCER

Pathway for patients diagnosed with prostate cancer

Prostate cancer detected by TRUS-guided biopsy3

Metastatic work-up and other investigations4

Low risk•Gleason’s score < 6•PSA < 10 ng/mL•T1, T2a

Very high risk or metastatic (T3c or T4, Any N, M1): Go to “Treatment of Very High Risk or Metastatic Prostate Cancer”

Follow-up

Intermediate risk•Gleason’s score 7•PSA 10-20 ng/mL•T2b, T2c

High risk•Gleason’s score 8-10•PSA >20 ng/mL•T3a, T3b

Consider participation in clinical trialsMultidisciplinary team meeting

Radiotherapy (RT) or high-intensity

focused ultrasound (HIFU)

Surgery or RT, consider

chemotherapy5

Node-negative after radical

prostatectomy

Node-positive for post-radical prostatectomy

patients

Pelvic lymph node dissection

and radical prostatectomy

RT or HIFU

Surgical failureTreatment failure (androgen independent disease): Go to “Treatment of Androgen Independent Disease”

Refer to Urological and Radiation Oncology

Services

Androgen deprivation6

Androgen deprivation5

Androgen deprivation6,7

31

PROSTATE CANCER

Treatment of Very High Risk or Metastatic Prostate Cancer

Very high risk or metastatic prostate cancer

• RT + androgen deprivation• Transurethral resection of the

prostate + orchiectomy

MetastaticNon-metastatic

IV Bisphosphonates for bone metastasis

Asymptomatic M1:Early hormonal

therapy5

Symptomatic M1: Hormonal +

Systemic chemotherapy7

Follow-up

Treatment of Androgen Independent Disease

Androgen independent disease

• Anti-androgen withdrawal• Ketoconazole 800-1,200

mg/day + corticosteroids• Estrogen• Diethylstilbestrol• Aminoglutethimide

Hormone-refractory disease

• Abiraterone + corticosteroid or• Systemic chemotherapy with

prednisone7,8

32

PROSTATE CANCER

Follow-up for patients with prostate cancer

Notes:1.% Free PSA cutoff for patients with PSA of 2.5 to 4 ng/mL is <19%. 2.% Free PSA cutoff for patients with PSA of 4.1 to 10 ng/mL is <24%.3.Hormonal treatment as a sole mode of treatment may be recommended in patients with a life expectancy of less than 5 years.4.Metastatic work-up and other investigations include: bone scan; CT scan of the chest, whole abdomen, and pelvis; complete blood count; serum creatinine, alanine aminotransferase, alkaline phosphatase, and calcium; and echocardiogram.5.Recent evidence suggests that early initiation of docetaxel offers a significant overall survival in patients recently diagnosed with metastatic prostate cancer, and adjuvant docetaxel in hormone-naïve high-risk prostate cancer patients.6.Androgen deprivation therapy includes goserelin, leuprorelin, bicalutamide, flutamide, megestrol, and cyproterone.7.For high-risk patients treated with transurethral resection of the prostate, bilateral orchidectomy is recommended.8.Systemic chemotherapy for prostate cancer include docetaxel, carboplatin, and mitoxantrone.9.Treatment of neutropenia includes granulocyte colony-stimulating factor. Treatment of anemia may include erythropoietin.

Watchful waiting or active surveillance

Low to moderate risk

Patients on hormonal therapy

High risk andmetastatic

PSA annually PSA annually PSA q 6 months PSA q 3 months

DRE annually DRE annually DRE q 6 months DRE q 6 months

CBC, creatinine,electrolytes, Ca++, alkaline phosphatase8

Bone scanannually

PSA, prostate specific antigen; DRE, digital rectal examination; CBC, complete blood count.

33

LYMPHOMA PATHWAY: HODGKIN’S LYMPHOMA

Lymphoma suspect

Excisional Biopsy (recommended)1

Hodgkin's lymphoma (HL) confirmed

Work-up:• History and PE• Complete blood count, erythrocyte sedimentation rate (ESR)• Lactate dehydrogenase• Liver function tests, albumin• Blood urea nitrogen, creatinine• Pregnancy Test (if child-bearing years)• Chest X-ray• CT scan with contrast (ideally positron emission tomography [PET]-CT)2

• Bone marrow aspiration with biopsy (if with unfavorable factors3)• 2D echocardiogram (if doxorubicin-based chemo is used)• Pulmonary Function Test (if bleomycin is used)

Nodular Lymphocyte Predominant Hodgkin’s Lymphoma

Classic Hodgkins Lymphoma4

Go to Nodular Lymphocyte Predominant Hodgkin’s Lymphoma

IA, IIA Favorable

I, II unfavorable

(bulky)

I, II unfavorable (non-bulky)

III, IV

Go to Stage IA,

IIA Favorable

Go toStage I, II

unfavorable (bulky)

Go toStage I, II

unfavorable (non-bulky)

Go toStage III,

IV

Notes:1. Core needle biopsy maybe adequate; if deemed diagnostic by a hematopathologist,immunohistochemical staining should be done.2. CT scan of the chest and whole abdomen. Neck CT scan if neck is involved.3. Unfavorable factors include: bulky disease, B symptoms, ESR >50, >3 sites of disease.4. Classic HL includes nodular sclerosis HL, mixed cellularity HL, lymphocyte-rich HL, lymphocyte depleted HL.

34

Clinical Pathway

Stage IA, IIA Favorable

Combined Modality of radiotherapy (RT) and

chemotherapy1,2 (preferred)

CT scan

Complete response (CR)4

Partial response (PR) or Stable Disease (SD)4

Progressive Disease (PD)4

Involved site RT (ISRT) ISRT

biopsy

CR

Follow-up

PR

PET CT/CT with contrast

Deauville 1-3 (CR)

Deauville 4-5 (PR / SD / PD)

biopsy

Negative Positive

Negative Positive

Observe Refractory Disease


Chemotherapy alone3

Go to the next page.

Observe

Notes:1. Chemotherapy includes adriamycin, bleomycin, vinblastine, and dacarbazine. Second-line chemotherapeutic

agents include etoposide, bleomycin, epirubicin, cyclophosphamide, vincristine, procarbazine and gemcitabine.2. Can be an option for younger patients who are in CR after 2 cycles of chemotherapy to avoid long-term

complications of RT3. 2 cycles sufficient if with only 2 sites of disease and no extralymphatic lesions4. Based on the response criteria for malignant lymphoma

35

Treatment for Stage IA, IIA Favorable

CT scan

Chemotherapy1 x 2

Follow-up

CR PR / SD PD Negative Positive

Refractory Disease


Stage IA, IIA Favorable

Combined Modality of radiotherapy (RT) and

chemotherapy1 (preferred) Chemotherapy1,2 x 2

Complete response (CR)

Partial response (PR) or Stable Disease (SD)

Progressive Disease (PD)

Biopsy Chemotherapy1 x 2

Chemotherapy1

ORRT

Chemotherapy1

PLUSRT

Negative Positive

Biopsy

ISRT

Notes:1. Chemotherapy includes adriamycin, bleomycin, vinblastine, and dacarbazine.2. Second-line chemotherapeutic agents include etoposide, bleomycin, epirubicin,

cyclophosphamide, vincristine, procarbazine and gemcitabine.3. Can be an option for younger patients who are in CR after 2 cycles of chemotherapy to

avoid long-term complications of RT.

36

Treatment for Stage IA, IIA Favorable

CT scan

Chemotherapy x 2Plus ISRT

OR

ISRT alone

Follow-up

CR PR / SD / PD Negative Positive

Refractory Disease


Stage IA, IIA Unfavorable (Bulky)

Chemotherapy1 x 4





ISRT

Negative Positive

Biopsy

ISRT


cyclophosphamide, vincristine, procarbazine, and gemcitabine.

PET-CT scan

Deauville 1-3 Deauville 4-5

37

Treatment for Stage IA, IIA Unfavorable (Bulky)

CT scan

Chemotherapy x 2-4

Plus ISRT

OR

Chemotherapy1 x 4(if stage 1A, IIA)

Follow-up

Negative Positive

Refractory disease


Stage IA, IIA Unfavorable (Non-bulky)

Chemotherapy1 x 2




Biopsy Chemotherapy1 x 2PLUSISRT


cyclophosphamide, vincristine, procarbazine and gemcitabine.

38

Treatment for Stage IA, IIA Unfavorable (Non-bulky)

CT scan

Chemotherapy x 4Plus ISRT to

initially bulky site

Follow-up

CR PR / SD / PD Negative Positive

Refractory Disease


Stage III, IV

Chemotherapy1 x 2





ISRT to initiallybulky site

Negative Positive

Biopsy


cyclophosphamide, vincristine, procarbazine and gemcitabine.

PET-CT scan

Deauville 1-3 Deauville 4-5

39

Treatment for Stage III, IV


Nodular Lymphocyte Predominant Hodgkin’s Lymphoma

IA, IIA Non-bulky

IA, IIA or IB, IIB bulky IIIA, IVA IIIB, IVB

Observe

Chemotherapy1 +ISRT +/- rituximab

ISRT Chemotherapy1 + ISRT +/- rituximab

ISRT

Negative Positive

PD (Deauville 5b)

Biopsy

Negative Positive

PD (Deauville 5a)

Biopsy

CR / PR / SD(Deauville 1-4)

Observe Refractorydisease

Observe is asymptomaticOR

2nd line chemoOR

ISRT if no prior RT

Observe is asymptomatic

ORISRT if no prior RT

40

Treatment of Nodular Lymphocyte Predominant Hodgkin’s Lymphoma

LYMPHOMA PATHWAY: DIFFUSE LARGE B-CELL LYMPHOMA

Lymphoma suspect

Excisional Biopsy (recommended)

Diffuse Large B-cell lymphoma (DLBL) confirmed

Work-up:•History and PE; complete blood count; renal function, liver function, electrolytes; lactate dehydrogenase; uric acid; hepatitis B (HBsAg, HBeAg, Anti-HBs, Anti-HBc, Anti-HBe) and C (anti-HCV) testing•CT scan of chest and whole abdomen; 2-D echocardiogram with Doppler

Oher Tests IF with indications:•Pregnancy test IF female of child-bearing age•HIV test IF with risk factors (exposure to HIV-positive or high-risk individuals thru blood or bodily fluid or history of intravenous drug use) and patient gives consent •CT scan of the neck IF symptoms and signs of neck involvement•CT scan of the head IF symptoms and signs of head and brain involvement•Bone marrow aspirate and biopsy IF patient consents and/or PET scan not available•PET scan IF available and/or patient does not consent to bone marrow•Lumbar puncture IF positive involvement of/with the following: paranasal sinus, testicle, epidural, large cell lymphoma, HIV, ≥ 2 extranodal sites, elevated LDH

Stage I, II non-bulky Stage I, II bulky Stage III, IV

1st-line chemotherapy1

x 31st-line chemotherapy1

X 6

Proceed to Evaluation of Stage I, II response on the next page

Proceed to Treatment of Stage III, IV DLBL

41

Clinical Pathway


Evaluation of Stage I, II response

Repeat CT scan and PET if initially done; if PET-positive, rebiopsy if accessible

Diffuse Large B-cell lymphoma (DLBL) confirmed

Complete response (CR) Partial response (PR) No response, stable

disease (SD), progressive disease

(PD)Refer to Radiation Oncology for Involved site radiation therapy

(ISRT)

Proceed to Treatment of refractory or relapsed disease

Stage I, II bulkyStage I, II non-bulky

Additional 3 cycles of chemotherapy1

ISRT using higher dose used to achieve CR

CT scan (+PET if done initially)

CR PR No response, SD, PD

Follow-up

42

Evaluation of Stage I, II response


Stage III, IV DLBL

First-line chemotherapy x 2-4

Repeat CT scan (+PET if initially done)

Complete response (CR) No response, stable

disease (SD), progressive disease

(PD)Complete chemotherapy1 for a

total of 6

Proceed to Treatment of refractory or relapsed disease

CT scan (+PET if done initially)

CR No response, PR, SD, PD

Follow-up

43

Treatment of Stage III, IV DLBL


Refractory or relapsed disease

Notes:1. First-Line Chemotherapy Regimens depend on patient characteristics:

a. For patients 80 y.o. and younger who are medically fit and have good left ventricular function: rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone

b. For patients 80 y.o. and younger who are not medically fit and have poor left ventricular function: rituximab, cyclophosphamide, etoposide, vincristine, prednisone

c. For patients older than 80 y.o. with comorbidities: rituximab and low-dose cyclophosphamide, doxorubicin, vincristine, prednisone

d. For patients with concurrent CNS disease: add methotrexate 3 g/m2 IV on day 15 of a 21-day RCHOP cycle with G-CSF support and leucovorin rescue.

2. Second-line chemotherapy includes alkylating agents (cyclophosphamide, gemcitabine, cisplatin, carboplain, oxaliplatin), topoisomerase inhibitors (etoposide), mitotic inhibitors (vincristine), and anthracyclines (doxorubicin) with or without rituximab.

Eligible and consenting to Autologous Stem Cell

Transplant Eligible and consenting to Autologous Stem Cell

Transplant

Refer to Transplant Service

Second-line chemotherapy2 if with

patient consent

Palliative medical management

Refer to Radiation Oncology for painful sites of involvement

44

Treatment of refractory or relapsed disease

Patient suspected with ovarian cancer

History and physical/gynecological examinationComplete blood count with platelet; Liver function tests; CA-125

Chest imaging; Abdominal and pelvic ultrasound + CT /MRU

Refer to gynecological oncologist for clinical staging and surgery

OVARIAN CANCER

Clinical Pathway

Consider enrollment into clinical trialsMultidisciplinary team meeting, including fertility specialist

• Completion surgery if possible

• Post-remission pazopanib if with complete remission

Stage I A/B Stage II to IV

Observe and follow-up

Chemotherapy2,3,4,5IV chemotherapy1,2 for 3 to 6 cycles

Stage I C

Diagnosis of ovarian cancer

Grade 1

Grade 2

Grade 3

or

45

OVARIAN CANCER

Follow-up of patients with ovarian cancer

NOTES1.Intravenous chemotherapy for stage I ovarian cancer includes taxanes (paclitaxel,docetaxel); and platinum-based chemotherapy (carboplatin and cisplatin).

2.Treatment of neutropenia includes granulocyte colony-stimulating factor. Treatmentof anemia may include erythropoietin.

3.Chemotherapy for stages II to IV ovarian cancer could be delivered intraperitoneallyfor <1cm optimally debulked stage II and III disease. Intraperitoneal chemotherapyincludes and paclitaxel.

4.Intravenous chemotherapy for stages II to IV ovarian cancer is given for 6 to 8cycles. It includes taxanes (paclitaxel, docetaxel) and platinum-based chemotherapy(carboplatin and cisplatin). Targeted therapy (bevacizumab) may be added for a totalof 22 cycles.

5.Chemotherapy for recurrence includes taxanes, carboplatin, as well as gemcitabine,liposomal doxorubicin, or topotecan.

Procedure Interval/comments

Physical examinationCA-125

Every 2-4 months for 2 yearsEvery 3-6 months for the next 3 yearsAnnual thereafter

CBC, serum chemistries, chest x-ray, abdominal/pelvic CT scan

As indicated

46

GASTRIC CANCER

Clinical Pathway

If carcinoma:Staging Work-up1

Her2neu testing (adenocarcinoma)Multidisciplinary team meeting

Consider enrollment in clinical trial

Locoregional (M0)Stage IB-III Metastatic (M1)

Palliative chemotherapy

+/- trastuzumab (HER2+) OR

entry to clinical trial OR best

supportive care

T1N0 (Stage IA)

Medically fit, potentially resectable

Medically fit, unresectable Medically unfit

(nonsurgical)

T1b

Medically unfit

(nonsurgical)

Medically fit

T2 and above, any N

Endoscopic resection +

anti H. pylori therapy

Concurrent Chemo-RT2

OR chemotherapy2 OR surgery

ECOG<2

Concurrent Chemo-RT

OR chemotherapy

OR entry to clinical trial

Best supportive

care

History and Physical examination Upper GI endoscopy and Helicobacter pylori testing

Carcinoembryonic antigenEndoscopic ultrasound (if warranted)

Concurrent chemoRT OR

palliative chemotherapy

OR entry to clinical trial

ECOG >2

Surgery

Surveillance3 Restaging4

Biopsy

Patient suspected with gastric cancer

47

R0 Resection R1 R2

T1N0

No adverse features

Adverse features

T3,4 or Any T; N+


OR chemotherapy2

T2N0

M1

SurveillanceConcurrent chemo-RT2 OR chemotherapy2 ORbest supportive care

As shown in the previous

algorithm


GASTRIC CANCER

Post-surgical therapyNo pre-operative chemoradiation or chemotherapy

Post-surgical gastric cancer

Adjunctive therapy (post-chemotherapy + radiotherapy)

Re-staging

Resectable Unresectable or progressive/metastatic

ECOG<2

ECOG >3R0 resection

T2N0 T3,4 or Any T, N+

Surveillance Chemotherapy

R1 resection

R2 resection

Chemo-RT (if not received

preoperatively)

Best supportive

care

Palliative chemotherapy +/-trastuzumab (HER2+) OR

entry to clinical trial OR Best supportive care


Surgery

48

NOTES:1.Staging work-up includes:

• Complete blood count (CBC) with platelets; blood urea nitrogen, serumcreatinine, liver function tests (alanine aminotransferase; aspartateaminotransferase; alkaline phosphatase; total bilirubin [direct and indirectbilirubin])

• Chest X-ray PA and lateral• CT scan of the Abdomen: contrast enhanced• CT scan/ Ultrasound of the pelvis (females )• Staging laparoscopy for Stage IB and above (if possible)• Positron-emission scan (optional)

2. Chemotherapy for gastric cancer may include: taxanes (paclitaxel, docetaxel);alkylating agents (cisplatin, carboplatin, oxaliplatin); antimetabolites (5-fluorouracil,capecitabine, tegafur-uracil); topoisomerase inhibitors (irinotecan); and cytotoxicantibiotics (epirubicin). Treatment of neutropenia includes granulocyte colony-stimulating factor. Treatment of anemia may include erythropoietin.

3. Surveillance and follow-up for gastric cancer patients include• Complete history and physical examination every 4-6 months until 3 years, thenannually thereafter.• Yearly chest x-rays, abdominal CT scans, and upper gastrointestinal (GI) endoscopyshould be considered.• Monitoring of vitamin B12 levels for those who underwent total gastrectomy.

4. Restaging includes:• CBC with platelet count, blood urea nitrogen, serum creatinine, liver function tests (alanine aminotransferase; aspartate aminotransferase; alkaline phosphatase; total protein and albumin; total, direct, and indirect bilirubin)• CT scan of the Abdomen• CT scan/ultrasound of the pelvis (females)• Upper GI endoscopy.

GASTRIC CANCER

49

NASOPHARYNGEAL CANCER

Clinical Pathway

Patient suspected with nasopharyngeal cancer

(NPCA)

History and physical examinationComplete otorhinolaryngological examination

Nasopharyngoscopy

No mass(High index of

suspicion)

Enlarged neck nodes only(+) Mass

Biopsy1

Head/neck CT scan or MRI (+) CA

Excision Observe

Biopsy of neck node

(-) CA (-) CA

Observe or CT/MRI

• Test for EBV, HPV, p53• Immunostain for undifferentiated histology2

• Metastatic work-up3

Negative Mass

Observe

Early (Stage I-II)Radiotherapy +chemotherapy4,6

Advanced (Stage III-IV)Concurrent radiotherapy and

chemotherapy4,5 andtargeted therapy6

• Consider enrolling to clinical trials

• Multidisciplinary team meeting

50

NASOPHARYNGEAL CANCER

Follow-up for patients with nasopharyngeal cancer

Notes:1. Repeat biopsy if first biopsy is negative for malignancy.2. Immunostaining for possible lymphoma includes cytokeratin and leukocyte

common antigen (CD45)3. Metastatic work-up and other investigations include: bone scan; CT scan of the

chest, whole abdomen, and pelvis; complete blood count; and serum creatinine, alanine aminotransferase, alkaline phosphatase, and calcium.

4. Chemotherapy for NPCA includes cisplatin, carboplatin, paclitaxel, docetaxel, 5-fluorouracil, and gemcitabine.

5. Treatment of neutropenia includes granulocyte colony-stimulating factor. Treatment of anemia may include erythropoietin.

6. Targeted therapy for NPCA includes cetuximab and nimotuzumab.

Early disease Advanced disease

Posterior rhinoscopyand/or endoscopy nasopharyngoscopy

• 1 month after radiotherapy• Every 2 months for the first year• Every 3 months on the second year• Every 4 months on the third year• Every 6 months on the fourth and fifth year• Yearly thereafter

Chest x-ray • Every 6 months for the first 3 years• Yearly thereafter

CT scan of the neck and nasopharynx

8 weeks post-radiotherapy then as needed

Liver ultrasound Yearly • Every 6 months for the first 3 years

• Yearly thereafter

Bone scan Yearly • Every 6 months for the first 3 years

• Yearly thereafter

CBC, creatinine,electrolytes, Ca++, alkaline phosphatase

Every 3 to 6 months Every 3 to 6 months

51

BIBLIOGRAPHY

Department of Health (Republic of the Philippines). Leading Causes ofMortality. Manila: Department of Health; 2011.

DeVita VT Jr., Lawrence TS, Rosenberg SA. DeVita, Hellman, andRosenberg's Cancer: 10th Edition. Principles & Practice of Oncology.Baltimore, MD: Wolters Kluwer Health, Inc. 2015.

International Agency for Research on Cancer. Globocan 2012: Worldwidecancer incidence, mortality and prevalence in 2012. Lyon: World HealthOrganization; 2012.

National Comprehensive Cancer Network Guidelines. Available at:www.nccn.org. Accessed September 24, 2015.

Philippine Society of Oncology. The Philippine Handbook of Clinical Oncology.Quezon City: Philippine Society of Oncology.

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PHILIPPINE SOCIETY OFMEDICAL ONCOLOGY

Copyright 2015

Documents

Clinical Pathways for the Medical Management · the patient and family members. Lastly, it is emphasized that the clinical pathways shown here only provide a general guideline to