Breast Cancer Pathway Map

Transcription

1 Care Ontario Pathway Map Printer Friendly Version Note: print 11x17 landscape for best results, some features and content are only available on web version of pathway map Prevention Screening Diagnosis Treatment Follow-Up Risk Assessment & Prevention Guidance (Page 2) Screening Risk Assessment (Page 3)» Average Risk Screening (Page 4)» High Risk Screening (Page 5) Assessment of Symptomatic Individuals (Page 6-7) Diagnostic Procedures (Page 8-9) Ductal Carcinoma In Situ (Page 10-11)) Invasive (Page 12-17) Distant Metastases (Page 18) Local and/or Regional Recurrence (Page 19-20) Survivorship (Page 21-22) End of Life Care (Page 23) DISCLAIMER: This pathway is a resource that provides an overview of the presentation and clinical work-up of a diagnosis that an individual in the Ontario system may receive. The pathway is intended to be used for informational purposes only. The pathway is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Further, all pathways are subject to clinical judgment and actual practice patterns may not follow the proposed steps set out in the pathway. 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. The information in the pathway does not create a physician-patient relationship between Care Ontario (CCO) and the reader. While care has been taken in the preparation of the information contained in the pathway, such information is provided on an as-is basis, without any representation, warranty, or condition, whether express, or implied, statutory or otherwise, as to the information s quality, accuracy, currency, completeness, or reliability. CCO and the pathway s content providers (including the physicians who contributed to the information in the pathway) shall have no liability, whether direct, indirect, consequential, contingent, special, or incidental, related to or arising from the information in the pathway or its use thereof, whether based on breach of contract or tort (including negligence), and even if advised of the possibility thereof. Anyone using the information in the pathway does so at his or her own risk, and by using such information, agrees to indemnify CCO and its content providers from any and all liability, loss, damages, costs and expenses (including legal fees and expenses) arising from such person s use of the information in the pathway. This pathway 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. It is possible that other relevant scientific findings may have been reported since completion of this pathway. This pathway may be superseded by an updated pathway on the same topic.

2 Risk Assessment & Prevention Guidance Risk Assessment & Prevention Guidance Risk Assessment & Prevention Guidance Risk Assessment & Prevention Guidance Risk Assessment & Prevention Guidance Risk Assessment & Prevention Guidance Risk Assessment & Prevention Guidance Risk Assessment & Prevention Guidance Risk Assessment & Prevention Guidance Risk Assessment & Prevention Guidance Risk Assessment & Prevention Guidance Risk Assessment & Prevention Guidance Risk Assessment & Prevention Guidance Risk Assessment & Prevention Guidance Risk Assessment & Prevention Guidance Risk Assessment of breast risk by family physician or other healthcare provider, or tool (i.e. My IQ) Lifetime risk of breast should be based on family history and must be assessed using IBIS or BOADICEA lifetime risk assessment tools. IBIS 10 year and BOADICEA 5 year risk assessment tools My IQ IBIS risk assessment INT-110 BOADICEA risk assessment Assessment outcome DEC-24 Screening DEC-27 Potentially eligible for High Risk OBSP program Refer for assessment via OBSP Requisition for High Risk Screening Eligible for genetic assessment but not eligible through High Risk OBSP program (e.g. strong family history & 18 to 29 years of age) Average lifetime risk of breast Lifetime risk of breast should be based on family history and must have been assessed using IBIS or BOADICEA lifetime D Increased risk of breast for non-genetic reasons (i.e. high risk lifestyle, alcohol, smoking, obesity, age) OBSP Requisition for High Risk Screening Show all Confirmed high risk benign lesion E.g. ADH, ALH, classical LCIS CHA-13 Refer to Genetics Program for formal assessment of hereditary breast risk and genetic test when eligible GENETICS Referral to appropriate Healthcare Provider E.g. Primary care, medical oncologist If not already with most appropriate healthcare provider CON-46 INT-111 From High Risk OBSP Screening Program of genetic assessment(s) Chemoprevention Considered if age 35 years; assessment for appropriateness using Gail risk score or other risk assessment model DEC-25 Carrier of pathogenic variant in BRCA 1/2 25% lifetime risk of breast or carrier of pathogenic variant in other penetrant genes (e.g. TP53, CDH1, PTEN, STK11, CHEK2, Lifetime risk of breast should be based on family history and must have been assessed using IBIS or BOADICEA lifetime <25% lifetime risk of breast IBIS risk assessment BOADICEA risk assessment INT-109 U.S. Preventive Services Task Force (USPSTF) recommendation on the use of medications for breast risk reduction. CHA-12 Discuss appropriate breast screening and OBSP average risk eligibility Eligible Referral to appropriate Healthcare Provider I.e. medical oncologist, surgeon, gynecologist, primary care provider Referral to appropriate Healthcare Provider I.e. medical oncologist, surgeon, gynecologist, primary care provider Not eligible CON-44 CON-45 DEC-22 Screening INT-124 Preventative treatment may influence one or more of the following Bilateral Salpingo-Oo phorectomy If age 35 years and BRCA 1/2 mutation carrier. For information on the examination of bilateral salpingo-oophorectomy specimens visit the CAP CAP Checklists Follow-up managed by Primary Care Provider PRIMARY CARE INT-112 National Institute for Health and Care Excellence (2013). Familial breast : Classification and care of people at risk of familial breast and management of breast and related risks in people with a family history of breast (updated March 2017) National Comprehensive Network (2015). Risk Reduction (version ). FOL-3 Bilateral Mastectomy (+/- reconstruction) See NICE (2013) & NCCN (2015) INT-113 NICE (2013). Familial breast : Classification and care of people at risk of familial breast and management of breast and related risks in people with a family history of breast (updated March 2017) NCCN (2015). Risk Reduction (version ). Preventative treatment may influence one or more of the following Bilateral Mastectomy (+/- reconstruction) See NICE (2013) & NCCN (2015) INT-115 NICE (2013). Familial breast : Classification and care of people at risk of familial breast and management of breast and related risks in people with a family history of breast (updated March 2017) NCCN (2015). Risk Reduction (version ). Chemoprevention Considered if age 35 years INT-116 U.S. Preventive Services Task Force (USPSTF) recommendation on the use of medications for breast risk reduction. Chemoprevention Considered if age 35 years INT-114 U.S. Preventive Services Task Force (USPSTF) recommendation on the use of medications for breast risk reduction. Discuss appropriate breast screening and reassess High Risk OBSP eligibility Eligible DEC-23 Screening DEC-18 Not eligible (i.e. age, bilateral mastectomy) Follow-up managed by Primary Care Provider PRIMARY CARE FOL-4

3 Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Screening Risk Assessment Sc Visit to Healthcar e Pr ovider Average Risk patients do not require a physician referral for the OBSP CON-48 Clinical pr esentation Asymptomatic DEC-27 Diagnosis CHA-14 Symptomatic or a finding on clinical exam Patient self-r efers to OBSP OBSP Screening Locations CON-50 Eligibility and risk assessment to determine appr opriate scr eening e.g. family and clinical history Nurse practitioners can assess patient risk and complete the Average Risk DEC-28 Screening INT-124 Women are considered eligible for average risk screening if they are asymptomatic and meet all of the following: 1) Are years of age*; 2) Have no personal history of breast ; 3) Have not had a screening mammogram within last 11 months; 4) No current breast implants *Women over age 74 can be screened with the OBSP; however, they are encouraged to Possible High Risk (Genetic assessment required to determine High Risk OBSP eligibility) Women may be eligible for high risk screening if they are asymptomatic, are years of Known High Risk (Eligible for direct entry into High Risk OBSP) Women may be eligible for high risk screening if they are asymptomatic, are years of D Not eligble for OBSP (e.g. <30 or >74 years of age)* *Women over age 74 can be screened with the OBSP; however, they are encourage to make a CCO Screening for OBSP Requisition for High Risk Screening Referral to OBSP for br east genetic assessment to determine eligibility for High Risk OBSP Nurse practitioners can assess patient risk and complete the OBSP requisition for high risk GENETICS CON-47 OBSP Requisition for High Risk Screening Referral to High Risk OBSP Nurse practitioners can assess patient risk and complete the OBSP requisition for high risk Discuss scr eening options with healthcar e pr ovider with r egards to the benefits and limitations of screening Screening INT-83 CON-49 OBSP Requisition for High Risk Screening INT-122 Formal assessment of her editary br east risk GENETICS INT-117 OBSP Genetic Assessment and/or T est Patient declines genetic r eferral Return to risk appr opriate scr eening INT-123 INT-118 Genetic Testing Eligibility Eligible DEC-26 Not eligible or patient declines testing Health car e pr ovider discusses risk appr opriate scr eening and discusses health behaviour interventions to reduce br east risk as appr opriate (e.g. exercise, nutrition) There is insufficient evidence to recommend appropriate PRIMARY CARE INT-121 EBS # Healthy Eating, Physical Activity, and Healthy Weights Guideline for Public Health in Ontario Genetic Test GENETICS INT-120 OBSP Genetic Assessment and/or T est DEC-30 Screening DEC-18 Prevention CHA-12 Carrier of pathogenic variant in BRCA 1/2 or carrier of other high penetrant gene (e.g. TP53, CDH1, PTEN, STK11) True negative result for known hereditary gene mutation in family No deleterious mutation identified or variant of undetermined significance Reevaluate patient risk DEC-29 Screening DEC-18 Prevention CHA-12 25% lifetime risk of breast Lifetime risk of breast should be based on family history and must have been assessed using IBIS or BOADICEA lifetime < 25% lifetime risk of breast Lifetime risk of breast should be based on family history and must have been assessed using IBIS or BOADICEA lifetime IBIS risk assessment BOADICEA risk assessment Health car e pr ovider discusses risk appr opriate scr eening and discusses health behaviour interventions to reduce br east risk as appr opriate (e.g. exercise, nutrition) There is insufficient evidence to recommend appropriate screening guidelines for some risk categories (e.g. a 40 year old woman at increased but not high risk). Risk appropriate screening in these cases is a personalized decision made between the woman and her healthcare provider. PRIMARY CARE INT-119 EBS # Healthy Eating, Physical Activity, and Healthy Weights Guideline for Public Health in Ontario

4 Decision Point Average Risk Screening Average Risk Screening Average Risk Screening Average Risk Screening Average Risk Screening Average Risk Screening Average Risk Screening Average Risk Screening Average Risk Screening Click to select between the following options. Average Risk Screening High Risk Screening Average Risk Screening Average Risk Screening Average Risk Screening Average Risk Screening Average Risk Screening Average Risk Screening Average Risk Screening Average Risk Screening Average Risk Screening Screening mammogram Every two years or annually as required for women ages As outlined within the OBSP, annual mammograms may be CCO Screening Recommendations INT-124 The management following the BI-RADS assessment categories are based on the recommendations from the American College of Radiology. DEC-31 Normal (e.g. BI-RADS 1 or 2) Abnormal (e.g. BI-RADS 0) ACR BI-RADS Atlas Diagnostic Assessment Diagnostic Mammogram Ultrasound AND/OR INT-126 DEC-32 Benign diagnostic assessment (e.g. normal tissue, simple cyst, minimally complicated cyst) Probably benign diagnostic assessment (e.g. BI-RADS 3) The management following the BI-RADS assessment categories are based on the recommendations Abnormal diagnostic assessment ACR BI-RADS Atlas Diagnosis DEC-39 Short-term imaging follow-up Repeat imaging within 6 months based on radiologist's recommendations. INT-125 Normal assessment Continue with screening or diagnostic imaging follow-up Abnormal assessment DEC-33 Diagnosis DEC-39 Continue screening FOL-5 Average Risk Screening Average Risk Screening Average Risk Screening Average Risk Screening Average Risk Screening Average Risk Screening Average Risk Screening Average Risk Screening Average Risk Screening

5 Decision Point High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening Click to select between the following options. Average Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening Patient Age Age Age DEC-18 Annual; a scr eening mammogram and MRI should be completed within 30 days of each other. Screening Mammogram INT-83 EBS # Magnetic Resonance Imaging Screening of Women at High Risk for Annual Scr eening Mammogram INT-80 EBS # Magnetic Resonance Imaging Screening of Women at High Risk for Screening MRI Screening ultrasound if MRI is not medically appropriate INT-84 EBS # Magnetic Resonance Imaging Screening of Women at High Risk for Normal DEC-15 Probably benign (BI-RADS 3) The management following the BI-RADS assessment categories are based on the recommendations from the American College of Radiology. Abnormal ACR BI-RADS Atlas Additional Imaging (e.g. second look ultrasound, repeat MRI, more mammographic views) INT-81 Abnormal Assessment DEC-16 Diagnosis DEC-39 Probably benign (BI-RADS 3) The management following the BI-RADS assessment categories are based on the recommendations from the American College of Radiology. Normal ACR BI-RADS Atlas Short-term imaging follow-up Repeat imaging within 6 months based on radiologist's recommendations INT-82 Normal assessment Abnormal Assessment DEC-17 Diagnosis DEC-39 Continue scr eening FOL-1 High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening High Risk Screening

6 Assessment of Symptomatic Individuals Assessment of Symptomatic Individuals Assessment of Symptomatic Individuals Assessment of Symptomatic Individuals Assessment of Symptomatic In Assessment of Symptomatic Individuals Assessment of Symptomatic Individuals Assessment of Symptomatic Individuals Assessment of Symptomatic Individuals Assessment of Symptomatic Individuals Patient presents with one or more symptoms of breast, such as: -Palpable mass -Concerning nipple discharge -New nipple retraction -Skin changes of the nipple or breast -Asymmetric thickening/nodularity CHA-14 Patient's Age <30 years of age and/or breastfeeding or pregnant 30 to 40 years of age >40 years of age DEC-34 Ultrasound Ultrasound Ultrasound INT-129 INT-135 INT-132 Mammogram Mammogram INT-136 INT-133 Galactography In appropriate clinical contexts INT-137 Galactography In appropriate clinical contexts INT-134 Imaging Normal DEC-35 Probably benign (BI-RADS 3) The management following the BI-RADS assessment categories are based on the recommendations from the American College of Radiology. Suspicious ACR BI-RADS Atlas Diagnosis DEC-39

7 Assessment of Symptomatic Individuals Assessment of Symptomatic Individuals Assessment of Symptomatic Individuals Imaging Normal DEC-35 Probably benign (BI-RADS 3) The management following the BI-RADS assessment categories are based on the recommendations from the American College of Radiology. Suspicious ACR BI-RADS Atlas Diagnosis DEC-39 Clinical reassessment of symptoms PRIMARY CARE INT-127 Short-term imaging follow-up Repeat imaging within 6 months based on radiologist's recommendations. INT-130 DEC-36 Persistent suspicious findings Normal assessment Clinical reassessment of symptoms PRIMARY CARE INT-131 Normal assessment Suspicious DEC-37 Healthcare provider discusses risk appropriate screening There is insufficient evidence to recommend appropriate screening guidelines for some risk categories (e.g. a 40 year old woman at increased but not high risk). Risk appropriate screening in these cases is a personalized decision made between the woman and her healthcare provider. PRIMARY CARE Screening DEC-27 INT-128 Assessment of Symptomatic Individuals Assessment of Symptomatic Individuals Assessment of Symptomatic Individuals Assessment of Symptomatic Individuals Assessment of Symptomatic Individuals

8 Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Referral to Finding(s) CON-52 DEC-39 Suspicious mass on ultrasound, complex cyst, intraductal nodule, concerning calcifications, suspicious mammographic finding An excisional biopsy may be considered for presumed isolated papillary lesions in the appropriate clinical context Axillary lymph nodes: indeterminate or concerning MRI suspicious lesion Only for high risk patients Biopsy INT-139 Core biopsy Referral to Core biopsy Vacuum assisted with clip placement INT-143 CON-53 INT-140 Fine needle aspiration OR Core Biopsy INT-141 E.g. ER, PgR, HER2 Biomarkers should be performed on core biopsies showing invasive. INT-142 Summary Statement: 2013 ASCO/CAP HER2 : Building a Consensus for Ontario Benign High risk/concerning benign lesions e.g. Atypical ductal hyperplasia, radial scars, papilloma D Insufficient tissue sampling DEC-38

9 tic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Consider short-term imaging follow-up or return to risk-appropriate screening FOL-6 Diagnostic Procedures Diagnostic Procedures Concordance with pathology, imaging and clinical examination Diagnostic Procedures Concordant Discordant DEC-40 Second core needle biopsy or vacuum biopsy If discordant upon second biopsy, refer to surgeon. INT-138 Diagnostic Procedures Diagnostic Procedures Benign High risk/concerning benign lesions e.g. Atypical ductal hyperplasia, radial scars, papilloma D Insufficient tissue sampling DEC-38 Type of Ductal Carcinoma In Situ Invasive DEC-42 Treatment CON-57 Referral to Biomarker Testing E.g. ER, PgR, HER2 If not already initiated CON-51 Treatment CON-7 INT-146 Summary Statement: 2013 ASCO/CAP HER2 : Building a Consensus for Ontario Decision regarding further diagnostic test(s) needed DEC-44 Excisional biopsy or short-term imaging Screening DEC-27 Risk appropriate screening Choose one of the following: Excisional biopsy INT-148 Short-term imaging follow-up Repeat imaging within 6 months based on radiologist's recommendations. FOL-7 Biomarkers should be performed on core biopsies showing invasive. INT-147 Benign DEC-43 Prevention CHA-13 Confirmed high risk benign Healthcare provider discusses risk appropriate screening or short term imaging follow-up There is insufficient evidence to recommend appropriate screening guidelines for some risk categories (e.g. a 40 year old woman at increased but not high risk). Risk appropriate screening in these cases is a personalized decision made between the woman and her healthcare provider. PRIMARY CARE Type of Screening DEC-27 INT-144 Ductal Carcinoma In Situ DEC-41 Treatment CON-57 Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Diagnostic Procedures Referral to Invasive Treatment CON-7 Diagnostic Procedures CON-54 Diagnostic Procedures Second core biopsy INT-145 Diagnostic Procedures Diagnostic Procedures

10 Decision Point Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In S Click to select between the following options. Ductal Carcinoma In Situ Invasive Breast Distant Metastases Local and/or Regional Recurrence Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Referral to CON-57 Genetics Clinic If not previously seen and potentially high risk Consider urgent referral to genetics clinic if treatment will be affected by genetic status, or if patients meet one of the following criteria: 1) First GENETICS INT-153 Determine local disease extent (as requir ed) for clinical decision making INT-154 Conversation regarding type of surgery Consider patient preference and clinically necessary procedures Consider referral to radiation oncologist to determine eligibility for radiation therapy. Some patients who are ineligible for radiation, may need a mastectomy. Mastectomy DEC-47 EBS # surgery DATA 4 Consultation with plastic surgeon may be appropriate in some cases. INT-152 EBS # Management of Ductal Carcinoma in Situ of the Breast Plastic surgeon Consultation with a radiation oncologist should be considered for patients who may be considered for immediate reconstruction. PLASTIC SURGERY CON-59 ER/PgR determination only at the request of the oncologist. HER2 for invasive or at the request of oncologist for microinvasion (<1mm). CAP checklists and protocols visit INT-151 EBS # Guideline on Hormone Receptor Testing in and Other Primary Care Providers Mastectomy (+/- reconstruction) and sentinel lymph node biopsy DATA 4 Contralateral prophylactic mastectomy is not recommended for average risk women. Consultation with a plastic surgeon may be appropriate in some cases. INT-156 EBS # Management of Ductal Carcinoma in Situ of the Breast EBS # EBS # Sentinel Lymph Node Biopsy in Early-Stage Indications for Contralateral Prophylactic Mastectomy: A Consensus Statement Using Modified Delphi Methodology r esults Invasive DCIS; positive margins DEC-46 Treatment DEC-11 For the purpose of this pathway map, positive margins are defined as ink on tumour and the optimal negative margin width DCIS; negative margins For the purpose of this pathway Society of Surgical Oncology-American Society for Radiation Oncology-American Society of Clinical Oncology Consensus Guideline on Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Ductal Carcinoma in Situ. ER/PgR determination only at the request of the oncologist. HER2 for invasive or at the request of oncologist for microinvasion (<1mm). CAP checklists and protocols visit INT-155 EBS # Guideline on Hormone Receptor Testing in and Other Primary Care Providers r esults Positive and negative margins Invasive DCIS; positive margins DEC-45 Treatment DEC-11 For the purpose of this pathway map, positive margins are defined as ink on tumour and the optimal negative margin width DCIS; negative margins For the purpose of this pathway Referral to Plastic PLASTIC SURGERY Re-excision To achieve negative margins. If margins positive after re-excision, consider mastectomy. Society of Surgical Oncology-American Society for Radiation Oncology-American Society of Clinical Oncology Consensus Guideline on Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Ductal Carcinoma In Situ. CON-55 For the purpose of this pathway map, positive margins are defined as ink on tumour and the optimal negative INT-157 Society of Surgical Oncology-American Society for Radiation Oncology-American Society of Clinical Oncology Consensus Guideline on Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Ductal Carcinoma In Situ.

11 Situ ma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Referral to Plastic PLASTIC SURGERY CON-55 Mastectomy (+/- reconstruction) and sentinel lymph node biopsy Contralateral prophylactic mastectomy is not recommended for average risk Ductal Carcinoma In Situ Ductal Carcinoma In Situ INT-149 Re-excision To achieve negative margins. If margins positive after re-excision, consider mastectomy. For the purpose of this pathway map, positive margins are defined as ink on tumour and the optimal negative EBS # Management of Ductal Carcinoma in Situ of the Breast EBS # EBS # Sentinel Lymph Node Biopsy in Early-Stage Indications for Contralateral Prophylactic Mastectomy: A Consensus Statement Using Modified Delphi Methodology INT-158 r esults Invasive DCIS DEC-48 Treatment DEC-11 Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ Ductal Carcinoma In Situ INT-157 Society of Surgical Oncology-American Society for Radiation Oncology-American Society of Clinical Oncology Consensus Guideline on Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Ductal Carcinoma In Situ. Referral to MULTIDISCIPLINARY CANCER CONFERENCE CON-56 Ductal Carcinoma In Situ Ductal Carcinoma In Situ r esults Positive and negative margins DEC-45 Treatment DEC-11 Referral to Medical Oncologist CON-60 Referral to Radiation Oncologist CON-61 Radiation therapy Post-Treatment CHA-15 INT-159 EBS # Management of Ductal Carcinoma in Situ of the Breast Endocrine therapy For prevention Post-Treatment CHA-15 INT-160 EBS # Management of Ductal Carcinoma in Situ of the Breast Ductal Carcinoma In Situ Ductal Carcinoma In Situ Invasive DCIS; positive margins For the purpose of this pathway map, positive margins are defined as ink on tumour and the optimal negative margin width Ductal Carcinoma In Situ DCIS; negative margins For the purpose of this pathway Referral to Medical Oncologist CON-58 Endocrine therapy For contralateral prevention Post-Treatment CHA-15 Ductal Carcinoma In Situ INT-150 Society of Surgical Oncology-American Society for Radiation Oncology-American Society of Clinical Oncology Consensus Guideline on Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Ductal Carcinoma In Situ. EBS # Management of Ductal Carcinoma in Situ of the Breast Ductal Carcinoma In Situ Ductal Carcinoma In Situ

12 Decision Point Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Click to select between the following options. Ductal Carcinoma In Situ Invasive Breast Distant Metastases Local and/or Regional Recurrence Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive CON-7 Genetics Clinic If not previously seen and potentially high risk Consider urgent referral to genetics clinic if treatment will be affected by genetic status, or if patients meet one of the following criteria: 1) First degree relative of a carrier of a GENETICS INT-17 Determine local disease extent (as required) for clinical decision making (e.g. tumour size, nodal status) Distant metastases suspected (e.g. clinical signs, symptoms, laboratory values) CHA-1 INT-18 Operability Inoperable Operable Consider the following to exclude metastatic disease: Abdominal and Chest Imaging As appropriate INT-56 EBS # Baseline Staging Tests in Primary DEC-4 Bone Scan INT-57 EBS # Baseline Staging Tests in Primary Treatment decision Imaging No distant metastases DEC-2 Treatment CON-2 Distant metastases (Stage IV) DEC-7 Candidate for primary surgical management Candidate for neoadjuvant therapy e.g. T3 N0, tumour > 2cm and triple negative or HER2+ Lymph node status Node positive on biopsy and neoadjuvant therapy not required Node negative DEC-1 Conversation regarding type of surgery Consider patient preference and clinically necessary procedures Consider referral to radiation oncologist to determine eligibility for radiation therapy. Some patients who are ineligible for radiation may need a mastectomy. Mastectomy Conversation regarding type of surgery Consider patient preference and clinically necessary procedures Consider referral to radiation oncologist to determine eligibility for radiation therapy. Some patients who are ineligible for radiation, may need a mastectomy. Mastectomy DEC-9 EBS # DEC-8 EBS #

13 Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Brea DATA 4 surgery and axillary lymph node dissection Consultation with plastic surgeon may be appropriate in some cases INT-15 If no in surgical specimen (e.g. very small tumours, <1cm) refer to core biopsy pathology including biomarker testing. For more information about CAP checklist and/or HER2 testing, Baseline staging May include bone scan and chest/abdominal imaging INT-35 EBS # Baseline Staging Tests in Primary If positive margins (For the pu [no cells adjacent to any on tumour. This definition has May defer re-excision or mast Lymph node status EBS #1-1 - Surgical Management of Early-Stage Invasive INT-22 INT-64 Node positive on biopsy and neoadjuvant therapy not required Node negative DEC-1 Conversation regarding type of surgery Consider patient preference and clinically necessary procedures Consider referral to radiation oncologist to determine eligibility for radiation therapy. Some patients who are ineligible for radiation may need a mastectomy. EBS # Sentinel L ymph Node Biopsy in Early-Stage EBS # Guideline on Hormone Receptor T esting in and Other Primary Care Providers ASCO Recommendations for HER2 receptor testing in breast Summary Statement: 2013 ASCO/CAP HER2 : Building a Consensus for Ontario Breast T issue Pathway Map DEC-9 DATA 4 Mastectomy EBS # Referral to Plastic Consultation with a radiation oncologist should be considered for patients who may be considered for immediate reconstruction. PLASTIC SURGERY INT-40 Mastectomy (+/- reconstruction) and axillary lymph node dissection Contralateral prophylactic mastectomy is not recommended for average risk women. If no in surgical specimen (e.g. very small tumours, <1cm) refer to core biopsy pathology including biomarker testing. For more information about CAP checklist and/or HER2 testing, refer to Resources and Tools. INT-39 INT-41 EBS #1-1 - Surgical Management of Early-Stage Invasive EBS # Sentinel L ymph Node Biopsy in Early-Stage EBS # Guideline on Hormone Receptor T esting in and Other Primary Care Providers Baseline staging May include bone scan and chest/abdominal imaging EBS # Indications for Contralateral Prophylactic Mastectomy: A Consensus Statement Using Modified Delphi Methodology ASCO Recommendations for HER2 receptor testing in breast Summary Statement: 2013 ASCO/CAP HER2 : Building a Consensus for Ontario Breast T issue Pathway Map INT-42 EBS # Baseline Staging Tests in Primary Conversation regarding type of surgery Consider patient preference and clinically necessary procedures Consider referral to radiation oncologist to determine eligibility for radiation therapy. Some patients who are ineligible for radiation, may need a mastectomy. Referral to Plastic Consultation with a radiation oncologist should be considered for patients who may be considered for immediate reconstruction. PLASTIC SURGERY INT-31 Mastectomy (+/- reconstruction) and sentinel lymph node dissection DATA 4 Contralateral prophylactic mastectomy is not recommended for average risk women. If axillary dissection is planned in the case that any axillary nodes are involved, consider intraoperative frozen section. If no in surgical specimen (e.g. very small tumours, <1cm) refer to core biopsy pathology including biomarker testing. For more information about CAP checklist and/or HER2 testing, refer to Resources and Tools. Baseline staging May include bone scan and chest/abdominal imaging INT-34 EBS # Baseline Staging Tests in Primary DEC-8 INT-33 INT-32 Mastectomy EBS #1-1 - Surgical Management of Early-Stage Invasive EBS # Guideline on Hormone Receptor T esting in and Other Primary Care Providers EBS # EBS # Sentinel L ymph Node Biopsy in Early-Stage EBS # ASCO Recommendations for HER2 receptor testing in breast Summary Statement: 2013 ASCO/CAP HER2 : Building a Consensus for Ontario Breast T issue Pathway Map Indications for Contralateral Prophylactic Mastectomy: A Consensus Statement Using Modified Delphi Methodology DATA 4 surgery and sentinel lymph node dissection Consultation with plastic surgeon may be appropriate in some cases. If axillary dissection is planned in the case that any axillary nodes are involved, consider intraoperative frozen section. INT-24 If no in surgical specimen (e.g. very small tumours, <1cm) refer to core biopsy pathology including biomarker testing. For more information about CAP checklist and/or HER2 testing, refer to Resources and Tools. INT-16 Baseline staging May include bone scan and chest/abdominal imaging INT-25 EBS # Baseline Staging Tests in Primary If positive margins (For the purpose of this pathway map, negative margins ar e defined as no ink on tumor [no cells adjacent to any inked edge/surface of the specimen] and positive margins ar e defined as ink on tumour. This definition has been adopted as per the American Society of Clinical Oncology guideline. May defer re-excision and mastectomy until after systemic therapy if high risk of systemic r ecurr ence.) One of the following may be completed: INT-65 EBS #1-1 - Surgical Management of Early-Stage Invasive EBS # Sentinel L ymph Node Biopsy in Early-Stage EBS # Guideline on Hormone Receptor T esting in and Other Primary Care Providers ASCO Recommendations for HER2 receptor testing in breast Summary Statement: 2013 ASCO/CAP HER2 : Building a Consensus for Ontario Re-excision To achieve negative margins INT-74 ASCO Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Stage I and II Invasive Breast Mastectomy (+/- reconstruction) Consultation with a radiation oncologist should be considered for patients who may be considered for immediate reconstruction. INT-75 Breast T issue Pathway Map EBS # ASCO Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Stage I and II Invasive Breast

14 or nk reast Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasiv If positive margins (For the purpose of this pathway map, negative margins are defined as no ink on tumor [no cells adjacent to any inked edge/surface of the specimen] and positive margins are defined as ink on tumour. This definition has been adopted as per the American Society of Clinical Oncology guideline. May defer re-excision or mastectomy until after systemic therapy if high risk of systemic recurrence.) Consider one of the following interventions: INT-64 Re-excision To achieve negative margins INT-72 ASCO Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Stage I and II Invasive Breast Mastectomy (+/- reconstruction) Consultation with a radiation oncologist should be considered for patients who may be considered for immediate reconstruction. INT-73 EBS # Adjuvant therapy based on type of surgery Sentinel lymph node biopsy INT-36 EBS # Sentinel Lymph Node Biopsy in Early-Stage ER/PgR and HER2 if not previously done CAP checklists and protocols, visit INT-37 ASCO Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Stage I and II Invasive Breast DEC-11 surgery for invasive surgery for DCIS showed invasive Mastectomy for invasive D Referral to Medical Oncologist Molecular profile test (e.g. Oncotype Dx) Mastectomy with sentinel lymph node biopsy for DCIS showed invasive CON-10 Candidates for molecular profile tests are patients with node negative (N0), ER positive and HER2 negative breast in whom the decision for chemotherapy is unclear. INT-23 RR MOAC-4 - Clinical Utility of Multigene Profiling Assays in Invasive Early-Stage Breast If positive lymph nodes and high risk of residual disease Referral to Referral to Radiation Oncologist Axillary lymph node dissection MULTIDISCIPLINARY CANCER CONFERENCE CON-21 CON-22 May defer axillary lymph node dissection until after systemic therapy if high risk of systemic recurrence. INT-67 INT-66 EBS # Sentinel Lymph Node Biopsy in Early-Stage

15 Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Breast C Treatment for inoperable disease Needle cytology of axillary nodes Molecular profile test Consider the following interventions: Clinical and radiological assessment of the axilla (e.g. Oncotype Dx) Referral to Medical Oncologist CON-27 Candidates for molecular profile tests are patients with node negative (N0), ER positive and HER2 negative breast in whom the decision for chemotherapy is unclear. Targeted therapy (e.g. Trastuzumab) Chemotherapy INT-59 Endocrine Therapy INT-60 INT-69 INT-38 INT-58 MRI ER/PgR and HER2 if not previously done CAP checklists and protocols, visit Referral to Radiation Oncologist RR MOAC-4 - Clinical Utility of Multigene Profiling Assays in Invasive Early-Stage Breast EBS #1-22A - Use of Adjuvant Bisphosphonates and Other Bone-Modifying Agents in Show all Show all To determine disease extent in the breast INT-70 CON-28 INT-37 Biomarkers ER/PgR and HER2 if not previously done. HER2 testing see ASCO INT-71 Referral to Radiation Oncologist CON-13 Radiation therapy Local +/- regional therapy Post-Treatment CHA-15 INT-47 ASCO Recommendations for Human Epidermal Growth Factor Receptor 2 Testing in Molecular profile test (e.g. Oncotype Dx) Candidates for molecular profile tests are patients with node negative (N0), ER positive and HER2 negative breast in whom the decision for chemotherapy is unclear. INT-23 RR MOAC-4 - Clinical Utility of Multigene Profiling Assays in Invasive Early-Stage Breast Consider the following interventions: Targeted therapy (e.g. Trastuzumab) INT-61 EBS #1-22A - Use of Adjuvant Bisphosphonates and Other Bone-Modifying Agents in Chemotherapy INT-62 Show all Endocrine Therapy INT-63 Show all Risk of local- regional recurrence DEC-3 High risk (e.g. Node positive, T2, T3, presence of lymphovascular invasion) Low risk Referral to Radiation Oncologist CON-14 EBS #1-2 - Breast Irradiation in Women with Early Stage Invasive Following Breast Conserving Surgery EBS # The Role of IMRT in Imaging for metastatic disease: To be considered for patients who exhibit clinical signs, symptoms and laboratory values indicating presence of metastases Abdominal and chest imaging As appropriate INT-78 Bone Scan INT-79 Medical Oncologist Radiation Oncologist CON-25 CON-26

16 asive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invas Treatment for inoperable disease DEC-6 Needle cytology of axillary nodes Treatment CON-2 Distant metastases Clinical and radiological assessment of the axilla INT-69 No distant metastases MULTIDISCIPLINARY CANCER CONFERENCE CON-11 Neoadjuvant systemic therapy can consist of: Response to optimal neoadjuvant systemic therapy MRI To determine disease extent in the breast INT-70 Referral to Medical Oncologist CON-19 Referral to Radiation Oncologist Targeted therapy (e.g. Trastuzumab) INT-53 EBS #1-22A - Use of Adjuvant Bisphosphonates and Other Bone-Modifying Agents in Chemotherapy INT-54 EBS #1-22A - Use of Adjuvant Bisphosphonates and Other Bone-Modifying Agents in Endocrine Therapy INT-55 EBS #1-22A - Use of Adjuvant Bisphosphonates and Other Bone-Modifying Agents in Distant metastases Operable DEC-14 Treatment CON-2 No distant metastases and inoperable CON-20 Biomarkers ER/PgR and HER2 if not previously done. HER2 testing see ASCO Radiation Oncologist CON-8 Radiation therapy Local +/- regional therapy INT-26 INT-71 EBS # Locoregional Therapy of Locally Advanced ASCO Recommendations for Human Epidermal Growth Factor Receptor 2 Testing in EBS # The Role of IMRT in Imaging for metastatic disease: To be considered for patients who exhibit clinical signs, symptoms and laboratory values indicating presence of metastases Abdominal and chest imaging Bone Scan MULTIDISCIPLINARY CANCER CONFERENCE CON-12 Presence of distant metastases Distant metastases DEC-13 Treatment CON-2 Radiation Oncologist CON-6 Radiation therapy Local +/- regional therapy Post-Treatment CHA-15 INT-28 As appropriate INT-78 INT-79 Neoadjuvant systemic therapy can consist of: Response to neoadjuvant therapy DEC-12 No distant metastases and inoperable No distant metastases and operable EBS # Locoregional Therapy of Locally Advanced EBS # The Role of IMRT in Chemotherapy INT-48 EBS #1-22A - Use of Adjuvant Bisphosphonates and Other Bone-Modifying Agents in Endocrine Therapy INT-49 Show all Targeted therapy (e.g. Trastuzumab) INT-50 Show all Not responding (Consider additional systemic options before considering other treatment options.) Responding MULTIDISCIPLINARY CANCER CONFERENCE CON-16 EBS # Locoregional Therapy of Locally Advanced Conversation regarding type of surgery Consider patient preference and clinically necessary procedures Consider referral to radiation oncologist to determine eligibility for radiation therapy. Some patients who are ineligible for radiation, may need a mastectomy. CON-15 DEC-10 Mastectomy EBS # Biomarkers ER/PgR and HER if not previously done Medical Oncologist Radiation Oncologist CAP checklist and/or HER2 testing, refer to Resources and Tools. CON-25 CON-26 INT-46 ASCO Recommendations for HER2 receptor testing in breast

17 asive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive cer Invasive Invasive Invasive Invasive Invasive Invasive Invasive Radiation therapy Local +/- regional therapy INT-26 Response Operable DEC-5 Referral to Plastic Immediate reconstruction not recommended. PLASTIC SURGERY CON-23 EBS # Referral to CON-24 Modified radical mastectomy (+/- reconstruction) DATA 4 INT-19 EBS # Locoregional Therapy of Locally Advanced EBS # If no in surgical specimen (e.g. very small tumours, <1cm) refer to core biopsy pathology including biomarker testing. For more information about CAP checklist and/or HER2 testing, refer to Resources and Tools. INT-20 EBS # Guideline on Hormone Receptor Testing in and Other Primary Care Providers Radiation Oncologist CON-9 Radiation therapy Local +/- regional therapy Post-Treatment CHA-15 INT-21 EBS # Locoregional Therapy of Locally Advanced EBS # The Role of IMRT in EBS # Locoregional Therapy of Locally Advanced EBS # The Role of IMRT in Inoperable Post-Treatment CHA-15 ASCO Recommendations for HER2 receptor testing in breast Summary Statement: 2013 ASCO/CAP HER2 : Building a Consensus for Ontario Radiation therapy Local +/- regional therapy Post-Treatment CHA-15 INT-28 Invasive EBS # Locoregional Therapy of Locally Advanced EBS # The Role of IMRT in Conversation regarding type of surgery Consider patient preference and clinically necessary procedures Consider referral to radiation oncologist to determine eligibility for radiation therapy. Some patients who are ineligible for radiation, may need a mastectomy. Mastectomy DEC-10 EBS # Referral to Plastic Consultation with a radiation oncologist should be considered for patients who may be considered for immediate reconstruction. PLASTIC SURGERY DATA 4 surgery and sentinel lymph node dissection Consultation with plastic surgeon may be appropriate in some cases. If the number of positive lymph nodes will change the radiation or systemic treatment plans consider a frozen section. If positive, consider an axillary lymph node dissection. INT-30 DATA 4 Mastectomy (+/- reconstruction) and sentinel lymph node dissection Contralateral prophylactic mastectomy is not recommended for average risk women. If axillary dissection is planned in the case that any axillary nodes are involved, consider intraoperative frozen section. INT-27 EBS # Locoregional Therapy of Locally Advanced EBS # Sentinel Lymph Node Biopsy in Early-Stage EBS # Indications for Contralateral Prophylactic Mastectomy: A Consensus Statement Using Modified Delphi Methodology If no in surgical specimen (e.g. very small tumours, <1cm) refer to core biopsy pathology including biomarker testing. For more information about CAP checklist and/or HER2 testing, refer to Resources and Tools. INT-44 If no in surgical specimen (e.g. very small tumours, <1cm) refer to core biopsy pathology including biomarker testing. For more information about CAP checklist and/or HER2 testing, refer to Resources and Tools. INT-29 EBS #22-1- Guideline on Hormone Receptor Testing in and Other Primary Care Providers ASCO Recommendations for HER2 receptor testing in breast Summary Statement: 2013 ASCO/CAP HER2 : Building a Consensus for Ontario If positive margins (For the purpose of this pathway map, negative margins are defined as no ink on tumor [no cells adjacent to any inked edge/surface of the specimen] and positive margins are defined as ink on tumour. This definition has been adopted as per the American Society of Clinical Oncology guideline. May defer re-excision and mastectomy until after systemic therapy if high risk of systemic recurrence.) One of the following may be completed: If positive lymph nodes including N1mic or ITC MULTIDISCIPLINARY CANCER CONFERENCE CON-17 Radiation Oncologist Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive Invasive CON-18 Axillary lymph node dissection May defer axillary lymph node dissection until after systemic therapy if high risk of systemic recurrence. INT-51 EBS # Sentinel Lymph Node Biopsy in Early-Stage INT-52 Radiation therapy Local +/- regional therapy Post-Treatment CHA-15 INT-45 EBS # Locoregional Therapy of Locally Advanced EBS # The Role of IMRT in INT-43 EBS # Locoregional Therapy of Locally Advanced EBS # Guideline on Hormone Receptor Testing in and Other Primary Care Providers ASCO Recommendations for HER2 receptor testing in breast Summary Statement: 2013 ASCO/CAP HER2 : Building a Consensus for Ontario INT-68 Re-excision To achieve negative margins INT-76 ASCO Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Stage I and II Invasive Breast Mastectomy (+/- reconstruction) Consultation with a radiation oncologist should be considered for patients who may be considered for immediate reconstruction. INT-77 EBS # ASCO Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Stage I and II Invasive Breast

18 Decision Point Distant Metastases Distant Metastases Distant Metastases Distant Metastases Distant Metastases Distant Metastases Distant Metastases Distant Metastases Distant Metastases Distant Metastases Distant Metastases Distant Metastases Distant Metastases Click to select between the following options. Ductal Carcinoma In Situ Invasive Breast Distant Metastases Local and/or Regional Recurrence Distant Metastases Distant Metastases Distant Metastases Distant Metastases Distant Metastases Distant Metastases Distant Metastases Dista Medical Oncologist CON-2 Radiation Oncologist CON-3 CON-4 Palliative Care PALLIATIVE CARE CON-5 Consider re-biopsy of metastasis INT-13 Biomarkers (ER/PgR and HER2) if not previously done CAP checklists and protocols, visit For more information about HER2 testing see ASCO (2013). Recommendations for HER2 receptor testing in breast : American Society of Oncology/College of American Pathologist Clinical Practice Guideline Update. INT-14 ASCO Recommendations for HER2 receptor testing in breast MULTIDISCIPLINARY CANCER CONFERENCE CON-1 Conversation regarding treatment Consider patient and tumour characteristics. INT-7 Appropriate therapy may include two or more of the following: Palliative systemic treatment Post-Treatment CHA-10 Palliative Care INT-8 Palliative radiation therapy Post-Treatment CHA-10 Palliative Care INT-9 Palliative surgery (e.g. CNS, local-regional) Post-Treatment CHA-10 INT-10 Palliative Care Psychosocial oncology and palliative care Referral to appropriate specialist if additional support is required. Post-Treatment CHA-10 Palliative Care INT-11 End of life care planning Post-Treatment CHA-10 Palliative Care INT-12 tases Distant Metastases Distant Metastases Distant Metastases Distant Metastases Distant Metastases Distant Metastases Distant Metastases