Breast Cancer Pathway Map
This pathway map provides an overview of the evidence-based best practices for the management of breast cancer patients in Ontario, across all phases of care.
Please note on screens smaller than 7 inches only the PDF version of the pathway map is available.
Please note this is a beta release. We are actively working on perfecting the pathway map, and are eager to hear your feedback on how to make it more useful.
Overall
- 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 map. For patients who do not have a primary care provider, Health Care Connect, is a government resource that helps patients find a family doctor or nurse practitioner.
- Throughout the pathway map, 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 Person-Centered Care Guideline and EBS #19-2 Provider-Patient Communication*
- Hyperlinks are used throughout the pathway map to provide information about relevant CCO tools, resources and guidance documents.
- The term ‘Healthcare provider’, used throughout the pathway map, includes primary care providers and specialists, nurse practitioners, and emergency physicians.
* Note. EBS #19-2 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.
Prevention
- Target population: Women who are at a higher than average risk for breast cancer.
- For more information about the evidence linking risk factors to breast cancer visit:
Screening
- Ontario Breast Screening Program (OBSP) Risk Categories & Criteria can be found in CCO’s Cancer Screening Guidelines
- Target Population: Women who present with signs and symptoms of breast cancer or women who are asymptomatic and eligible for the Ontario Breast Screening Program (OBSP) or High Risk OBSP.
- The OBSP provides high quality breast cancer screening free-of-charge in Ontario. The OBSP is developed based on the guidelines developed by the Canadian Task Force on Preventative Health Care, CMAJ. 2011;183(17):1991–2001, and the High Risk OBSP is developed based on EBS 15-11 V2. For more information on the OBSP refer to Healthcare Provider Resources – Breast Screening
- It is presumed that the patient is assessed clinically throughout the entire pathway map.
- It is presumed that at each step along the pathway map, the risks and benefits of screening are discussed with the patient.
- Glossary:
- IBIS – an evaluation tool that uses a woman’s family history to calculate the likelihood of her carrying an adverse gene and calculates the risk of developing breast cancer. For more information visit http://www.ems-trials.org/riskevaluator/
- BOADICEA (Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm) – an evaluation tool used to calculate the risk of breast and ovarian cancer in a woman based on her family history. For more information visit http://ccge.medschl.cam.ac.uk/boadicea/
- BI-RADS (Breast Imaging Reporting and Data System) – a reporting system developed by the American College of Radiology to report the results of ultrasounds, mammograms and MRIs. BI-RADS assessment categories include:
Management Recommendations | |||
---|---|---|---|
Assessment Categories | For mammography | For MRI | For ultrasound |
Category 0 – Incomplete | Additional imaging evaluation and/or comparison with no previous examinations | Routine screening | Routine screening |
Category 1 – Negative | Routine mammography screening | Routine breast MRI screening | Routine screening |
Category 2 – Benign | Routine mammography screening | Routine breast MRI screening | Routine screening |
Category 3 – Probably benign | Short-interval (6-month) follow-up or continued surveillance mammography | Short-interval (6 month) follow-up | Short-interval (6 month) follow-up or continued surveillance |
Category 4 – Suspicious
|
Tissue diagnosis | Tissue diagnosis | Tissue diagnosis |
Category 5 – Highly suggestive of malignancy | Tissue diagnosis | Tissue diagnosis | Tissue diagnosis |
Category 6 – Proven malignancy | Surgical excision when clinically appropriate | Surgical excision when clinically appropriate | Surgical excision when clinically appropriate |
Adapted from D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA et al. ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System. Reston, VA, American College of Radiology; 2013
Diagnosis
- Target Population: Women who present with signs and symptoms of breast cancer
Treatment
- Target Population: Patients with a confirmed breast cancer diagnosis who have undergone the recommended diagnostic and staging procedures outlined in the Breast Cancer Pathway Map
- Consider recommendation for exercise. For more information visit: Exercise for people with cancer.
- Multidisciplinary Cancer Conferences provide a forum for discussing patients with breast cancer about whom there are complexities regarding diagnosis and management. For more information on Multidisciplinary Cancer Conferences visit MCC Tools
- For more information on wait time prioritization, visit: Wait time for Surgeries and Procedures
- Clinical trials should be considered for all phases of the pathway map.
- 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. For more information, visit EBS #19-3*
- The following should be considered when weighing the treatment options described in this pathway map for patients with potentially life-limiting illness:
- Palliative care may be of benefit at any stage of the cancer journey, including alongside curative treatment or as the main focus of care once curative treatments are no longer effective
- 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
* 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.
Post-Treatment
- Target Population: Breast cancer patients who have completed primary treatment for breast cancer and are without evidence of disease, but would potentially be candidates for further treatment if recurrence or new breast cancer were detected.
- Follow-up care can be delivered in the institution or by primary care. Institutional follow-up care may be delivered by oncologist, general practitioner in oncology or an advanced practice nurse (e.g., nurse practitioner, clinical nurse specialist).
We'd like your feedback on this Pathway Map!