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.
LUNG CANCER: NON-SMALL CELL LUNG CANCER
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.
LUNG CANCER: NON-SMALL CELL LUNG CANCER
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)
LUNG CANCER: NON-SMALL CELL LUNG CANCER
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)
LUNG CANCER: NON-SMALL CELL LUNG CANCER
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
Performance status 3 to 4
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
Evaluate tumor response via CT
scan
Progression Response or stable disease
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
Performance status 0 to 2
Performance status 3 to 4
LUNG CANCER: NON-SMALL CELL LUNG CANCERFirst-line Chemotherapy and Subsequent
Therapies for Squamous Cell CA
Doublet chemotherapy
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 gemcitabine or afatinib, gefitinib
or erlotinib
4 to 6 cycles total
Evaluate tumor response via CT
scan
Progression Response or stable disease
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
HEPATOCELLULAR CARCINOMA
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
HEPATOCELLULAR CARCINOMA
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
LYMPHOMA PATHWAY: HODGKIN’S LYMPHOMA
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
LYMPHOMA PATHWAY: HODGKIN’S LYMPHOMA
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
LYMPHOMA PATHWAY: HODGKIN’S LYMPHOMA
Stage IA, IIA Unfavorable (Bulky)
Chemotherapy1 x 4
Complete response (CR)
Partial response (PR) or Stable Disease (SD)
Progressive Disease (PD)
Biopsy Chemotherapy1 x 2
ISRT
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.
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
LYMPHOMA PATHWAY: HODGKIN’S LYMPHOMA
Stage IA, IIA Unfavorable (Non-bulky)
Chemotherapy1 x 2
Complete response (CR)
Partial response (PR) or Stable Disease (SD)
Progressive Disease (PD)
Biopsy Chemotherapy1 x 2PLUSISRT
Notes:1. Chemotherapy includes adriamycin, bleomycin, vinblastine, and dacarbazine.2. Second-line chemotherapeutic agents include etoposide, bleomycin, epirubicin,
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
LYMPHOMA PATHWAY: HODGKIN’S LYMPHOMA
Stage III, IV
Chemotherapy1 x 2
Complete response (CR)
Partial response (PR) or Stable Disease (SD)
Progressive Disease (PD)
Biopsy Chemotherapy1 x 2
ISRT to initiallybulky site
Negative Positive
Biopsy
Notes:1. Chemotherapy includes adriamycin, bleomycin, vinblastine, and dacarbazine.2. Second-line chemotherapeutic agents include etoposide, bleomycin, epirubicin,
cyclophosphamide, vincristine, procarbazine and gemcitabine.
PET-CT scan
Deauville 1-3 Deauville 4-5
39
Treatment for Stage III, IV
LYMPHOMA PATHWAY: HODGKIN’S LYMPHOMA
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
LYMPHOMA PATHWAY: DIFFUSE LARGE B-CELL LYMPHOMA
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
LYMPHOMA PATHWAY: DIFFUSE LARGE B-CELL LYMPHOMA
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
LYMPHOMA PATHWAY: DIFFUSE LARGE B-CELL LYMPHOMA
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+
Concurrent chemo-RT2
OR chemotherapy2
T2N0
M1
SurveillanceConcurrent chemo-RT2 OR chemotherapy2 ORbest supportive care
As shown in the previous
algorithm
Concurrent chemo-RT2
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
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