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.

Discrepancies between Canadian cancer research funding and site-specific cancer burden: a spotlight on ten disease sites

Background

Cancer research is essential in evaluating the safety and effectiveness of emerging cancer treatments, which in turn can lead to ground-breaking advancements in cancer care. Given limited research funding, allocating resources in alignment with societal burden is essential. However, evidence shows that such alignment does not typically occur. The objective of the present study was to provide an updated overview of site-specific cancer research investment in Canada and to explore potential discrepancies between the site-specific burden and the level of research investment.

Methods

The 10 cancer sites with the highest mortality in 2015-which included brain, female breast, colorectal, leukemia, lung, non-Hodgkin lymphoma, ovary, pancreas, prostate, and uterus-were selected for the analysis. Information about site-specific research investment and cancer burden (raw incidence and mortality) was obtained from the Canadian Cancer Research Survey and Statistics Canada's cansim (the Canadian Socio-Economic Information Management System) respectively. The ratio of site-specific research investment to site-specific burden was used as an indicator of overfunding (ratio > 1) or underfunding (ratio < 1).

Results

The 3 cancer sites with the highest research investments were leukemia, prostate, and breast, which together represented 51.3% of 2015 cancer research funding. Conversely, the 3 cancer sites with the lowest investments were uterus, pancreas, and ovary, which together represented 7.8% of 2015 research funding. Relative to site-specific cancer burden, the lung, uterus, and colorectal sites were consistently the most underfunded.

Conclusions

Observed discrepancies between cancer burden and research investment indicate that some cancer sites (such as lung, colorectal, and uterus) seem to be underfunded when site-specific incidence and mortality are taken into consideration.

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.

Acute-Care Hospital Use Patterns Near End-of-Life for Cancer Patients Who Die in Hospital in Canada

Background: Acute-care hospitals have a role in managing the needs of people with cancer when they are at the end-of-life; however, overutilization of hospital care at the end-of-life results in poorer quality of life and can worsen the patient's experience. Early integration of comprehensive palliative care can greatly reduce unplanned visits to the emergency department, reduce avoidable admissions to hospital, shorten hospital stays, and increase the number of home deaths as well as improve the quality of life of patients with advanced cancer. Aim: To describe the current landscape of acute-care hospital utilization near the end-of-life across Canada and indirectly examine access to palliative care in cancer patients who die in hospital. Methods: Data were obtained from the Canadian Institute for Health Information. The analysis was restricted to adults aged 18+ who died in an acute care hospital in 2014/15 and 2015/16 for nine provinces and three territories. The Discharge Abstract Database was used to extract acute-care cancer death abstracts. Data on intensive care unit (ICU) admissions includes only facilities that report ICU data. Results: Acute care utilization at end-of-life remains commonplace. In Canada (excluding Québec), 43% (48,987) of deaths from cancer occurred in acute-care hospitals, with 70% admitted through the emergency department (ED). In the last six months of life, cancer patients dying in hospital had a median cumulative length of stay ranging from 17 to 25 days, depending on the province. Between 18.1% and 32.8% of patients experienced two or more admissions to the hospital in the last month of life. The proportion of cancer patients admitted to the ICU in the last 14 days of life ranged from 6.4% to 15.1%. Patient demographics (age, sex, place of residence) and clinical factors (cancer type) were often predictors of hospital utilization at end-of-life and likely point to inequities in access to palliative and end-of-life care. Conclusion: Despite previous patient surveys indicating that patients would prefer to receive care and spend their finals days at home or in a hospice, there appears to be overuse of and overreliance on acute care hospital services near the end-of-life in Canada. The high rates of hospital deaths and admissions through the ED at the end-of-life for cancer patients may signal a lack of planning for impeding death and inadequate availability of or access to community- and home-based palliative and end-of-life care services. Acute care hospitals may have a role in managing the health care needs of people affected by cancer; however, end-of-life care should be an option in other settings that align with patient preferences. Standards or practice guidelines to identify, assess and refer patients to palliative care services earlier in their cancer journey should be developed and implemented to ensure optimal quality of life.

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.

Acute care hospitalization near the end of life for cancer patients who die in hospital in Canada

Acute care hospitals have a role in managing the health care needs of people affected by cancer when they are at the end of life. However, there is a need to provide end-of-life care in other settings, including at home or in hospice, when such settings are more appropriate. Using data from 9 provinces, we examined indicators that describe the current landscape of acute care hospital use at the end of life for patients who died of cancer in hospital in Canada. Interprovincial variation was observed in acute care hospital deaths, length of stay in hospital, readmission to hospital, and intensive care unit use at the end of life. High rates of acute care hospital use near the end of life might suggest that community and home-based end-of-life care might not be suiting patient needs.

Choosing wisely in cancer control across Canada-a set of baseline indicators

Value-based care, which balances high-quality care with the most efficient use of resources, has been considered the next frontier in cancer care and a means to maintain health system sustainability. Created to promote value-based care, Choosing Wisely Canada-modelled after Choosing Wisely in the United States-is a national clinician-driven campaign to identify unnecessary or harmful services that are frequently used in Canada. As part of the campaign, national medical societies have developed recommendations for tests and treatments that clinicians and patients should question. Here, we present baseline indicator findings about current practice patterns associated with 7 cancer-related recommendations from Choosing Wisely Canada and about the effects of those practices on patients and the health care system. Indicator findings point to substantial variations in cancer system performance between Canadian jurisdictions, most notably for breast cancer screening practices, treatment practices for men with low-risk localized prostate cancer, and radiation therapy practices for early-stage breast cancer and bone metastases. Extrapolating indicator findings to the entire country, it was estimated that 740,000 breast and cervical cancer screening tests were performed outside of the recommended age ranges, and within 1 year of diagnosis, 17,000 patients received treatments that could be low-value. A 15% reduction in the use of the 7 screening and treatment practices examined could lead to multiple benefits for patients and the health care system: 9000 false-positive results and 3000 treatments and related side effects could be avoided, and 4500 hours of linear accelerator capacity could be freed up each year. Interjurisdictional performance variations suggest potential differences in clinical practice patterns in the planning and delivery of cancer control services, and in some cases, in disease management outcomes. Although the cancer screening and treatment practices described might be unnecessary for some patients, it is important to realize that they could, in fact, be necessary for other patients. Further research into appropriate rates of use could help to determine how much cancer care represents overuse of practices that are not supported by evidence or underuse of practices that are supported by evidence.

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.

Use of low-value radiotherapy practices in Canada: an analysis of provincial cancer registry data

BACKGROUND

As part of Choosing Wisely Canada (a national campaign to encourage patient-provider conversations about unnecessary medical tests, treatments, and procedures), a list of ten oncology practices that could be low-value in some instances was developed. Of those practices, two were specific to radiation therapy (rt): conventional fractionation as part of breast-conserving therapy (bct) for women with early-stage breast cancer, and multifraction radiation for palliation of uncomplicated painful bone metastases. Here, we report baseline findings for the current utilization rates of those two rt practices in Canada.

RESULTS

The use of conventional fractionation as part of bct varied substantially from province to province. Of women 50 years of age and older, between 8.8% (Alberta) and 36.5% (Saskatchewan) received radiation in 25 fractions (excluding boost irradiation) as part of bct. The use of hypofractionated rt (that is, 16 fractions excluding boost irradiation)-a preferred approach for many patients-was more common in all 6 reporting provinces, ranging from 43.2% in Saskatchewan to 94.7% in Prince Edward Island. The use of multifraction rt for palliation of bone metastases also varied from province to province, ranging from 40.3% in British Columbia to 69.0% in Saskatchewan. The most common number of fractions delivered to bone metastases was 1, at 50.2%; the second most common numbers were 2-5 fractions, at 41.7%.

CONCLUSIONS

Understanding variation in the use of potentially low-value rt practices can help to inform future strategies to promote higher-value care, which balances high-quality care with the efficient use of limited system resources. Further work is needed to understand the factors contributing to the interprovincial variation observed and to develop benchmarks for the appropriate rate of use of these rt practices.

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.

Patterns of care and treatment trends for Canadian men with localized low-risk prostate cancer: an analysis of provincial cancer registry data

BACKGROUND

Many prostate cancers (pcas) are indolent and, if left untreated, are unlikely to cause death or morbidity in a man's lifetime. As a result of testing for prostate-specific antigen, more such cases are being identified, leading to concerns about "overdiagnosis" and consequent overtreatment of pca. To mitigate the risks associated with overtreatment (that is, invasive therapies that might cause harm to the patient without tangible benefit), approaches such as active surveillance are now preferred for many men with low-risk localized pca (specifically, T1/2a, prostate-specific antigen ≤ 10 ng/mL, and Gleason score ≤ 6). Here, we report on patterns of care and treatment trends for men with localized low-risk pca.

RESULTS

The provinces varied substantially with respect to the types of primary treatment received by men with localized low-risk pca. From 2010 to 2013, many men had no record of surgical or radiation treatment within 1 year of diagnosis-a proxy for active surveillance; the proportion ranged from 53.3% in Nova Scotia to 80.8% in New Brunswick. Among men who did receive primary treatment, the use of radical prostatectomy ranged from 12.0% in New Brunswick to 35.9% in Nova Scotia. The use of radiation therapy (external-beam radiation therapy or brachytherapy) ranged from 4.1% in Newfoundland and Labrador to 17.6% in Alberta. Treatment trends over time suggest an increase in the use of active surveillance. The proportion of men with low-risk pca and no record of surgical or radiation treatment rose to 69.9% in 2013 from 46.1% in 2010 for all provinces combined.

CONCLUSIONS

The provinces varied substantially with respect to patterns of care for localized low-risk pca. Treatment trends over time suggest an increasing use of active surveillance. Those findings can further the discussion about the complex care associated with pca and identify opportunities for improvement in clinical practice.

Treatment patterns among Canadian men diagnosed with localized low-risk prostate cancer

In general, guideline-recommended treatment options for men with low-risk prostate cancer (pca) include active surveillance, radical prostatectomy, and external-beam radiation therapy or brachytherapy. Because of the concern about overdiagnosis and consequent overtreatment of pca, patients with low-risk disease are increasingly being managed with active surveillance. Using data from six provincial cancer registries, we examined treatment patterns within a year of a diagnosis of localized low-risk pca, and we assessed differences by age. Of patients diagnosed in 2010 in four of the six reporting provinces, most received surgery or radiation therapy within 1 year of diagnosis. Depending on the province, either surgery or radiation therapy was the most commonly used primary treatment. In the other two provinces, most patients had no record of treatment within a year of diagnosis. Examining treatment patterns by age demonstrated a lesser likelihood of receiving surgery or radiation therapy within 1 year of diagnosis among men more than 75 years of age than among men 75 years of age or younger (no record of treatment in 69.1% and 46.3% respectively). In conclusion, we observed interprovincial and age-specific variations in the patterns of care for men with low-risk pca. The findings presented in this report are intended to identify opportunities for improvement in clinical practice that could lead to improved care and experience.

Wait times for prostate cancer treatment and patient perceptions of care in Canada: a mixed-methods report

BACKGROUND

Access to cancer care is a significant concern for Canadians. Prolonged delays between cancer diagnosis and treatment have been associated with anxiety, stress, and perceived powerlessness for patients and their family members. Longer wait times can also be associated with poorer prognosis, although the evidence is inconclusive. Here, we report national wait times for radiation therapy and surgery for localized prostate cancer (pca) and the effect of wait time on patient perceptions of their care.

RESULTS

Treatment wait times showed substantial interprovincial variation. The longest 90th percentile wait times for radiation therapy and surgery were, respectively, 40 days and 105 days. In all provinces, waits for radiation therapy were longer for pca patients than for patients with breast, colorectal, or lung cancer. In the focus groups and interviews conducted with 47 men treated for pca, many participants did not perceive that wait times for treatment were prolonged. Those who experienced delays between diagnosis and treatment voiced issues with a lack of communication about when they would receive treatment and a lack of support or information to make an informed decision about treatment. Minimizing treatment delays was an aspect of the cancer journey that participants would like to change because of the stress it caused.

CONCLUSIONS

Although wait time statistics are useful, a review of cancer control in Canada cannot be considered complete unless an effort is made to give voice to the experiences of individuals with cancer. The findings presented here are intended to provide a snapshot of national care delivery for localized pca and to identify opportunities for improvement in clinical practice.

Rectal cancer resection and circumferential margin rates in Canada: a population-based study

INTRODUCTION [...]

Use of pet in the management of non-small-cell lung cancer in Canada

Positron-emission tomography (pet) has emerged as an effective imaging method for diagnosing, staging, [...]

Adjuvant and neoadjuvant treatment for rectal cancer, colon cancer, and non-small-cell lung cancer in older patients

Evidence-based treatment guidelines exist to improve quality of care for patients and are based on randomized trials that show evidence of benefit.[...]

Two indicators of hospital resource efficiency in cancer care

Acute inpatient hospital stays represent a major portion of cancer care costs. [...]

Geographic disparities in surgery for breast and rectal cancer in Canada

Equitable access to appropriate cancer treatment is fundamental for achieving universal, high-quality cancer care [...]

Examining Cancer-Risk Profiles for the Largest Metropolitan Areas across Canada

Because health behaviours can be influenced at many different levels, there is value in examining differences in risk factors and health behaviours between the largest cities in Canada. [...]

Provincial rates and time trends in pancreatic cancer outcomes

Pancreatic cancer, often called the “silent killer,” is the twelfth most common cancer in Canada, with an estimated 4600 new cases in 2012. [...]

Measuring concordance with guidelines for the diagnosis and treatment of colon cancer

Colorectal cancer is the second leading cause of cancer death and the third most commonly diagnosed cancer in Canada, with an estimated 9200 deaths and 23,300 new cases in 2012. [...]

Examining the use of salpingectomy with hysterectomy in Canada

Ovarian cancer is the fifth leading cause of cancer death among women in Canada, with an estimated 1750 deaths and 2600 new cases occurring in 20121.[...]

New chart review data validate administrative data-based indicator for guideline-recommended treatment of locally advanced non-small-cell lung cancer and shed light on reasons for non-referral and non-treatment

The 2012 Cancer System Performance Report is the 4th annual report on the Canadian cancer control system produced by the System Performance initiative at the Canadian Partnership Against Cancer, in collaboration with its provincial and national partners. [...]

Indicator measures er/pr and her2 testing among women with invasive breast cancer

As part of its System Performance initiative, the Canadian Partnership Against Cancer released Breast Cancer Control in Canada: A System Performance Special Focus Report in September 2012, presenting a broad range of system performance indicators that measure breast cancer control across the continuum. [...]

A retrospective chart review validates indicator results and provides insight into reasons for non-concordance with evidence-based guidelines

As part of the system performance initiative of the Canadian Partnership Against Cancer, indicators measuring treatment practice patterns across the country relative to evidence-based guidelines were first published in 2010 and are updated annually. Among the treatment indicators examined is the percentage of resected stage ii and iii rectal cancer patients receiving neoadjuvant (preoperative) radiation therapy (RT), the treatment approach recommended for locally advanced rectal cancer

Recently published indicators allow for comparison of radiation treatment rates relative to evidence-based guidelines for rectal cancer

The system performance initiative of the Canadian Partnership Against Cancer is the first pan-Canadian report to offer indicators for measuring treatment practice patterns by province and for comparing practice with current guidelines [...]

Conditional survival in Canada: adjusting patient prognosis over time

Five-year relative survival statistics are often used to measure cancer control across jurisdictions, and international comparisons such as the CONCORD or EUROCARE studies often point to substantial survival differences across participating countries [...]

Randomized Double-Blind Placebo-Controlled Clinical Trial Testing Ketorolac Tromethamine for Reducing the Pain and Discomfort Experienced during Mammography

OBJECTIVE: To study the possibility of reducing the pain and discomfort experienced during mammography, by means of using an analgesic as premedication. PATIENTS AND METHODS: This was a randomized double-blind placebo-controlled clinical trial testing ketorolac tromethamine for reducing the pain and discomfort experienced during mammography. There were 308 participants in the study, who all signed a free and informed consent statement. Of these, 153 patients (group 1) received 10 mg of ketorolac tromethamine orally and 155 (group 2) received placebo orally, 60 minutes before undergoing mammographic examination. After taking the medication and while waiting to undergo the procedure, the patients themselves filled out a form asking about personal data and possible factors relating to pain and discomfort while undergoing mammography. After the examination, the patients subjectively assessed the pain and discomfort experienced during the examination using a visual analog scale (VAS) graded from zero to ten. The statistical analysis consisted of characterizing the groups using absolute and relative frequencies and comparing the dependent and independent variables between the groups using the chi-squared association test, with Yates correction when necessary. RESULTS: The mean VAS pain level presented by the patients was 3.36 and the median was 2.90. It was observed that 51 (16.6%) of the patients did not present any pain, 106 (34.4%) presented mild pain, 94 (30.5%) moderate pain, 40 (13%) severe pain and 17 (5.5%) intolerable pain. With regard to discomfort, 68 (54.9%) reported tolerable discomfort, 63 (20.5%) a lot of discomfort and 8 (2.6%) intolerable discomfort. Among the factors related to pain, only the presence of previous mastalgia was significant (p &lt; 0.05). Somnolence was the adverse event most present: 2.6 and 5.8% in the ketorolac and placebo groups, respectively. CONCLUSIONS: The use of 10 mg of ketorolac tromethamine did not have any influence regarding reduction of the pain and discomfort experienced by the patients during mammography, when compared with placebo. Among the factors studied, the only one associated with greater possibility of pain and discomfort while undergoing mammography was a history of mastalgia.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4014.

Assessing compliance with practice treatment guidelines by treatment centers and the reasons for noncompliance

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Background: Cancer Care Ontario (CCO) is the chief advisor on cancer care to the government of Ontario, a province with a population of more than 12 million. One of the many roles of CCO is to develop evidence based consensus-derived treatment practice guidelines for all major cancer types, through its Program in Evidence-based Care (PEBC). To determine province-wide compliance with these guidelines, a pilot project assessed the proportion of patients with stage III colon cancer (CC) treated in concordance with the corresponding treatment guideline. Initial results are made available to the regional cancer centers (RCC) in the province and to the public through web based Cancer Systems Quality Index (CSQI, http://www.cancercare.on.ca/qualityindex2007/ ). Methods: The guideline (http://www.cancercare.on.ca/pdf/pebc2–29s.pdf) states that patients with resected stage 3 CC will have adjuvant fluoropyrimidine-based chemotherapy within eight weeks of resection. Patients at each of 11 RCC who presented in 2007/2008 with stage III CC and the proportion treated according to the guidelines were identified. Individual charts of those patients who were not treated according to guideline were reviewed to determine the reason. Results: Across eight RCC with complete chart results to date 376 patients with stage 3 CC were identified, 244 (65%, range 47% to 72%) treated in concordance with the guideline, including 13% treated with capecitabine and 6% on clinical trials. The reasons for non-concordance of the 132 remaining cases were: age and co morbid conditions 48 (13%), patient choice 36 (10%), referred for treatment outside the RCC system 16 (4%), stage incorrect and other 32 (9%). Conclusions: Adjuvant chemotherapy treatment of stage III CC at the RCC across the Province of Ontario was concordant with the guideline in the majority of patients, and appropriate clinical reasons for non-compliance were identified. Data from all 11 RCC will be presented along with concordance within the eight-week time frame stated in the guideline . Refinement in province-wide data collection and interpretation will allow results from this pilot to be expanded to other PEBC practice guidelines for dissemination through the CSQI.

No significant financial relationships to disclose.