For a better experience, we suggest using Chrome web browser to view this pathway map.

Pathway Maps

About Pathway Maps Email Disease Pathway Management

Breast Cancer Pathway Map

Publication Date: March 15, 2018

Version:

08.08

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
Prevention
Screening
Diagnosis
Treatment
Post-Treatment

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:
- Cancer Risk Factors in Ontario: Healthy Weights, Healthy Eating and Active Living
- Cancer Risk Factors in Ontario: Alcohol Report

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 4A - Low suspicion 4B - Moderate suspicion 4C - High suspicion	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).

Breast Cancer Pathwaymap V318 Printer Friendly Version.pdf

The following individuals are acknowledged for their involvement in the development of the Breast Cancer Pathway Map, in their capacity as clinical experts, as listed below. They have reviewed the content of the pathway map and confirm that, with respect to their medical specialty and to the best of their clinical judgment and opinion, the pathway map depicts evidence-based best practice and is informed appropriately by expert opinion where evidence is conflicting or missing. The following individuals support the release of the pathway map on the external Cancer Care Ontario (CCO) website and they consent to their names being listed as contributors to the pathway map.

Experts Involved in the Update of the Breast Cancer Pathway Map (2018)

Andrea Eisen, MD FRCPC (Chair) Associate Professor, Department of Medicine, University of Toronto Ontario Breast Cancer Lead, Cancer Care Ontario Toronto, Ontario	Amanda Hey, MD CCFP FCFP Regional Primary Care Lead, North East Health Science North Sudbury, Ontario
Angel Arnaout, MD MSc FRCPC FACS Breast Surgical Oncologist and General Surgeon Clinician Investigator, Ottawa Hospital Research Institute Assistant Professor, University of Ottawa Ottawa, Ontario	Brian Pinchuk, MDCM FRCSC General Surgery & Surgical Oncology, North York General Hospital Toronto, Ontario
Derek Muradali, MD FRCPC Radiologist-in-Chief, Ontario Breast Screening Program, Cancer Care Ontario Toronto, Ontario	Francisco Perera, BSc ENG MD FRCP (C) Radiation Oncologist, London Health Sciences Centre Associate Professor, University of Western Ontario London, Ontario
Glykeria Martou, MD Plastic Surgeon, Kingston Regional Cancer Centre Assistant Professor, Queen's University Kingston, Ontario	Ian Dayes, MSc MD FRCPC Associate Professor, Department of Oncology, McMaster University Radiation Oncologist, Juravinski Cancer Centre Hamilton, Ontario
Kathleen Bell, MSc, CGC Genetic Counsellor – DAP Lead, Juravinski Regional Cancer Centre Assistant Professor (Part-Time), Department of Oncology, McMaster University Hamilton, Ontario	Leta Forbes, MD Provincial Head, Systemic Treatment, Cancer Care Ontario Chief and Medical Director of Oncology, Palliative Care and Medical Genetics, Lakeridge Health Oshawa, Ontario
Lynne Kroeger, RN Nurse, Oncology, The Ottawa Hospital Ottawa, Ontario	Martin Chang, MD, PhD, FCAP, FRCPC Pathologist, Mount Sinai Hospital Associate Professor, University of Toronto Toronto, Ontario
Maureen Trudeau, MA, MD, FRCPC Medical Oncologist, Odette Cancer Centre Affliliate Scientist, Sunnybrook Research Institute Professor, University of Toronto Toronto, Ontario	Suzanne Kamel-Reid, BA, MA, PhD, FACMG Molecular Genetics, University Health Network Professor, University of Toronto Toronto, Ontario

Experts Involved in the Original Breast Cancer Pathway Map (2015)

Co-Chair: Andrea Eisen, MD FRCPC Associate Professor, Department of Medicine, University of Toronto Ontario Breast Cancer Lead, Cancer Care Ontario Toronto, Ontario	Co-Chair: Derek Muradali, MD FRCPC Radiologist-in-Chief, Ontario Breast Screening Program, Cancer Care Ontario Toronto, Ontario
Co-Chair: Margaret Forbes, RN(EC) MN CON(C) Nurse Practitioner, Juravinski Cancer Centre Assistant Clinical Professor, School of Nursing, McMaster University Hamilton, Ontario	Alexandra Ginty, MD CCFP(EM) FCFP Regional Primary Care Lead, Mississauga Halton Adjunct Assistant Clinical Professor, McMaster University Hamilton, Ontario
Alice Peter Director, Population Health and Prevention, Cancer Care Ontario Toronto, ON	Amanda Hey, MD CCFP FCFP Regional Primary Care Lead, North East Health Science North Sudbury, Ontario
Anat Kornecki, MD FRCPC Associate Professor, Director of Breast Imaging Program, Department of Medical Imaging, St Joseph Health Care Western University London, Ontario	Angel Arnaout, MD MSc FRCPC FACS Breast Surgical Oncologist and General Surgeon Clinician Investigator, Ottawa Hospital Research Institute Assistant Professor, University of Ottawa Ottawa, Ontario
Angela Leahey, RN BScN MN Professional Lead, Oncology Nursing, Odette Cancer Centre Toronto, Ontario	Brian Pinchuk, MDCM FRCSC General Surgery & Surgical Oncology, North York General Hospital Toronto, Ontario
Carole Mayer, PhD RSW Director of Research and Regional Clinical Lead, Supportive Care Oncology Program, Northeast Cancer Centre Sudbury, Ontario	Frances Wright, MD MEd FRCSC Associate Professor of Surgery, University of Toronto Cross appointed Department of Health Policy, Management and Evaluation, University of Toronto Program Director of General Surgery Oncology Fellowship, University of Toronto Head of Breast and Melanoma Surgery, Louise Temerty Breast Cancer Centre, Sunnybrook Health Sciences Centre Toronto, Ontario
Grace Lee, MHSc MRT(T) CMD Clinical Specialist Radiation Therapist, Radiation Medicine Program, Princess Margaret Cancer Centre Toronto, Ontario	Ian Dayes, MSc MD FRCPC Associate Professor, Department of Oncology, McMaster University Radiation Oncologist, Juravinski Cancer Centre Hamilton, Ontario
Jonathan Sussman, MD CCFP FRCPC MSc Associate Professor, Department of Oncology, McMaster University Director, Supportive Cancer Care Research Unit Chair, Survivorship Advisory Committee, Cancer Care Ontario Juravinski Cancer Centre Hamilton, Ontario	Jory Simpson, MD FRCSC Lecturer, Surgery, University of Toronto Assistant Medical Director CIBC Breast Centre, Surgical Oncology, Division of General Surgery, St. Michael’s Hospital Toronto, Ontario
Justin Lee, MD MSc FRCPC Assistant Professor, Department of Radiation Oncology, University of Toronto Staff Radiation Oncologist, Sunnybrook Odette Cancer Centre Toronto, Ontario	Kelly Metcalfe, RN PhD Professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto Adjunct Scientist, Women’s College Research Institute Toronto, Ontario
Laura Snell, MD MS FRCSC Assistant Professor, Department of Surgery, University of Toronto Plastic and Reconstructive Surgery, Sunnybrook Health Sciences Centre Toronto, Ontario	Leela Elavathil, MD FRCPC Associate Professor, Department of Pathology and Molecular Medicine, McMaster University Anatomical Pathology, Juravinski Hospital Hamilton, Ontario
Linda L. Patient and Family Advisor, Cancer Care Ontario Toronto, Ontario	Marcie Dunn, RN(EC) NP Simcoe Muskoka Regional Cancer Centre Royal Victoria Regional Health Centre Barrie, Ontario
Maria Rugg, MN CHPCN (C) Regional Lead, Psychosocial Oncology and Patient Education; Manager, Supportive Care and Psychosocial Oncology, Carlo Fidani Regional Cancer Program Interim Provincial Lead, Psychosocial Oncology, Cancer Care Ontario Mississauga, Ontario	Marla Ash, MD FCFP Regional Primary Care Lead, Central Toronto, Ontario
Melissa Kaan, BSc, MRT(NM), MBA Group Manager, Diagnostic Assessment Programs, Planning and Regional Programs, Cancer Care Ontario Toronto, Ontario	Mihaela Mates, MD FRCPC Medical Oncologist, KGH Cancer Centre of Southeastern Ontario Kingston, Ontario
Muriel Brackstone, MD MSc PhD(C) FRCSC Surgical Oncologist, London Regional Cancer Program Director, London Breast Care Clinic Director, London Tumour Biobank Assistant Professor of Surgery & Oncology, Western University London, Ontario	Nicole J Look Hong, MD MSc FRCSC Breast and Melanoma Oncology, Division of Surgical Oncology, Sunnybrook Health Sciences Centre Toronto, Ontario
Orit Freedman, MD FRCPC RS McLaughlin Durham Regional Cancer Centre Oshawa, Ontario	Patricia P. Patient and Family Advisor, Cancer Care Ontario Toronto, Ontario
Paul Oh, MD FRCPC Medical Director, Cardiovascular Prevention and Rehabilitation Program Scientist, Toronto Rehabilitation Institute (TRI) Toronto, Ontario	Petrina Causer, MD FRCP Staff Radiologist, North York General Hospital Radiologist, York Radiology Consultants Assistant Professor, Medical Imaging, University of Toronto
Renee Hanrahan, MD FRCSC Assistant Clinical Professor, Department of Surgery, McMaster University General Surgery, Breas Oncology & Reconstructive Surgeon, Royal Victoria Hospital Barrie, Ontario	Sandip SenGupta, MD FRCPC CCPE Professor of Pathology and Oncology, Queen’s University Medical Laboratory Director & Deputy Head, Department of Pathology & Molecular Medicine, Kingston General Hospital & Hotel Dieu Hospital Kingston, Ontario
Sheila-Mae Young, MD Physician Lead, City of Kawartha Family Health Organization Lindsay, Ontario	Sonal Gandhi, MD FRCPC Medical Oncologist, Sunnybrook Odette Cancer Centre Assistant Professor, Department of Medicine, University of Toronto Regional Quality Lead Toronto Central North, Systemic Therapy, Cancer Care Ontario Toronto, Ontario
Sukbinder Dhesy-Thind, MD FRCPC Associate Professor, Department Education Coordinator, Department of Oncology, McMaster University Medical Oncologist, Juravinski Hospital and Cancer Centre Hamilton, Ontario	Talia Mancuso, MSc CCGC Genetic Counsellor & OBSP High Risk Navigator, Cancer Genetics and High Risk Clinic, Sunnybrook Health Sciences Centre Toronto, Ontario
Terri Stuart-McEwan, RN BScN MHS CHE Executive Director Solid Tumour Oncology & Gattuso Rapid Diagnosis Centre, Princess Margaret Cancer Centre Toronto, Ontario	Toni Zhong, MD, FRSCC, MHS Associate Professor, Surgery, University of Toronto Active Staff/ Plastic Surgeon, Plastic & Reconstructive Surgery, University Health Network/Toronto General Hospital Surgical Staff (Cross appointment), Surgery, Mount Sinai Hospital Toronto, Ontario
Vivian Glenns, MDCM FRCPC ABIM Lecturer, Department of Medicine, University of Toronto Active Staff, Medical Oncology & Internal Medicine, North York General Hospital Toronto, Ontario	Whitney Lake, RN Charge Nurse, Cancer and Supportive Care Clinic, Northhumberland Hills Hospital Coburg, Ontario
Xinni Song, MD FRCPC Medical Oncologist, The Ottawa Hospital Cancer Centre Assistant Professor, University of Ottawa Ottawa, Ontario

During prevention care, health behaviour interventions (i.e. exercise, nutrition) should be considered for all individuals of any risk category

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.

Breast Cancer Pathwaymap V318 Printer Friendly Version.pdf

For a better experience, we suggest using Chrome web browser to view this pathway map.

Breast Cancer Pathway Map

We'd like your feedback on this Pathway Map!

Quick Start

Navigating Pathway Maps

Views

Zoom

Quick zoom – node

Full screen

Filters

Mobile

Notifications

Reminders

Loading map

Download, Print or Share

Types of Nodes

Components of a Node

Node icon

Solid or dotted line

Node colour

Data tab

Ellipses

Guidelines tab

Expert consensus tab

Resources tab

Node ID

Connecting the Nodes

Grouped nodes

Line

Line jump

Node jump (“Connected to”)