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Colon Cancer Treatment Pathway

Disease Pathway Management Secretariat


Version 2013.5

Disclaimer
The Colon Cancer Treatment Pathway (Pathway) is intended to be used for informational purposes
only. While the Pathway represents an overview of the presentation, clinical work-up and treatment of
a typical colon cancer, it is not intended to constitute or be a substitute for medical advice and should
not be relied upon in any such regard. Further, all clinical work-ups and treatments are subject to
clinical judgment and actual practice patterns may not follow the proposed steps set out in the
Pathway.
Colon Cancer Treatment Pathway Pathway Preamble Version 2013.5 Page 2 of 6

Pathway Disclaimer Pathway Legend


The Colon Cancer Treatment Pathway (Pathway) is a resource that provides an overview of the treatment of a typical colon
cancer. The pathway is only intended for primary adenocarcinoma and familial cancers (Lynch/non-Lynch) and cancers Primary Care Provider (Family Physician, Nurse Practitioner, Emergency Department Physician)
complicating inflammatory bowel disease are handled differently. Endoscopist
Pathologist
The information contained in this Pathway is intended for healthcare providers and other stakeholders in the cancer system,
including administrators and organizers. The Pathway is intended to be used for informational purposes only. While the Diagnostic Assessment Program (DAP)
Pathway represents an overview of the treatment of a typical colon cancer, it is not intended to constitute or be a Surgeon
substitute for medical advice and should not be relied upon in any such regard. Further, all clinical work-ups and
Radiation Oncologist
treatments are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in
the Pathway. Medical Oncologist
Imaging
The Pathway is not intended for patients. In the situation where the reader is a patient, the reader should always consult a
healthcare provider if he/she has any questions regarding the information set out in the Pathway. The information in the Multi-disciplinary Cancer Conferences (MCC)
Pathway does not create a physician-patient relationship between CCO and the reader. Palliative Care and Psychosocial Oncology Team
No Specific Specialist Designated
While care has been taken in the preparation of the information contained in the Pathway, 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 Possible Action or Result
informations quality, accuracy, currency, completeness, or reliability. CCO and the Pathways content providers (including the Referral to
physicians who contributed to the information in the Pathway) shall have no liability, whether direct, indirect, consequential,
contingent, special, or incidental, related to or arising from the information in the Pathway or its use thereof, whether based on Managing Physician at Pathway Entry Point
breach of contract or tort (including negligence), and even if advised of the possibility thereof. Anyone using the information in
the Pathway 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 persons
use of the information in the Pathway.
Pathway Target Population
Patients with a confirmed colon cancer diagnosis who have undergone the recommended diagnostic
Pathway Considerations and staging procedures as outlined in the Colorectal Cancer Diagnosis Pathway.

The family physician should be informed of all tests and consultations. Usual ongoing care with the family physician is
assumed to be part of the Pathway.
Clinical trials should be considered for all phases of the Colon Cancer Treatment Pathways, where available.
All patients under consideration for an ostomy should be referred to an Enterostomal Therapy Nurse preoperatively.
Patients should have access to an Enterostomal Therapy Nurse before and after ostomy surgery.
Ostomy Care and Management, Clinical Best Practice Guideline, Registered Nurses Association of Ontario.
Colon Cancer Treatment Pathway Stage 0 Version 2013.5 Page 3 of 6

Stage 0
Tis | N0 | M0

AJCC Cancer Staging Manual


7th edition.

Endoscopist Colonoscopy Surveillance


Review Histopathology confirms Colonoscopy Surveillance
(Surgeon or Polypectomy or
Pathology Pathology stage 0 and complete Refer to Guidelines for Colonoscopy Surveillance After Polypectomy
Gastroenter- Local Excision Refer to Guidelines for Colonoscopy Surveillance After Polypectomy
Report resection
ologist) To complement the colonoscopy standards, CCC adopted these surveillance guidelines:
Guidelines for Colonoscopy Surveillance after Polypectomy: A consensus update by the US
Multi-Society Task Force on Colorectal Cancer and the American Cancer Society.
Gastroenterology 2006; 130:1872-1885
Colon Cancer Treatment Pathway Stage I Version 2013.5 Page 4 of 6

Colon Cancer
Histopathology Colonoscopy Surveillance
confirms Stage 1 and Refer to Guidelines for Colonoscopy Surveillance After Polypectomy
Stage I complete resection To complement the colonoscopy standards, CCC adopted these surveillance
T1 | N0 | M0
T2 | N0 | M0 Review guidelines: Guidelines for Colonoscopy Surveillance after Polypectomy: A consensus
Polypectomy Pathology Pathology update by the US Multi-Society Task Force on Colorectal Cancer and the American
AJCC Cancer Staging Manual Report Cancer Society. Gastroenterology 2006; 130:1872-1885
7th edition. Histopathology:
- Cannot confirm complete resection margins
(negative margins are the goal of resection; can
consider further endoscopic resection) OR
- Unfavourable histopathological features (e.g., Pathological
poorly differentiated or undifferentiated, Stage II (High Risk*)
lymphovenous invasion) or Stage III
*High-risk includes
Proceed to the Colon
inadequate samples
Cancer Treatment
of nodes, T4 lesions,
Stage II and Stage III
perforation, poorly
Pathway (page 5 of 6)
differentiated
(hemi) Colectomy
histology or
Endoscopist With En Bloc Review
Pathology obstruction
(Surgeon or Resectable Removal Of Regional Pathology
Refer to EBS #17-4
Gastroenter- Lymph Nodes Report
Proceed to the
ologist) Refer to EBS #17-4
Colorectal Cancer
Follow-up Care Pathway
Surgeon

Appropriate palliative therapy may include one or more of the following:

Medically Palliative Palliative Observation


Inoperable Radiation Medical Chemotherapy Radiation Therapy if asymptomatic
MCC
Review (i.e., medically Oncologist Oncologist
Pathology unfit for surgery) Surgical/interventional
Report management for complications
MCC Guidelines (e.g., stent, diverting stoma)
and Resources

Biopsy Pathology

NOTE: Early referral to psychosocial oncology and palliative care team is recommended
Colon Cancer Treatment Pathway Stage II and Stage III Version 2013.5 Page 5 of 6

EBS #2-29 is older than 3 years old and is UNDER REVIEW for currency and relevance. Proceed to the
Colon Cancer Low Risk Stage II Disease Colorectal Cancer
Refer to EBS #2-29 Follow-up Care
Stage II Pathway
Stage IIA High-Risk Stage II patients with
T3 | N0 | M0 completely resected colon cancer
MCC especially Proceed to the
Negative High-risk includes inadequately Consider Adjuvant
Stage IIB Resection
recommended for
MCC sampled nodes, T4 lesions,
Medical
Chemotherapy
Colorectal Cancer
T4a | N0 | M0 any patients with Oncologist Follow-up Care
Margins perforation, poorly differentiated Refer to EBS #2-29
Stage IIC uncertain features Pathway
histology or obstruction
T4b | N0 | M0 Refer to EBS #2-29
(hemi) Colectomy Proceed to the
Stage III with en bloc removal Review All Stage III patients with
Medical
Consider Adjuvant
Colorectal Cancer
of regional lymph Pathology Pathology completely resected colon cancer Chemotherapy
Stage IIIA Resectable Oncologist Follow-up Care
nodes Report Refer to EBS #2-29 Refer to EBS #2-29
T1-T2 | N1/N1c | M0 Pathway
T1 | N2a | M0 Refer to EBS #17-4
Stage IIIB
T3-T4a | N1/N1c | M0
T2-T3 | N2a | M0 Positive Consider Radiation
T1-T2 | N2b | M0 Consider Medical Radiation
Resection MCC and Chemotherapy Therapy
re-resection Oncologist Oncologist
Stage IIIC Margins (Chemoradiotherapy)
T4a | N2a | M0
T3-T4a| N2b | M0
T4b| N1-N2 | M0 Appropriate referrals based on MCC
Interventional
management for Re-evaluate
AJCC Cancer Staging Manual Locally Chemotherapy
symptomatic primary, Chemotherapy Combined Modality resectability.
7th edition. Advanced MCC Radiation Medical Or Regardless of
as necessary Surgeon* Chemoradiotherapy Resection if
Unresectable Oncologist Oncologist resectability
(e.g., stent, diverting feasible.
stoma, bypass)

*Opinion from a surgeon with relevant expertise should


Surgeon be obtained
Interventional Appropriate palliative therapy may include one or more of the following:
management for
symptomatic primary, Radiation Medical Interventional management for
Medically MCC Palliative Palliative Observation
as necessary Oncologist Oncologist complications
Inoperable Chemotherapy Radiation Therapy if asymptomatic
(e.g., stent, diverting (e.g., stent, diverting stoma)
stoma, bypass)

For more information about Multidisciplinary Case Conferences (MCC):


Refer to MCC Standards and MCC Resources
NOTE: Early referral to psychosocial oncology and palliative care team is recommended
Colon Cancer Treatment Pathway Stage IV Version 2013.5 Page 6 of 6

Colon Cancer Neoadjuvant Staged or


Chemotherapy Proceed to the
Synchronous
Adjuvant Colorectal Cancer
Resectable Resection of
Stage IV Chemotherapy Follow-up Care
Metastatic and
Pathway
Stage IVA Liver and/or Directly to Resection Colon Cancer**
Any T | Any N | M1a Lung (no neoadjuvant therapy)
Oligo-
Stage IVB Metastases*
metastases
Any T | Any N | M1b Refer to
EBS #17-7 Resectable
AJCC Cancer Staging Manual Potentially Re-evaluate
7th edition. Chemotherapy
Resectable Resectability**
Medical
Oncologist Unresectable** Chemotherapy

Colon
MCC
Resection
Managing MCC especially Symptomatic
Only if
Physician recommended for primary must
Surgeon*** imminent risk
from diagnosis any patients with be dealt with
of obstruction
and staging uncertain initially
or significant
features
bleeding
There are a variety
of physicians that
may bring the patient MCC Guidelines
and Resources Palliative Care
into the stage IV
& Psychosocial
Colon Cancer
Oncology Team
Treatment Pathway
(e.g., surgeon,
gastroenterologist, Consider stoma Other therapy for palliation may include one or more of the following:
family physician, ***Opinion from a surgeon and/or bypass or
Extensive
etc.) with relevant expertise surgical resection Interventional management for
Metastases or Chemotherapy Palliative Palliative
should be obtained (e.g., If imminent risk of complications
Unresectable Chemotherapy Radiation Therapy
Hepatobiliary or thoracic obstruction or (e.g., stent, diverting stoma)
surgeon) significant bleeding

*Individuals with isolated peritoneal metastases could be evaluated for resectability/peritoneal debulking and hyperthermic intraperitoneal chemotherapy (HIPEC).
**Individuals with oligo-metastases who are not surgical candidates could be considered for stereotactic ablative radiotherapy (SABR) or radiofrequency ablation.
NOTE: Early referral to psychosocial oncology and palliative care team is recommended

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