Moving toward the elimination of cervical cancer: modelling the health and economic benefits of increasing uptake of human papillomavirus vaccines

Background

The human papillomavirus (hpv) is a common sexually transmitted infection and a primary cause of cervical cancer. The Government of Canada has set a target of reaching 90% hpv vaccine coverage among adolescents by 2025. Here, we examine hpv vaccine uptake in school-based immunization programs across Canada and explore how achieving the 90% target could affect the future incidence of cervical cancer, mortality, and health system expenditures in a cohort of Canadian women.

Methods

Data for hpv vaccine uptake in the most recent reported school year available in each jurisdiction were provided in 2017 by jurisdictional school-based immunization programs and were used to estimate a national weighted average of 67%. The OncoSim microsimulation model (version 2.5) was used to compare 3 different levels of hpv vaccine uptake (0%, 67%, 90%) on health and economic outcomes for a hypothetical cohort of all 5- to 10-year-old girls in Canada in 2015.

Results

Vaccine uptake for girls in school-based programs varied from 55.0% to 92.0% in the jurisdictions reviewed. The OncoSim model projects that increasing uptake to 90% from 67% would result in a 23% reduction in cervical cancer incidence rates (to 3.1 cases from 4.0 cases per 100,000, averaged across the lifetime of the cohort) and a 23% decline in the average annual mortality rate (to 1.0 deaths from 1.3 deaths per 100,000). Finally, the model projects that the health system will incur a cost of $9 million (1% increase) during the lifetime of the cohort if uptake is increased to 90% from 67%. Costs are discounted (1.5%) and expressed in 2016 Canadian dollars. Costs reflect the payer perspective.

Conclusions

Our model shows that increasing hpv vaccine uptake to 90% from current levels for girls in school-based immunization programs could result in substantial reductions in the future incidence and mortality rates for cervical cancer in Canada.

Palliative care for cancer patients near end of life in acute-care hospitals across Canada: a look at the inpatient palliative care code

Hospitals play an important role in the care of patients with advanced cancer: nearly half of all cancer deaths occur in acute-care settings. The need for increasing access to palliative care and related support services for patients with cancer in acute-care hospitals is therefore growing. Here, we examine how often and how early in their illness patients with cancer might be receiving palliative care services in the 2 years before their death in an acute-care hospital in Canada. The palliative care code from inpatient administrative databases was used as a proxy for receiving, or being referred for, palliative care. Currently, the palliative care code is the only data element routinely collected from patient charts that allows for the tracking of palliative care activity at a pan-Canadian level. Our findings suggest that most patients with cancer who die in an acute-care hospital receive a palliative designation; however, many of those patients are identified as palliative only in their final admission before death. Of the patients who received a palliative designation before their final admission, nearly half were identified as palliative less than 2 months before death. Findings signal that delivery of services within and between jurisdictions is not consistent, that the palliative care needs of some patients are being missed by physicians, and that palliative care is still largely seen as end-of-life care and is not recognized as an integral component of cancer care. Measuring the provision of system-wide palliative care remains a challenge because comprehensive national data about palliative care are not currently reported from all sectors. To advance measurement and reporting of palliative care in Canada, attention should be focused on collecting comparable data from regional and provincial palliative care programs that individually capture data about palliative care delivery in all health care sectors.

Understanding the Experiences of Cancer Patients as They Transition From Treatment to Primary and Community Care: A Pan-Canadian Study of Over 13,000 Cancer Survivors

Background: Being diagnosed with cancer can be overwhelming, with many physical and emotional challenges. As needs of survivors shift from disease management to recovery, the adjustment is often not seamless. Ideally, a health care system is integrated and responsive to the needs of survivors, however, when cancer treatment is complete, they often face lingering concerns. Limited patient-reported data were available in Canada on experiences and barriers survivors face posttreatment. Aim: The Experiences of Cancer Patients in Transition study is the first national survey gathering data from cancer survivors in Canada as they transition from cancer care to the broader health care system. Methods: A survey was developed in consultation with patients/survivors, health care providers and researchers to address experiences related to physical, emotional, informational and practical needs. Ethics approvals were obtained and 10 provinces participated. Cancer survivors expected to have completed treatment within 1-3 years were identified from provincial cancer registries. Included were those aged 30+ at diagnosis of nonmetastatic breast, colorectal, prostate, melanoma or hematologic cancer; or aged 15-29 at diagnosis of any nonmetastatic cancer or metastatic testicular cancer. Despite the intention of the sampling, the final sample included some survivors diagnosed with a site other than the target sites, and some whose time since treatment was outside 1-3 years. All respondents are included in this analysis. Results are not weighted to represent the true distribution of cancer survivors. Results: From a total survey population of 40,790 Canadian cancer survivors, 33% completed the survey. The respondents were 48% male, 51% female; 2.5% were under 30 years old, 60% were 65+. 68% of respondents reported challenging periods posttreatment, with 48% of these saying that the first 6 months to 1 year were most challenging. Cancer survivors continued to live with side-effects: 87% reported physical challenges; 78% reported emotional challenges; 45% reported practical challenges. The most prevalent concerns were fatigue (68%), anxiety about cancer returning (68%) and returning to work/school (23%). Less than half of those with emotional or practical concerns received useful information (42% and 46%, respectively). 42% of respondents could not get help to address their most difficult concern. Of those who could get help, 10.7% waited a year or more. Conclusion: The results provide insight into the nature of challenges cancer survivors face, as well as needed supports and barriers faced in accessing them. There is a clear need for health systems to ensure a seamless patient experience throughout the cancer journey, for instance, through development and adoption of resources to help health care providers and their patients identify and address challenges from diagnosis through to survivorship.

Geographic Variation in Colorectal Cancer Incidence and the Disparities in the Prevalence of Modifiable Risk Factors Across Canada

Background: Colorectal cancer is the third most common cancer worldwide. There is wide geographic variation in incidence with rates varying ten-fold between high- and low-income countries. This heavy burden can be mitigated given previous research has estimated that nearly half of all colorectal cancer cases could have been prevented through healthier diets and physically active lifestyles. In Canada, there is considerable geographic variation in age-adjusted incidence rates for colorectal cancer between jurisdictions, greater than that seen for many other cancers. These wide variations likely reflect differences in the prevalence of risk factors across provinces and territories. Aim: To describe the extent of the variation in colorectal cancer incidence rates across Canada and the disparities in the prevalence of modifiable risk factors across jurisdictions known to contribute to this burden. Methods: Colorectal cancer incident cases were obtained from the Canadian Cancer Registry; 2014 was used for provinces (except Quebec where 2010 was the most recent year available) and years 2012 to 2014 were combined to achieve more stable rates for the territories, which are much smaller in population. Data on four known modifiable risk factors for colorectal cancer (excess weight, physical inactivity, alcohol intake and low fruit and vegetable consumption) were obtained from the 2015-16 combined Canadian Community Health Survey. Results: Findings suggest that there is a north-south and east-west gradient in colorectal cancer modifiable risk factors in Canada. For instance, the percentage of adults with excess body weight ranged from 56.8% in British Columbia (west) to 73.1% in New Brunswick (east) and the percentage of adults not meeting physical activity guidelines ranged from 31.8% in Yukon (north) to 50.3% in New Brunswick (east). Generally, this pattern also reflects colorectal cancer incidence rates. The highest prevalence of modifiable risk factors and rates of colorectal cancer are typically in the northern (territories) and eastern provinces of Canada. Conclusion: The global burden of colorectal cancer is expected to increase by nearly 60% by 2030; therefore, targeted interventions are needed to ensure there is not a widening gap in colorectal cancer burden worldwide. Based on current knowledge, the most effective approaches to reduce the burden of colorectal cancer include: 1) adopting public policies that make healthy choices easier and create healthier environments where people live, work and play, and 2) continuing emphasis on screening and early detection. Strategic approaches to addressing modifiable risk factors, as well as mechanisms for detecting colorectal cancer before it develops, have the potential to translate into positive effects on population health and less people developing and dying from cancer.

The north-south and east-west gradient in colorectal cancer risk: a look at the distribution of modifiable risk factors and incidence across Canada

Colorectal cancer (crc) is the 2nd most common cancer in Canada and the 2nd leading cause of cancer death. That heavy burden can be mitigated given the preventability of crc through lifestyle changes and screening. Here, we describe the extent of the variation in crc incidence rates across Canada and the disparities, by jurisdiction, in the prevalence of modifiable risk factors known to contribute to the crc burden. Findings suggest that there is a north-south and east-west gradient in crc modifiable risk factors, including excess weight, physical inactivity, excessive alcohol consumption, and low fruit and vegetable consumption, with the highest prevalence of risk factors typically found in the territories and Atlantic provinces. In general, that pattern reflects the crc incidence rates seen across Canada. Given the substantial interjurisdictional variation, more work is needed to increase prevention efforts, including promoting a healthier diet and lifestyle, especially in jurisdictions facing disproportionately higher burdens of crc. Based on current knowledge, the most effective approaches to reduce the burden of crc include adopting public policies that create healthier environments in which people live, work, learn, and play; making healthy choices easier; and continuing to emphasize screening and early detection. Strategic approaches to modifiable risk factors and mechanisms for early cancer detection have the potential to translate into positive effects for population health and fewer Canadians developing and dying from cancer.

Measuring patient-reported outcomes to improve cancer care in Canada: an analysis of provincial survey data

Patient-reported outcomes measures (proms) are an important component of the shift from disease-centred to person-centred care. In oncology, proms describe the effects of cancer and its treatment from the patient perspective and ideally enable patients to communicate to their providers the physical symptoms and psychosocial concerns that are most relevant to them. The Edmonton Symptom Assessment System-revised (esas-r) is a commonly used and validated tool in Canada to assess symptoms related to cancer. Here, we describe the extent to which patient-reported outcome programs have been implemented in Canada and the severity of symptoms causing distress for patients with cancer. As of April 2017, 8 of 10 provinces had implemented the esas-r to assess patient-reported outcomes. Data capture methods, the proportion of cancer treatment sites that have implemented the esas-r, and the time and frequency of screening vary from province to province. From October 2016 to March 2017 in the 8 reporting provinces, 88.0% of cancer patients were screened for symptoms. Of patients who reported having symptoms, 44.3% reported depression, with 15.5% reporting moderate-to-high levels; 50.0% reported pain, with 18.6% reporting moderate-to-high levels; 56.2% reported anxiety, with 20.4% reporting moderate-to-high levels; and 75.1% reported fatigue, with 34.4% reporting moderate-to-high levels. There are some notable areas in which the implementation of proms could be improved in Canada. Findings point to a need to increase the number of cancer treatment sites that screen all patients for symptoms; to standardize when and how frequently patients are screened across the country; to screen patients for symptoms during all phases of their cancer journey, not just during treatment; and to assess whether giving cancer care providers real-time patient-reported outcomes data has led to appropriate interventions that reduce the symptom burden and improve patient outcomes. Continued measurement and reporting at the system level will allow for a better understanding of progress in proms activity over time and of the areas in which targeted quality improvement efforts could ensure that patient symptoms and concerns are being addressed.

The experience of patients with cancer during diagnosis and treatment planning: a descriptive study of Canadian survey results

BACKGROUND

Communication with health care providers during diagnosis and treatment planning is of special importance because it can influence a patient's emotional state, attitude, and decisions about their care. Qualitative evidence suggests that some patients experience poor communication with health care providers and have negative experiences when receiving their cancer diagnosis. Here, we use survey data from 8 provinces to present findings about the experiences of Canadian patients, specifically with respect to patient-provider communication, during the diagnosis and treatment planning phases of their cancer care.

METHODS

Data from the Ambulatory Oncology Patient Satisfaction Survey, representing 17,809 survey respondents, were obtained for the study.

RESULTS

Most respondents (92%) felt that their care provider told them of their cancer diagnosis in a sensitive manner. Most respondents (95%) also felt that they were provided with enough information about their planned cancer treatment. In contrast, more than half the respondents who had emotional concerns upon diagnosis (56%) were not referred to services that could help with their anxieties and fears. Also, 18% of respondents reported that they were not given the opportunity to discuss treatment options with a care provider, and 17% reported that their care providers did not consider their travel concerns while planning for treatment.

CONCLUSIONS

Measuring the patient experience allows for an understanding of how well the cancer control system is addressing the physical, emotional, and practical needs of patients during diagnosis and treatment planning. Although results suggest high levels of patient satisfaction with some aspects of care, quality improvement efforts are still needed to provide person-centred care.

How different is cancer control across Canada? Comparing performance indicators for prevention, screening, diagnosis, and treatment

Meaningful performance measures are an important part of the toolkit for health system improvement. The Canadian Partnership Against Cancer has been reporting on pan-Canadian cancer system performance indicators since 2009-work that has led to the availability of standardized measures that can help to shed light on the extent of variation and opportunities for quality improvement across the country. Those measures include a core set of system indicators ranging from prevention and screening, through diagnosis and treatment, to survivorship and end-of-life care. Key indicators were calculated and graphed, showing the range from worst to best result for the provinces and territories included in the data. There were often significant differences in cancer system performance between provinces and territories. For example, smoking prevalence rates ranged from 14% to 62%. The 90th percentile wait times from an abnormal breast screen to resolution (without biopsy) ranged from 4 weeks to 8 weeks. The percentage of breast cancer resections that used breast-conserving surgery rather than mastectomy ranged from 38% to 75%. Clinical trial participation rates for adults ranged from 0.2% to 6.6%. Variations in performance indicators between Canadian jurisdictions suggest potential differences in the planning and delivery of cancer control services and in clinical practice patterns and patient outcomes. Understanding sources of variation can help to identify opportunities for improvements in the quality and outcomes of cancer control service delivery in each province and territory.

Smoking behaviours of current cancer patients in Canada

Evidence shows that continued smoking by cancer patients leads to adverse treatment outcomes and affects survival. Smoking diminishes treatment effectiveness, exacerbates side effects, and increases the risk of developing additional complications. Patients who continue to smoke also have a higher risk of developing a second primary cancer or experiencing a cancer recurrence, both of which ultimately contribute to poorer quality of life and poorer survival. Here, we present a snapshot of smoking behaviours of current cancer patients compared with the non-cancer patient population in Canada. Minimal differences in smoking behaviours were noted between current cancer patients and the rest of the population. Based on 2011-2014 data from the Canadian Community Health Survey, 1 in 5 current cancer patients (20.1%) reported daily or occasional smoking. That estimate is comparable to findings in the surveyed non-cancer patient population, of whom 19.3% reported smoking daily or occasionally. Slightly more male cancer patients than female cancer patients identified as current smokers. A similar distribution was observed in the non-cancer patient population. There is an urgent need across Canada to better support cancer patients in quitting smoking. As a result, the quality of patient care will improve, as will cancer treatment and survival outcomes, and quality of life for these patients.

A first look at relative survival by stage for colorectal and lung cancers in Canada

Monitoring and reporting on cancer survival provides a mechanism for understanding the effectiveness of Canada's cancer care system. Although 5-year relative survival for colorectal cancer and lung cancer has been previously reported, only recently has pan-Canadian relative survival by stage been analyzed using comprehensive registry data. This article presents a first look at 2-year relative survival by stage for colorectal and lung cancer across 9 provinces. As expected, 2-year age-standardized relative survival ratios (arsrs) for colorectal cancer and lung cancer were higher when the cancer was diagnosed at an earlier stage. The arsrs for stage i colorectal cancer ranged from 92.2% in Nova Scotia [95% confidence interval (ci): 88.6% to 95.1%] to 98.4% in British Columbia (95% ci: 96.2% to 99.3%); for stage iv, they ranged from 24.3% in Prince Edward Island (95% ci: 15.2% to 34.4%) to 38.8% in New Brunswick (95% ci: 33.3% to 44.2%). The arsrs for stage i lung cancer ranged from 66.5% in Prince Edward Island (95% ci: 54.5% to 76.5%) to 84.8% in Ontario (95% ci: 83.5% to 86.0%). By contrast, arsrs for stage iv lung cancer ranged from 7.6% in Manitoba (95% ci: 5.8% to 9.7%) to 13.2% in British Columbia (95% ci: 11.8% to 14.6%). The available stage data are too recent to allow for meaningful comparisons between provinces, but over time, analyzing relative survival by stage can provide further insight into the known differences in 5-year relative survival. As the data mature, they will enable an assessment of the extent to which interprovincial differences in relative survival are influenced by differences in stage distribution or treatment effectiveness (or both), permitting targeted measures to improve population health outcomes to be implemented.