Disclaimer
The pathway map is intended to be used for informational purposes only. The pathway map is not
intended to constitute or be a substitute for medical advice and should not be relied upon in any such
regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may
not follow the proposed steps set out in the pathway map. In the situation where the reader is not a
healthcare provider, the reader should always consult a healthcare provider if he/she has any
questions regarding the information set out in the pathway map. The information in the pathway map
does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.
HPV-Negative Oropharyngeal Squamous Cell Carcinoma
Treatment Pathway MapVersion 2019.09
Pathway Map Preamble Version yyyy.mm Page 2 of 13Confidential Draft
For Review Only
© CCO retains all copyright, trademark and all other rights in the pathway map, including all text and graphic images. No portion of this pathway map may be used or reproduced, other than for personal use, or distributed, transmitted or "mirrored" in any form, or by any means, without the prior written permission of CCO.
Pathway Map Preamble Version 2019.09 Page 2 of 13
Pathway Map Disclaimer This pathway map is a resource that provides an overview of the treatment that an individual in the Ontario cancer system
may receive.
The pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or
be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject
to clinical judgment and actual practice patterns may not follow the proposed steps set out in the pathway map . In the
situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has
any questions regarding the information set out in the pathway map. The information in the pathway map does not create a
physician-patient relationship between Cancer Care Ontario (CCO) and the reader.
While care has been taken in the preparation of the information contained in the pathway map, such information is provided
on an as-is basis, without any representation, warranty, or condition, whether express, or implied, statutory or otherwise,
as to the information s quality, accuracy, currency, completeness, or reliability.
CCO and the pathway map s content providers (including the physicians who contributed to the information in the pathway
map) shall have no liability, whether direct, indirect, consequential, contingent, special, or incidental, related to or arising
from the information in the pathway map or its use thereof, whether based on breach of contract or tort (including
negligence), and even if advised of the possibility thereof. Anyone using the information in the pathway map does so at his
or her own risk, and by using such information, agrees to indemnify CCO and its content providers from any and all liability ,
loss, damages, costs and expenses (including legal fees and expenses) arising from such person s use of the information in
the pathway map.
This pathway map may not reflect all the available scientific research and is not intended as an exhaustive resource. CCO
and its content providers assume no responsibility for omissions or incomplete information in this pathway map. It is
possible that other relevant scientific findings may have been reported since completion of this pathway map. This pathway
map may be superseded by an updated pathway map on the same topic.
Colour Guide
Primary Care
Palliative Care
Pathology
Surgery
Radiation Oncology
Medical Oncology
Radiology
Multidisciplinary Cancer Conference (MCC)
Psychosocial Oncology (PSO)Line Guide
Required
Possible
or
Shape Guide
Intervention
Decision or assessment point
Patient (disease) characteristics
Consultation with specialist
Exit pathway map
Off-page reference
Patient/Provider Interaction
Referral
Wait time indicator time point
Pathway Map Legend
W
R
X
X
HPV-Negative Oropharyngeal Squamous
Cell Carcinoma Treatment Pathway Map
Pathway Map Considerations Primary care providers play an important role in the cancer journey and should be informed of relevant tests and consultations.
Ongoing care with a primary care provider is assumed to be part of the pathway. For patients who do not have a primary care provider, is a government resource that helps patients find a family doctor or nurse practitioner.
Throughout the pathway, a shared decision-making model should be implemented to enable and encourage patients to play an active
role in the management of their care. For more information see .
Hyperlinks are used throughout the pathway to provide information about relevant CCO tools, resources and guidance documents.
The term health care provider , used throughout the pathway, includes primary care providers and specialists, nurse practitioners, otolaryngologists, speech language pathologists, registered dietitians, and emergency physicians.
Psychosocial oncology (PSO) is the interprofessional specialty concerned with understanding and treating the social, practical, psychological, emotional, spiritual and functional needs and quality-of-life impact that cancer has on patients and their families. Psychosocial care should be considered an integral and standardized part of cancer care for patients and their families at all stages of the illness trajectory. PSO support may include social worker and psychiatric support. Psychiatric support may be provided by a Psychologist, a Psychiatrist or by a Primary Care Provider. For more information, visit
For more information on Multidisciplinary Cancer Conferences visit
For more information on wait time prioritization, visit:
Clinical trials should be considered for all phases of the pathway.
The following should be considered when weighing the treatment options described in this pathway for patients with potentially life-limiting illness:
- Palliative care may be of benefit at any stage of the cancer journey, and may enhance other types of care - including restorative or rehabilitative care - or may become the total focus of care- Ongoing discussions regarding goals of care is central to palliative care, and is an important part of the decision-making process. Goals of care discussions include the type, extent and goal of a treatment or care plan, where care will be provided, which health care providers will provide the care, and the patient s overall approach to care
For more information on the systemic treatment QBP please refer to the Quality-Based Procedures Clinical Handbook for Systemic Treatment
Counseling and treatment for smoking cessation should be initiated early on in the pathway and continued by care providers throughout the pathway as necessary.
Organizational Guidance for the Care of Patients with Head and Neck Cancer in Ontario recommendations apply across this pathway and establish the minimum requirements to maintain a head and neck disease site program. For more information visit:
MCC Tools
Surgery, Systemic Treatment, Radiation Treatment Wait Times prioritizations.
EBS #19-3
Health Care Connect,
Person-Centered Care Guideline
* Note. EBS #19-3 is older than 3 years and is currently listed as For Education and Information Purposes . This means that the recommendations will no longer
be maintained but may still be useful for academic or other information purposes.
Program Training & Consultation Centre – Hospital Based Resources
Quality-Based Procedures Clinical Handbook for Systemic Treatment
GL 5-3ORG
Stage I/II Version 2019.09 Page 3 of 13
HPV-Negative Oropharyngeal Squamous
Cell Carcinoma Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the pathway map. In the situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions regarding the information set out in the pathway map. The information in the pathway map does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
Treatment
Decision
Tumor originates from midlineor
Lateral origin with medial extension
Lateralized tonsillar cancer or
Very small palate and lateral pharyngeal wall
MCC or
MDT
Dental
Oncologist
Speech
Language
Pathologist
Registered
Dietitian
From
Diagnosis
Pathway
Map (Page
5)
Bilateral Neck Radiation Therapy
Peer Review
Ipsilateral Neck Radiation
TherapyPeer Review
Audiologist
Smoking
Cessation
Program
Nursing1
Radiation
Therapy
Surgery7
Indications include:
Contraindications for
radiation therapy,
Patient choice,
Previous radiation,
Amenable to transoral
resection without free flap
reconstruction
Pathology
Indications
for Post-
operative
Therapy4
Yes
No
Surgical Management of
Primary and Neck
(Nodal levels II-IV and those
with clinical or radiographic
evidence disease)
Radiation Therapy4
Concurrent
Chemotherapy5
EBS 5-11
Peer Review
Disease
Characteris-
tics
Social
Worker
PSO Support
Primary
Care
Provider2
Dental Evaluation
Nutrition, speech
and swallowing
evaluation/therapy,
and dysphagia
prevention
Psychosocial
Intervention
May include:
Financial:
disability, drug
benefits
Transportation
Placement
Medication
management
Counselling
regarding
diagnosis,
appearance
changes & HPV
Blood Work
Audiometry
R
Proceed
to Page 10
GL 5-3ORG
A
During Treatment
Ototoxicity Management
If patient is on chemotherapy
On Treatment Review
To include:
Radiation Medicine Clinician
Oncology Nurse
Patients should also have
access to:
Clinical Nurse Specialist /
Nurse Practitioner
Registered Dietitian
Speech Language Pathologist
Dental Oncology
Social Worker
Medical
OncologistR
Smoking cessation
counselling &
intervention where
appropriate
Note. EBS #5-11 is currently listed as In Review .
Proceed
to Page 11
BGL 5-3ORG
Stage I
T1 | N0 | M0
Stage II
T2 | N0 | M0
AJCC Cancer Staging
Manual 8th edition
UICC The TNM
Classification of
Malignant Tumours,
8th Edition
Stage I/II
1 All patients should have access to specialized oncology nurse, clinical nurse specialist or nurse practitioner to manage the complex physical, social and psychological health needs that arise during treatment and in early follow-up post treatment2 Some patients may require on-going direct care with their Primary Care Provider during treatment.3 Surgery may be an option for some patients. Patients should be included in trials investigating Transoral Robotic Surgery (TORS) where available.4 Indications for post-operative radiotherapy: Deep margins <5mm OR one or more of the following at the primary site: peri-neural invasion, lymph-vascular invasion OR lymph node involvement ( 2 lymph nodes, any lymph node >3 cm (N2+), nodal level IV-V LN positive, extracapsular extension (ECE)). 5 Indications for concurrent chemotherapy: positive margins or extracapsular extension (ECE).
Stage III Version 2019.09 Page 4 of 13
HPV-Negative Oropharyngeal Squamous
Cell Carcinoma Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the pathway map. In the situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions regarding the information set out in the pathway map. The information in the pathway map does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
From
Diagnosis
Pathway
Map (Page
5)
Treatment
Decision
Radiation
Therapy
Surgery3
Indications include:
Contraindications for
radiation therapy,
Patient choice,
Previous radiation,
Amenable to transoral
resection without free
flap reconstruction
Pathology
Indications
for Post-
Operative
Therapy4
Yes
Surgical Management of
Primary and Neck
(Nodal levels II-IV and those
with clinical or radiographic
evidence disease)
Proceed
to Page 10
Radiation Therapy
Peer ReviewDuring Treatment
Ototoxicity Management
If patient is on
chemotherapy
R
Age
70
Age
Age
>70
Concurrent
Chemotherapy
EBS 5-11
Radiation
TherapyPeer Review
Dental Evaluation
Nutrition, speech
and swallowing
evaluation/therapy,
and dysphagia
prevention
Psychosocial
Intervention
May include:
Financial:
disability, drug
benefits
Transportation
Placement
Counselling
regarding
diagnosis,
appearance
changes & HPV
Blood Work
Audiometry
Feeding Tube
Placement
NoProceed
to Page 11
Radiation
Therapy
Peer
Review
Concurrent Therapy
Targeted Therapy ChemotherapyOr
EBS 5-11
C
D
On Treatment Review
To include:
Radiation Medicine
Clinician
Oncology Nurse
Patients should also
have access to:
Clinical Nurse
Specialist / Nurse
Practitioner
Registered Dietitian
Speech Language
Pathologist
Dental Oncology
Social Worker
Concurrent Therapy5
Targeted Therapy
Only consider if
age >70
Chemotherapy5Or
EBS 5-11
Radiation Therapy4
Peer Review
Node
negative
Nodal
status Node
positiveMCC or
MDT
Dental
Oncologist
Speech
Language
Pathologist
Registered
Dietitian
Social
Worker
PSO
Support
Audiologist
Smoking
Cessation
Program
Nursing1
Primary
Care
Provider2
Medical
Oncologist
Smoking cessation
counselling &
intervention where
appropriate
Note. EBS #5-11 is currently listed as In Review .
GL 5-3ORG
GL 5-3ORG
T3 | N0 | M0
T1-3 | N1 | M0
AJCC Cancer Staging
Manual 8th edition
UICC The TNM
Classification of Malignant
Tumours, 8th Edition
Stage III
1 All patients should have access to specialized oncology nurse, clinical nurse specialist or nurse practitioner to manage the complex physical, social and psychological health needs that arise during treatment and in early follow-up post treatment2 Some patients may require on-going direct care with their Primary Care Provider during treatment.3 Surgery may be an option for some patients. Patients should be included in trials investigating Transoral Robotic Surgery (TORS) where available.4 Indications for post-operative radiotherapy: Deep margins <5mm OR one or more of the following at the primary site: peri-neural invasion, lymph-vascular invasion OR lymph node involvement ( 2 lymph nodes, any lymph node >3 cm (N2+), nodal level IV-V LN positive, extracapsular extension (ECE)). 5 Indications for concurrent chemotherapy: positive margins or extracapsular extension (ECE).
Stage IV A-B Version 2019.09 Page 5 of 13
HPV-Negative Oropharyngeal Squamous
Cell Carcinoma Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the pathway map. In the situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions regarding the information set out in the pathway map. The information in the pathway map does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.
1 All patients should have access to specialized oncology nurse, clinical nurse specialist or nurse practitioner to manage the complex physical, social and psychological health needs that arise during treatment and in early follow-up post treatment2 Some patients may require on-going direct care with their Primary Care Provider during treatment.3 Surgery may be an option for some patients. Patients should be included in trials investigating Transoral Robotic Surgery (TORS) where available.4 Indications for post-operative radiotherapy: Deep margins <5mm OR one or more of the following at the primary site: peri-neural invasion, lymph-vascular invasion OR lymph node involvement ( 2 lymph nodes, any lymph node >3 cm (N2+), nodal level IV-V LN positive, extracapsular extension (ECE)). 5 Indications for concurrent chemotherapy: positive margins or extracapsular extension (ECE).
Age
Age 70
Age >70
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
Proceed
to Page 10
MCC or
MDT
Dental
Oncologist
Speech
Language
Pathologist
Registered
Dietitian
Social
Worker
PSO
Support
Audiologist
Smoking
Cessation
Program
Nursing1
Primary
Care
Provider2
From
Diagnosis
Pathway
Map (Page
5)
R
Radiation Therapy
Concurrent
Chemotherapy
Peer Review
Radiation Therapy
Concurrent Therapy
Targeted Therapy ChemotherapyOr
Peer Review
Dental Evaluation
Nutrition, speech
and swallowing
evaluation/therapy,
and dysphagia
prevention
Psychosocial
Intervention
May include:
Financial:
disability, drug
benefits
Transportation
Placement
Counselling
regarding
diagnosis,
appearance
changes & HPV
Blood Work
Audiometry
Feeding Tube
Placement
Treatment
Decision
Radiation
Therapy6 E
Medical
Oncologist
Smoking cessation
counselling &
intervention where
appropriate
EBS 5-11
EBS 5-11
Surgery3
Indications include:
Contraindications for
radiation therapy,
Patient choice,
Previous radiation
PathologyIndications for
Post-Operative
Therapy4
YesSurgical Management
of Primary and Neck
(Nodal levels II-IV and
those with clinical or
radiographic evidence
disease)
NoProceed
to Page 11
Radiation Therapy4
Concurrent
Chemotherapy5
Peer Review
pT4a,
Gross bone
invasion
F
During Treatment
Ototoxicity Management
If patient is on chemotherapy
On Treatment Review
To include:
Radiation Medicine
Clinician
Oncology Nurse
Patients should also
have access to:
Clinical Nurse
Specialist / Nurse
Practitioner
Registered Dietitian
Speech Language
Pathologist
Dental Oncology
Social Worker
GL 5-3ORG
GL 5-3ORG
Stage IVA
T4a | N0-1 | M0
T1-4a | N2 | M0
Stage IVB
T4b | any N | M0
Any T | N3 | M0
AJCC Cancer Staging Manual 8th
edition
UICC The TNM Classification of
Malignant Tumours, 8th Edition
Stage IVA-B Cancer
EBS 5-11
Stage IV C Metastatic Disease Version 2019.09 Page 6 of 13
HPV-Negative Oropharyngeal Squamous
Cell Carcinoma Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the pathway map. In the situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions regarding the information set out in the pathway map. The information in the pathway map does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.
From
Page 7
R
Medical
Oncologist
Palliative Care
From
Diagnosis
Pathway
(Page 5)
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
MCC or
MDT
Dental
Oncologist
Speech
Language
Pathologist
Registered
Dietitian
Social
Worker
PSO Support
Audiologist
Smoking
Cessation
Program
Nursing1
Oligometastatic
disease
Disseminated
metastases
Fit for
systemic
therapy?
Yes
Systemic Therapy6
(e.g. Targeted therapy
or chemotherapy)
Proceed
to Page11
Consider aggressive local therapies
SurgeryAnd/Or
Extent of
Disease
Proceed
to Page 11
Observation
May be an option for
asymptomatic,
minimal bulk disease
Progression
Dental Evaluation
Nutrition, speech and
swallowing evaluation/
therapy, and dysphagia
prevention
In the recurrent and metastatic
scenario, patients may require
any and all of the same
supportive care as patients
undergoing primary treatment
Psychosocial Intervention
May include:
Financial: disability, drug
benefits
Transportation
Placement
Counselling regarding
diagnosis, appearance
changes & HPV
Blood Work
Audiometry
Feeding Tube Placement
Any T | Any N | M1
AJCC Cancer
Staging Manual 8th
edition
UICC The TNM
Classification of
Malignant Tumours,
8th Edition
Stage IV C/
Metastatic
Disease
Proceed to
End of Life
Care
Pathway Map
(page 12)
Appropriate therapy may include one or
more of the following:
Palliative Systemic Therapy6
(e.g. Targeted therapy or
chemotherapy)
Psychosocial oncology and
palliative care
Referral to appropriate specialist if
additional support is required
End of life care planning
Palliative Surgery
(e.g. CNS, local-regional)No
Clinical Trials
Palliative Radiation Therapy
Peer Review
G
H
K
Recurrence or
Progression
GL 5-3ORG
GL 5-3ORG
GL 5-3ORG
Systemic
TherapyAnd/Or
1 All patients should have access to specialized oncology nurse, clinical nurse specialist or nurse practitioner to manage the complex physical, social and psychological health needs that
arise during treatment and in early follow-up post treatment6 Platinum-containing agents (single or multi-agent) alone or in combination with other agents; other systemic therapy options may also exist including targeted therapies such as Nivolumab
as indicated. Consider referral to Head & Neck centre.
Radiation
Therapy
Peer Review
Recurrence Version 2019.09 Page 7 of 13
HPV-Negative Oropharyngeal Squamous
Cell Carcinoma Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the pathway map. In the situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions regarding the information set out in the pathway map. The information in the pathway map does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.
Local
Recurrence
Regional
Recurrence
Metastatic
From
Page 9 R
Medical
Oncologist
Proceed
to Page 9
Proceed
to Page 6
R
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
MCC or
MDT
Dental
Oncologist
Speech
Language
Pathologist
Registered
Dietitian
Social
Worker
PSO Support
Audiologist
Smoking
Cessation
Program
Nursing1
Palliative Care
Dental Evaluation
Nutrition, speech and
swallowing evaluation/
therapy, and dysphagia
prevention
In the recurrent and metastatic scenario, patients may require any and all of the
same supportive care as patients undergoing primary
treatment
Psychosocial
Intervention
May include:
Financial: disability,
drug benefits
Transportation
Placement
Counselling regarding
diagnosis, appearance
changes & HPV
Blood Work
Audiometry
Feeding Tube
Placement
J
K
R
1 All patients should have access to specialized oncology nurse, clinical nurse specialist or nurse practitioner to manage the complex physical, social and psychological health needs that arise during treatment and in early follow-up post treatment.
Surgical
Oncologist
Radiation
Oncologist
Proceed
to Page 8
I
Type of
recurrence
Tissue Biopsy
Locoregional
Imaging:
CT Head & Neck
or
MRI Nasopharynx
and Oropharynx
CT Thorax
Restaging, if not
previously done
CT Abdomen
PETPET Scans Ontario
GL 5-3ORG
Local Recurrence Version 2019.09 Page 8 of 13
HPV-Negative Oropharyngeal Squamous
Cell Carcinoma Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the pathway map. In the situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions regarding the information set out in the pathway map. The information in the pathway map does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.
Local
Recurrence
Previous
Radiation
Treatment?
Yes
No
From
Page 7
Surgical
Assessment
Yes
No
Proceed
to Page11
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
Salvage Surgery
Salvage Re-irradiation Therapy
Palliative
Systemic TherapyPalliative Care
And/
Or
Palliative therapies, which may include:
And/
Or
Palliative Radiation Therapy
Peer Review
Proceed to
End of Life
Care
Pathway Map
(page 12)
Pathology
Indications for
Post-operative
Therapy8, 9
Yes
No
Post-operative
re-irradiation therapy8
Concurrent
Chemotherapy9
Salvage
Surgery7 Proceed
to Page 11Pathology
Indications for
Post-operative
Therapy4
Yes
No
Post-operative
radiation therapy
Concurrent
Chemotherapy5
Peer Review
Progression
Proceed to
End of Life
Care
Pathway Map
(page 12)
Progression
Radiation Therapy with
Curative Intent
Concurrent
Chemotherapy
Peer Review
Resectable?
Palliative
Systemic
Therapy
Palliative
Care
And/
Or
Palliative therapies, which may include:
And/
Or
Palliative
Radiation Therapy
Peer Review
Peer Review
Peer Review
L
M
I
4 Indications for post-operative radiotherapy: Deep margins <5mm OR one or more of the following at the primary site: peri-neural invasion, lymph-vascular invasion OR lymph node involvement ( 2 lymph nodes, any lymph node >3 cm (N2+), level IV-V LN positive, extracapsular extension (ECE)). 5 Indications for concurrent chemotherapy: positive margins or extracapsular extension (ECE).7 Surgery may be an option for some patients if procedure can be completed in conservatively/transorally. Patients should be
included in trials investigating Transoral Robotic Surgery (TORS) where available.8 Post-operative re-irradiation to be considered for very high risk scenarios in appropriate patients after careful discussion with the surgeon and patient on the risk vs. benefits of re-irradiation. 9 Appropriateness of concurrent chemotherapy with re-irradiation should be considered on an individual basis after discussion with a multidisciplinary team.
Resectable?
Yes
No
Concurrent
Chemotherapy9
Re-irradiation with or without concurrent systemic treatment 8,9
Surgical
Assessment
Treatment
intent?
Palliative
Curative
Treatment
intent?
Palliative
Curative
During Treatment
Ototoxicity Management
If patient is on chemotherapy
On Treatment ReviewTo include: Radiation Medicine Clinician Oncology NursePatients should also have access to: Clinical Nurse Specialist / Nurse
Practitioner Registered Dietitian Speech Language Pathologist Dental Oncology Social Worker
During Treatment
Ototoxicity Management
If patient is on chemotherapy
On Treatment ReviewTo include: Radiation Medicine Clinician Oncology NursePatients should also have access to: Clinical Nurse Specialist / Nurse
Practitioner Registered Dietitian Speech Language Pathologist Dental Oncology Social Worker
GL 5-3ORG
GL 5-3ORG
EBS 5-11
EBS 5-11
Regional Recurrence Version 2019.09 Page 9 of 13
HPV-Negative Oropharyngeal Squamous
Cell Carcinoma Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the pathway map. In the situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions regarding the information set out in the pathway map. The information in the pathway map does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.
Regional
Recurrence
Previous
Radiation
Treatment to
the Neck?
Yes
No
From
Page 9
Surgical
Assessment
Yes
No
Proceed
to Page 11
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Consider the introduction of palliative care, early and across the cancer journey Click here for more information about palliative care
Salvage Neck Dissection
Salvage Re-irradiation Therapy
Palliative Systemic
TreatmentPalliative Care
And/
Or
Palliative therapies, which may include:
And/
Or
Palliative Radiation Therapy
Peer Review
Pathology
Indications
for Post-
operative
Therapy8, 9
Yes
No
Post-operative
re-irradiation therapy8
Concurrent
Chemotherapy9
Neck
Dissection7
Proceed
to Page 11
Pathology
Indications for
Post-operative
Therapy4
Yes
No
Post-operative
radiation therapy
Concurrent
Chemotherapy5
Peer Review
Progression
Proceed to
End of Life
Care
Pathway Map
(page 12)
Progression
Radiation Therapy with
Curative Intent
Concurrent
Chemotherapy
Peer Review
Resectable?
ChemotherapyPalliative
Care
And/
Or
Palliative therapies, which may include:
And/
Or
Re-irradiation
Therapy
Peer Review
Peer Review
Peer Review
N
O
J
4 Indications for post-operative radiotherapy: Deep margins <5mm OR one or more of the following at the primary site: peri-neural invasion, lymph-vascular invasion OR lymph node involvement ( 2 lymph nodes, any lymph node >3 cm (N2+), level IV-V LN positive, extracapsular extension (ECE)). 5 Indications for concurrent chemotherapy: positive margins or extracapsular extension (ECE).7 Surgery may be an option for some patients if procedure can be completed in conservatively/transorally. Patients
should be included in trials investigating Transoral Robotic Surgery (TORS) where available.8 Post-operative re-irradiation to be considered for very high risk scenarios in appropriate patients after careful discussion with the surgeon and patient on the risk vs. benefits of re-irradiation. 9 Appropriateness of concurrent chemotherapy with re-irradiation should be considered on an individual basis after discussion with a multidisciplinary team.
Resectable?
Yes
No
Concurrent
Chemotherapy9
Re-irradiation with or without concurrent systemic treatment 9
Surgical
Assessment
During Treatment
Ototoxicity Management
If patient is on chemotherapy
On Treatment ReviewTo include: Radiation Medicine Clinician Oncology NursePatients should also have access to: Clinical Nurse Specialist / Nurse
Practitioner Registered Dietitian Speech Language Pathologist Dental Oncology Social Worker
Treatment
intent?
Curative
Palliative
Treatment
intent?
Curative
Palliative
During Treatment
Ototoxicity Management
If patient is on chemotherapy
On Treatment ReviewTo include: Radiation Medicine Clinician Oncology NursePatients should also have access to: Clinical Nurse Specialist / Nurse
Practitioner Registered Dietitian Speech Language Pathologist Dental Oncology Social Worker
Proceed to
End of Life
Care
Pathway Map
(page 12)
GL 5-3ORG
GL 5-3ORG
EBS 5-11
EBS 5-11
Post-Chemoradiotherapy Response Evaluation Version 2019.09 Page 10 of 13
HPV-Negative Oropharyngeal Squamous
Cell Carcinoma Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the pathway map. In the situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions regarding the information set out in the pathway map. The information in the pathway map does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.
Proceed
to Page 11
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
Neck Dissection
(Nodal levels II-IV and those with clinical
or radiographic evidence of disease)
From
Pages 3-8
Post Treatment
Dental
Evaluation
(4-8 weeks post
radiation)
Assessment
and
management of
treatment-
related
symptoms and
side effects
A C E
Management of treatment-related symptoms and side effects
Lymphedema or stiffness of
the neck or shoulders
Physiotherapist
or Lymphedema
Clinic
R
If any of the following
persist post-treatment:
Dysphagia
Nutritional risk
Changes in voice or
communication status
Persistent weight loss
Presence of or high
risk for trismus
post-treatment
Speech
Language
Pathologist
Dental
Oncologist
R
R
Speech
Language
Pathologist
Registered
Dietitian
And/Or
Psychosocial
DistressR PSO SupportSocial Work
No
Evidence of
residual disease
or adverse
features12?
Locoregional
Imaging:
CT Head & Neck
or
MRI Nasopharynx
and Oropharynx10
10-12 weeks post-
treatment
Pathology
Indications
for Post-
operative
Therapy
Yes
No
Yes
Location
Local
Regional
Local and
Regional
Biopsy Pathology
Proceed
to Page 11
Result
Positive for viable
residual disease
Negative for viable
residual disease
PET11
Yes
No
Resectable?
Salvage Surgical
Management of Primary
Yes
No
Resectable?
Post-operative
re-irradiation therapy8
Systemic Therapy9
Individualized Plan
Peer Review
Yes
Resectable?
Salvage
Surgical
Management
of Primary
and Neck
Biopsy of primary
tumour with or
without lymph
node biopsy
Pathology Result
Positive for viable
residual disease
Negative for viable
residual disease
No
Re-irradiation therapy
Systemic Therapy9
Individualized Plan
Peer Review
Palliative Care
Proceed
to End of
Life Care
Pathway
Map (page
12)
Progression
Re-irradiation therapy
Systemic Therapy9
Individualized Plan
Peer Review
Palliative Care
Proceed
to End of
Life Care
Pathway
Map (page
12)
Progression
Systemic Therapy9
Individualized Plan
Palliative Care
Proceed
to End of
Life Care
Pathway
Map (page
12)
Progression
Proceed
to Page 11
MCC or
MDT
Re-irradiation therapyPeer Review
Q
P
GL 5-3ORG
GL 5-3ORG
GL 5-3ORG
8 Post-operative re-irradiation to be considered for very high risk scenarios in appropriate patients after careful discussion with the surgeon and patient on the risk vs. benefits of re-irradiation. 9 Appropriateness of concurrent chemotherapy with re-irradiation should be considered on an individual basis after discussion with a multidisciplinary team.10 Same modality should be used as baseline imaging11 Restaging after chemoradiotherapy treatment to assess patients with N1-N3 squamous-cell carcinoma of the H&N, if patients have residual neck nodes 1.5cm on re-staging CT performed 10-12 weeks post therapy for HPV positive disease.12 Adverse features include central necrosis and extracapsular extension.
Follow-Up Version 2019.09 Page 11 of 13
HPV-Negative Oropharyngeal Squamous
Cell Carcinoma Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the pathway map. In the situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions regarding the information set out in the pathway map. The information in the pathway map does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.
Recurrence or
Progression
Proceed
to Page 7
Screen for psychosocial needs, and assessment and management of symptoms. Click here for more information about symptom assessment and management tools
From
Pages 3-8
Return to
primary care
provider for
follow-up
Management of treatment-related symptoms and side effects
Follow-Up
Every 3 months for year 1,
Every 4 months for year 2,
Every 6 months for year 3-5
Dental Assessment
In previously irradiated patients, extractions must be performed
by dental oncologists or dentists experienced in head and neck
cancers due to risk of osteoradionecrosis
Imaging
Frequency determined as
indicated by clinical suspicion
of recurrent disease
Physical Examination
Including indirect inspection
or fibre-optic nasendoscopy
Audiology or ophthalmology assessment
Blood Work
May include Complete Blood
Count (CBC) and Thyroid
Stimulating Hormone (TSH)
History
Including swallowing function
and pain
Assessment and management of treatment-related
symptoms and side effects
Lymphedema or
stiffness of the neck
or shoulders
Physiotherapist
or Lymphedema
Clinic
R
If any of the following
persist post-treatment:
Dysphagia
Nutritional risk
Changes in voice or
communication status
Persistent weight loss
Trismus is noted
or persists post
treatment
Speech
Language
Pathologist
Dental
Oncologist
R
R
Speech
Language
Pathologist
Registered
Dietitian
And/Or
B D FG H LM N OP Q
R
Psychosocial
DistressR PSO SupportSocial Work
Result
No Recurrence
or
Progression
10 Same modality should be used as baseline imaging
End of Life Care Version 2019.09 Page 12 of 13
HPV-Negative Oropharyngeal Squamous
Cell Carcinoma Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the pathway map. In the situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions regarding the information set out in the pathway map. The information in the pathway map does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.
Pathway Map Target
Population: Individuals with cancer
approaching end of life, and their
families.
While this section of the pathway
map is focused on the care
delivered at the end of life, the
palliative care approach begins
much earlier on in the illness
trajectory.
Refer to
within the Psychosocial &
Palliative Care Pathway Map
Triggers that
suggest patients
are nearing the
last few months
and weeks life
ECOG/Patient-
ECOG/PRFS = 4
OR
PPS 30
Declining
performance
status/functional
ability
Gold Standards
Framework
indicators of high
mortality risk
Screen, Assess,
Plan, Manage
and Follow-Up
End of Life Care
planning and
implementation
Collaboration and
consultation
between
specialist-level
care teams and
primary care
teams
End of Life Care
Revisit Advance Care Planning
Ensure the patient has determined who will be their Substitute Decision Maker (SDM)
Ensure the patient has communicated to the SDM his/her wishes, values and beliefs to help guide that SDM in future decision making
Discuss and document goals of care with patient and family
Assess and address patient and family s information needs and understanding of the disease, address gaps between reality and expectation, foster
realistic hope and provide opportunity to explore prognosis and life expectancy, and preparedness for death
Introduce patient and family to resources in community (e.g., day hospice programs)
Develop a plan of treatment and obtain consent
Determine who the person wants to include in the decision making process (e.g., substitute decision maker if the person is incapable)
Develop a plan of treatment related to disease management that takes into account the person s values and mutually determined goals of care
Obtain consent from the capable person or the substitute decision maker if the person is incapable for an end-of-life plan of treatment that includes:
- Setting for care
- Resuscitation status
- Having, withholding and or withdrawing treatments (e.g. lab tests, medications, etc.)
Screen for specific end of life psychosocial issues
Specific examples of psychological needs include: anticipatory grief, past trauma or losses, preparing children (young children, adolescents, young
adults), guardianship of children, death anxiety
Consider referral to available resources and/or specialized services
Identify patients who could benefit from specialized palliative care services (consultation or transfer)
Discuss referral with patients and family
Proactively develop and implement a plan for expected death
Explore place-of-death preferences and assess whether this is realistic
Explore the potential settings of dying and the resources required (e.g., home, residential hospice, palliative care unit, long term care or nursing home)
Anticipate/Plan for pain & symptom management medications and consider a Symptom Response Kit (SRK) for unexpected pain & symptom
management
Preparation and support for family to manage
Discuss emergency plans with patient and family (who to call if emergency in the home or long-term-care or retirement home)
Home care planning
Connect with Home and Community Care early (not just for last 2-4 weeks)
Ensure resources and elements in place
Consider a Symptom Response Kit (SRK) with access to pain, dyspnea and delirium medication
Identify family members at risk for abnormal/complicated grieving and connect them proactively with bereavement resources
+
Screen, Assess & Plan
Eastern Cooperative Oncology Group Performance Status (ECOG); Palliative Performance Scale (PPS); Patient Reported Functional Status (PRFS)
For more information on the Gold Standards Framework, visit
(refer to Collaborative Care Plan)
http://www.goldstandardsframework.org.uk/
End of Life Care cont. Version 2019.09 Page 13 of 13
HPV-Negative Oropharyngeal Squamous
Cell Carcinoma Treatment Pathway MapThe pathway map is intended to be used for informational purposes only. The pathway map is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathway maps are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the pathway map. In the situation where the reader is not a healthcare provider, the reader should always consult a healthcare provider if he/she has any questions regarding the information set out in the pathway map. The information in the pathway map does not create a physician-patient relationship between Cancer Care Ontario (CCO) and the reader.
At the time of death:
Pronouncement of death
Completion of death certificate
Allow family members to spend time with loved one upon
death, in such a way that respects individual rituals, cultural
diversity and meaning of life and death
Implement the pre-determined plan for expected death
Arrange time with the family for a follow-up call or visit
Provide age-specific bereavement services and resources
Inform family of grief and bereavement resources/services
Initiate grief care for family members at risk for complicated
grief
Encourage the bereaved to make an appointment with an
appropriate health care provider as required
Provide opportunities
for debriefing of care
team, including
volunteers
Patient Death
Bereavement Support and Follow-Up
Offer psychoeducation and/or counseling to the bereaved
Screen for complicated and abnormal grief (family members, including
children)
Consider referral of bereaved family member(s) and children to
appropriate local resources, spiritual advisor, grief counselor, hospice
and other volunteer programs depending on severity of grief
Top Related