Lung Cancer Diagnosis Pathway Map

Version 2017.11

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.
 Pathway Map Preamble Version
Version yyyy.mm
2017.11 Page
Page 22 of
of 77

Target Population Pathway Map Legend Shape Guide

Patients who present with signs or symptoms suspicious of lung cancer. Colour Guide Intervention

Primary Care Decision or assessment point

Pathway Map Considerations Palliative Care Patient (disease) characteristics
 Primary care providers play an important role in the cancer journey and should be informed of relevant tests and consultations. Pathology Consultation with specialist
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,
Health Care Connect, is a government resource that helps patients find a doctor or nurse practitioner. Diagnostic Assessment Program (DAP) Exit pathway
 Throughout the pathway, a shared decision-making model should be implemented to enable and encourage patients to play an active
X
X
Surgery or Off-page reference
role in the management of their care. For more information see Person-Centered Care Guideline and
Radiation Oncology Patient/Provider interaction
EBS #19-2 Provider-Patient Communication*
 Hyperlinks are used throughout the pathway to provide information about relevant CCO tools, resources and guidance documents. R Referral
Medical Oncology
 The term ‘health care provider’, used throughout the pathway, includes primary care providers and specialists, nurse practitioners, and Radiology W Wait time indicator time point
emergency physicians.
Multidisciplinary Cancer Conference (MCC)
 For more information on the Diagnostic Assessment Program (DAP) refer to the Organizational Standards for DAPs Line Guide
 Psychosocial oncology (PSO) is the interprofessional specialty concerned with understanding and treating the social, practical, Respirologist
psychological, emotional, spiritual and functional needs and quality-of-life impact that cancer has on patients and their Required
Psychosocial Oncology (PSO)
families. Psychosocial care should be considered an integral and standardized part of cancer care for patients and their families at all Possible
stages of the illness trajectory. For more information, visit EBS #19-3*
 Counseling and treatment for smoking cessation should be initiated early on in the pathway and continued by care providers
throughout the pathway as necessary Program Training & Consultation Centre – Hospital Based Resources Pathway Map Disclaimer
This pathway map is a resource that provides an overview of the treatment that an individual in the Ontario cancer system
* Note. EBS #19-2 and EBS #19-3 is older than 3 years and is currently listed as ‘For Education and Information Purposes’. This means that the may receive.
recommendations will no longer be maintained but may still be useful for academic or other information purposes.
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.
© 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.
Lung Cancer Diagnosis Pathway Map Suspicion Version 2017.11 Page 3 of 7

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.

Patient presenting with any of the following signs suspicious

for cancer:
 Hemoptysis (single episode)
 New finger clubbing
 Suspicious lymphadenopathy (e.g. cervical, supraclavicular)
 Dysphagia
 Features of metastatic lung cancer (e.g. weight loss >5 kg, focal skeletal pain,
headaches)1
 Features suggestive of paraneoplastic syndromes1
Or
Patient presents with any of the following unexplained symptoms for > 3 weeks (or

 Cough
sooner if patient has known risk factors)2:
 Chest and/or shoulder pain
A
 Anorexia Chest Imaging Proceed
 Abnormal chest sounds
 Dyspnea CT (or chest x-ray) to page 4
 Hoarseness
EBS #25-1-2
EBS #24-2
Visit to Health Care
Provider Underlying chronic respiratory problems presenting
with unexplained changes in existing symptoms
EBS #24-2 Follow-up
with
R No
Visit to emergency department appropriate
Patient presenting with any of the following:
These are emergency situations specialist
 Stridor Lung
and the patient should be seen Treatment for
 Massive hemoptysis Imaging as cancer
presenting
 New neurological signs suggestive of brain metastases or spinal in the ER (if not presenting appropriate suspected?
there) and referred emergently to symptoms
Smoking cord compression including seizure
Cessation
Program
EBS #24-2 specialist Yes R4 B
Proceed
Patient presenting with any of the following: to Page 4
 Persistent non-massive hemoptysis (Multiple episodes of coughing
Smoking blood or blood-streaked sputum)
cessation  Superior vena cava syndrome/obstruction3
counselling & EBS #24-2
intervention R4
where
appropriate Patient presenting with abnormal imaging that
reports suspicion of lung cancer (including screen detected cancers)
EBS #24-2; EBS #15-10

1 Refer to the American College of Chest Physicians Clinical Practice Guideline, Chest, 132, 149-160 for features of a standardized evaluation for systematic metastases and a list of paraneoplastic syndromes associated with lung cancer.
2 The following factors have been shown to increase the risk of lung cancer: current or previous smoker or second-hand exposure to tobacco smoke, history of chronic obstructive pulmonary disease, previous exposure to asbestos or other known
carcinogens (e.g. radon, chromium, nickel), occupational exposure to dust or other microscopic particles (e.g. wood dust, silica), personal or family history of cancer (especially lung, head & neck), silicosis, tuberculosis.
3 These patients should be accepted by the lung DAP if the lung DAP can facilitate a diagnosis within one week.
4 An abnormal chest x-ray or an abnormal CT scan of chest suspicious of lung cancer is required with each DAP referral. A CT scan of the chest is not required for acceptance of a lung DAP referral if the chest x-ray is abnormal but a CT scan-chest is

required prior to assessment at a lung DAP. Patient history should be mandatory as part of the referral and include, at a minimum: comorbidities, medications, allergies major health issues and symptoms that prompted the DAP referral.
Lung Cancer Diagnosis Pathway Map Initial Presentation and Imaging Version 2017.11 Page 4 of 7

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.

Resolved
Return to
primary care
New or growing
solitary peripheral C
Follow-up provider for mass or suspicious Proceed
Consolidation or Treatment Begin staging test at
chest x-ray follow-up pulmonary nodule(s) to Page 5
unexplained as Results presentation to avoid
(or CT chest) without mediastinal or
pleural effusion appropriate Non- delay in staging
EBS #24-2 hilar
resolving phase.
EBS #24-2 Suspected
PET should be done
before biopsy or IMS
lymphadenopathy
D
cancer Proceed
Tests may include: Central mass
additional CT scan, or clinical N1, N2, N3 to Page 5
bone scan, PET scan,
High suspicion of CT chest
lung cancer
(based on imaging R DAP
(If not previously
done) Results
MRI, or CT of brain (see
page 7 for more detail) E
Suspected Proceed
and/or clinical Cancer Imaging Pleural effusion
A judgement) Guidelines
cancer to Page 6

From Return to
Results
Page 3
Pleural effusion Thoracentesis Results
Normal imaging
results
primary care
provider for
F
Suspected stage IV Proceed
follow-up
Based on scans and/ to Page 6
or patient history
B Positive for
cancer
From
Page 3
G
Proceed
Treatment to Page 6
Chest x-ray Not resolved
with Within one month
Suspected pneumonia Status and suspected
antibiotics after starting lung cancer Abnormal
(1 cycle) treatment
Repeat
chest x-ray
Not resolved
Low suspicion of Follow-up with and lung cancer Results
Suspected other
lung cancer Respirologist specialist (notify not suspected
infectious disease process Sputum culture
(based on imaging R (or Tuberculosis public health if TB Normal Return to
(e.g. tuberculosis, atypical
and/or clinical Specialist) is diagnosed) primary care
infections)
judgement) provider for
Resolved follow-up
Suspected chronic Follow-up with
obstructive pulmonary Respirologist specialist or
disease (COPD) or other R
(or Internist) return to primary
benign lung disease (e.g. care provider for
sarcoidoisis) follow-up

Other conditions (e.g. Treatment as

pulmonary embolus, trauma) appropriate

4 An abnormal chest x-ray or an abnormal CT scan of chest suspicious of lung cancer is required with each DAP referral. A CT scan of the chest is not required for acceptance of a lung DAP referral if the chest x-ray is abnormal but a CT scan-chest is required prior to assessment at a lung DAP. Patient history should be mandatory
as part of the referral and include, at a minimum: comorbidities, medications, allergies major health issues and symptoms that prompted the DAP referral.
Lung Cancer Diagnosis Pathway Map Diagnostic Procedures Version 2017.11 Page 5 of 7

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.

Positive for cancer

H
PET/CT scan Proceed
Needle biopsy not or suspicious
EBS #7-20 and to Page 7
possible Positive for
PET Scans Ontario cancer
Cytology7
Thoracic Cell block should be
Negative but high
Surgery
C New or growing
solitary peripheral
Interventional
Results level of clinical
suspicion
For diagnostic
obtained
And/Or
Results

mass or suspicious purposes

From Radiology Pathology7,8
pulmonary nodule(s) Return to
Page 4 Cancer Imaging Negative for primary care
without mediastinal or
Guidelines Core Fine Needle cancer provider for
hilar
lymphadenopathy Biopsy Or Biopsy Change in follow-up
Cytology7
Bronchoscopy Choice is based on the expertise of the result
Cell block should be Follow-up by family EBS #7-20
not possible radiologist and pathologist and the physician, specialist
obtained
Cancer Imaging ability to obtain sufficient tissue for And/Or Negative and low or pulmonary nodule
Guidelines morphological diagnosis and molecular level of clinical clinic Results
testing. Pathology7,8 suspicion Follow-up CT Return to
ES #25-1-1 and As per Fleischner primary care
Cancer Imaging Guidelines Stable
guidelines9 provider for
follow up

Positive for

If there is CT evidence of hilar

cancer
Proceed
I
and/or mediastinal to Page 7
lymphadenopathy
Positive for
May be performed by
Mediastinoscopy cancer
D surgeon or respirologist
EBS #17-6 Cytology7
Cell block should be
Suspicious or
Repeat biospy or Thoracic
Cytology7
Cell block should be
Central mass Bronchoscopy5 Or negative but
From obtained other diagnostic Surgery obtained
or clinical N1, N2, Results high level of Results
Page 4 Endobronchial ultrasound6 And/Or testing For diagnostic And/Or
N3 Endobronchial clinical
If not previously done As appropriate purposes
ultrasound6 EBS #17-6 Pathology7,8 suspicion Pathology7,8 Return to
EBS #17-6 Or Negative for primary care
cancer provider for
Interventional Radiology follow-up

Change in
result
EBS #7-20
Negative and low
Follow-up by
level of clinical Results
specialist
suspicion

5 Depending on local resources, radial miniprobe navigational bronchoscopy with lung biopsy may be considered. Return to
6 If the endobronchial ultrasound transbronchial needle aspiration is negative but there is a high level of suspicion of lung cancer, a mediastinoscopy should be completed.
Stable for 2 primary care
7 Results go to ordering and referring physician and family physician
years provider for
follow-up
8 For more information about biomarkers, refer to the Lung Cancer Tissue Pathway
9 Follow-up as per the Fleischner guidelines. For more information see Guidelines for Management of Small Pulmonary Nodules Detected on CT Scans: A Statement from the Fleischner Society. (2005). Radiology, 237, 395-400.
Lung Cancer Diagnosis Pathway Map Diagnostic Procedures (cont'd) Version 2017.11 Page 6 of 7

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.

G
From Positive for cancer
Tests on pleural fluid: page 4 (Stage IV)
Thoracentesis  Cytology (cell block should be Proceed to
Perform procedure promptly. obtained) Treatment
Can be done for diagnosis or  Lactate dehydrogenase Pathway Map
Pleural effusion for symptom relief. Note: If  Protein concentration (NSCLC page
malignant cells found, this  Glucose 7, 8; SCLC
condition makes the patient  Amylase page 4)

E
inoperable.  Cell count and differential
Cancer Imaging Guidelines Positive for
 Culture and sensitivity
F Cytology7
(cell block should be
Suspicious or Repeat biospy,
Thoracic
Cytology7
Cell block should be
cancer

negative but thoracentesis or

From obtained) Surgery obtained
Results high level of other diagnostic Results
page 4 And/Or For diagnostic And/Or
clinical testing
Pathology7,8 purposes
suspicion As appropriate Pathology7,8
Return to
Obtain sufficient tissue sample for Negative for primary care
histological and molecular diagnosis cancer provider for
Suspected stage IV via least invasive, most accessible and follow up
Based on scans and/or most likely to up-stage the patient
patient history Cancer Imaging Guidelines
Change in
result
EBS #7-20

Negative and low

Follow-up by Results
level of clinical
specialist
suspicion
Palliative Return to
Care primary care
Stable
provider for
follow up
PSO

7 Results go to ordering and referring physician and family physician

8 For more information about biomarkers, refer to the Lung Cancer Tissue Pathway
Lung Cancer Diagnosis Pathway Map Staging Version 2017.11 Page 7 of 7

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.

Proceed
to NSCLC
Clinical Stage I Treatment
Pathway Map
(Page 3)

Proceed
to NSCLC
Clinical Stage II Treatment
Tests to be completed Pathway Map
(if not previously done) Clinical Stage II Invasive Mediastinal Staging
(Page 4)
or IIIA EBS #17-6
PET/CT scan
EBS #7-20 and Endobronchial Proceed
Mediastinoscopy Or
Pathological PET Scans Ontario Ultrasound to NSCLC
Non-Small Cell Lung Clinical Stage
Results Treatment
Cancer Diagnosis IIIA or B
MRI brain Pathway Map
(NSCLC) Clinical Stage (Page 6)
For stage II, III, and IV. No MRI if
IIIB
H patient is clinical stage I and
asymptomatic Proceed
I Cancer Imaging Guidelines No CNS
metastases
to NSCLC
Treatment
From Pathway Map
Page 5 (Page 7)
Clinical Stage IV

Proceed
to NSCLC
CNS metastases Treatment
Pathway Map
(Page 8)

PET/CT scan
PET Report #9
PET Scans Ontario
Proceed
Tests to be completed if not Bone scan to SCLC
Clinical
Medical previously done If suspected metastasis, bone pain or Treatment
Stage I-III
Oncologist abnormal calcium and alkaline Pathway Map
Medical history, MRI brain phosphatase. Not indicated if PET/CT (Page 3)
Pathological Small
physical exam CT if MRI is not available or is negative
Cell Lung Cancer Radiation
R and blood work contraindicated Cancer Imaging Guidelines
Diagnosis Oncologist10 (If not done Cancer Imaging Guidelines
(SCLC)
already)
Thoracic CT chest and abdomen Bone scan Proceed
Surgeon If not already performed or outdated If suspected metastasis, bone pain or to SCLC
Cancer Imaging Guidelines Clinical abnormal calcium and alkaline Treatment
Stage IV phosphatase. Pathway Map
Cancer Imaging Guidelines (Page 4)

10 If emergency situation, symptomatic brain metastases, superior vena cava obstruction, spinal compression or stage I-III disease.