Download - Ontario Cancer Plan
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I want to live... Im still young, many peoplein my family have lived to be 100. I want to
be around to watch my grandchildren growup. Screening saved my life, I tell everybodyto talk to their doctor about screening.
Eugnia Prountzopoulos, colorectal cancer survivor
ONTA RIO C A NC ER PLA N 2011-2015
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Cancer is a process that begins with a small series o genetic changes with-in cells. It culminates in a lie-changing journey or patients involving amily, riends,
healthcare proessionals, and ultimately, the entire healthcare system.
In Ontario, someone is diagnosed with cancer every eight minutes. With an aging
population and increasing lie expectancy, more than 400,000 Ontarians will be
living with or have survived cancer by 2015. Cancer continues to be the number one
cause o premature death in Ontario.
Cancer Care Ontario (CCO) is the provincial governments cancer advisor. We are the
agency responsible or continually improving services to ensure that patients receive
the right care, at the right time, rom the right person, in the right place, at every step
o their journey with cancer.
This is the third Cancer Plan we have developed since 2005. It is a roadmap or how
CCO, healthcare proessionals and organizations, cancer experts and the provincial
government will work together to reduce the risk o Ontarians developing cancer whileimproving the quality o care and treatment or current and uture patients.
This Cancer Plan is centred on people and patients in prevention, screening, diagnosis,
treatment, ollow-up, and palliative care. It is driven by a commitment to quality and
guided by our vision o providing Ontarians with the best cancer system in the world.
01 Message rom Terrence Sullivan
03 Cancer: Impact and progress
07 Driving quality and accountability in Ontarios cancer system
11 Our record so ar: progress under the rst two cancer plans
13 About this Plan
17 Strategic Priorities
19 Strategic Priority 1: Develop and implement a ocused approach to cancer risk reduction
25 Strategic Priority 2: Implement integrated cancer screening
29 Strategic Priority 3: Continue to improve patient outcomes through accessible, sae, high quality care
37 Strategic Priority 4: Continue to assess and improve the patient experience
42 Strategic Priority 5: Develop and implement innovative models o care delivery
45 Strategic Priority 6: Expand our eorts in personalized medicine
49 Enabling success
59 In summary
60 Investment strategy
Better cancer services every step of the way
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I am proud to present the 2011-2015 Ontario Cancer Plan.
This plan brings together the best ideas o our partners the Ministry
o Health and Long-Term Care, clinical and management leaders,
Regional Cancer Programs, Local Health Integration Networks, amily
doctors, the Canadian Cancer Society, the Ontario Institute or Cancer
Research, patients and patient groups on how to position the cancer
system to meet the challenge o cancer over the next our years.
It continues the transormation o cancer services across Ontario, in-
cluding the development o new, patient-centred models o care deliv-
ery. It is driven by a commitment to quality in prevention, screening,
diagnosis, treatment, ollow-up and palliative care as the most eective
way to manage cancer. It will pay o in delivering value or money,
managing long-term cost growth, improving outcomes and increasing
patient satisaction.
Building on a strong oundation
We have laid a solid oundation since Canadas rst provincial cancer
plan was developed in Ontario in 2005. Prevention and early detection
strategies are proving successul in saving lives. More patients are living
longer with cancer. Wait times have been reduced. Clear standards or
care are in place in every Regional Cancer Program in the province.
Ontarians no longer need to travel out o the province to nd radiation
treatment. More people are surviving cancer. In short, we have averted
the pending crisis in cancer care that Ontario aced at the beginning othe last decade.
But as Ontarios population grows and ages, the cancer system aces
new challenges. The number o people diagnosed with cancer will
inexorably rise. Over the next decade, Ontario will see an increase o
more than one third in the number o people living with or beyond
cancer. That equates to more than 400,000 Ontarians, compared with
300,000 in 2007. In the process, cancer touches the lives o virtually
every Ontarian, either directly or through amily, riends and colleagues
who know someone with cancer.
Meeting the challenge
Continuing to improve survival rates or cancers, and providing care
and treatment or more people who are living with cancer will require
ongoing investments in capacity and inrastructure.
Newer, more sophisticated approaches are also required to ensure the
long-term sustainability o cancer services. Patient-centred care and
our province-wide ocus on quality will be expanded in this Plan to help
ensure the nancial sustainability o the cancer system while improving
Message rom Terrence Sullivan
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patient outcomes and satisaction. These initiatives are also aligned
with government priorities including the governments healthcare
transormation agenda and Bill 46, theExcellent Care for All Act.
Core lines o business
In addition to driving quality in the cancer system, Cancer Care Ontario
plays a key role in driving quality in other areas o healthcare delivery
including Access to Care, the newly ormed Ontario Renal Network, and
specialized services such as Positron Emission Tomography (PET). They
demonstrate how the systems and processes that we have developed
or the cancer system in Ontario can be extended into other areas o
healthcare to drive quality, enhance patient-centred care and deliver
increasing value or money.
Pragmatic, measured investments
This Plan is ambitious but not extravagant. It calls or pragmatic,measured investments in areas that our partners, cancer patients, and
our own perormance measures are telling us need to improve.
It includes a more ocused emphasis on prevention, early detection and
research-inormed ways to manage growth in costs, particularly as we
enter the era o personalized medicine. It places increased emphasis
on bringing cancer care as close to home as quality permits or more
Ontarians. It involves all o our partners in a drive to improve quality.
Most important, this Plan will more actively involve patients, providing
them with the knowledge and understanding that will allow them to
make inormed decisions aecting their care and engage with them inopportunities that continue to improve their experience in the cancer
system. The two previous Ontario Cancer Plans have demonstrated
how much can be achieved in a ew short years.
Since 2005, we have learned that we can make the system better. We
understand what works and why. With the 2011-2015 Ontario Cancer
Plan, we will apply this knowledge throughout the system and push
urther as we continue the transormation o prevention, treatment
and palliative services across the province. This Plan will bring us a
major step closer to realizing our vision o creating the best cancer
system in the world.
Terrence Sullivan, PhD
President and CEO
Cancer Care Ontario
< O n t a r i O C a n C e r P l a n
This Plan will bring
us a major step closer
to realizing our vision
o creating the best
cancer system in
the world.
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Having this diagnosis is a lie
experience that no one should
have to go through, says Nanc
Ridgway, who knows only too
well how devastating it is to
be told you have cancer. In an
instant, everything changed
or Ridgway when she got the
news. At rst, she was very ma
and very araid. But as she metwith oncologists, radiologists
and other caregivers, the anxi-
ety subsided, or at least becam
manageable. Once we had a
game-plan going, I was able to
relax a little, she says. Having
a plan really helped. >>
ncy
Rick and Nancy Ridgway
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Once we had a game-plan going,
I was able to relax a little.
Dealing with cancer also brought her thoughts into sharper
ocus. It makes you appreciate your loved ones and your
quality o lie, and you tend to start concentrating on those
things more, and orget the petty things that once seemed
so important, she says. Throughout her treatment, she has
learned to continually adjust. You have to work through the
medication, which makes you tired, lethargic and ill. Then
there is a shining moment when you eel better. Then you
go back or the next round, she says. She is deeply grateul
or the support she receives, including her caregivers who
guide me and help me in moments o terror and conusion,
and praises the sta at the Sunnybrook Health Sciences
Centres Odette Cancer Centre or doing a good job under
stress and strain... always maintaining good spirits. Family
support is also crucial, she says, citing the need or some-
one who listens. From her perspective the single most
important actor is inormation, noting that being advised
o the strategies and timelines helped relieve the stress,
giving her a sense o what she was waiting or. And she
appreciates her caregivers giving her just the right amount
o detail. You need to digest the inormation slowly, shesays. Theres a lot o emotion, a lot o upset, a lot o deci-
sions along the way.
Nancy Ridgway, lung cancer patient
Ater a courageous battle with cancer, Nancy passed away on June 16, 2010.
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The impact o cancerCancer is largely a disease o aging. As Ontarios population ages and
grows, the number o people diagnosed with cancer will increase. It
is estimated that 45 percent o males and 40 percent o emales in
Ontario are likely to develop cancer in their lietimes.
Given the increasing number o Ontarians living with cancer, coupled
with expensive new drugs and treatments, the cost o cancer to the
healthcare system will rise and consume an ever increasing share o a
limited healthcare budget. Healthcare costs already account or more
than 40 percent o all provincial government spending. The cost in
human terms, both to patients with cancer and to their amily, riends
and colleagues, is incalculable.
Changing incidence o cancer
There are more than 200 dierent types o cancer. The our most
common types lung, prostate, breast and colorectal account or 54
percent o all cancers in Ontario. Thanks to concerted eorts to reduce
smoking, rates o lung cancer have declined dramatically in men and
are remaining steady in women, refecting the more recent drop in
smoking in emales. The incidence rate o colorectal cancer is also on the
decline or both men and women, refecting both increased screening
and changes in liestyle. Incidence rates are rising or some o the less
malesemales
numb of w css of ccs combd, by sx d y
(cu o 2007 d pojcd 2008-15)
Nancy Ridgway
45,000
40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
01990 1995 2000 2005 2010 2015
year
number
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Cancer Care Ontario (CCO) is the governments provincial agency
responsible or continually improving cancer services and or advisingon all cancer-related issues. We drive quality and accountability
through a set o initiatives that are developed according to our guiding
principles, applied through a system-wide quality ramework and
improvement cycle, and enabled through Regional Cancer Programs
which have made improvements in the cancer system.
The Quality Framework and Quality Improvement Cycle
CCO has established a Quality Framework that includes eight dimen-
sions o quality (i.e., sae, eective, accessible, timely, responsive,
patient-centred, ecient and equitable). Each o these dimensions
is integrated in the development o initiatives to improve the cancer
system. These initiatives are implemented through a quality and per-
ormance improvement cycle with our key steps:
Driving quality and accountability inOntarios cancer system
Ou Gudg Pcps
> Transparency: We will adopt a transparent approach to sharing
perormance-related inormation and oster a culture o open
communication with colleagues, partners and the public.
> Equity:We will ensure airness across regions in the development
o a strong provincial cancer system.
> Evidence-based: We will make decisions and provide policy
advice based on the best available evidence.
> Performance oriented: We will advance new ideas, promote
change and take action toward quality improvements in the
cancer system.
> Active engagement: We will consult widely and collaborate
with other organizations and service providers in order to achieve
our goals.
> Value for money:We will use public resources wisely and promote
the efcient use o these resources throughout the cancer system.
Based on these guiding principles, we have been able to drive
perormance across the cancer care system through the application
o a system-wide quality ramework and improvement cycle.
Medical Oncologist Dr. Som Mukherjassesses patient Dollard Morin priorto treatment.
Photo courtesy o Juravinski Cancer Centrepart o Hamilton Health Sciences.
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Information: The collection o system-level perormance data and
the development o quality indicators.
Knowledge: The synthesis o data, evidence, and expert opinion into
clear clinical and organizational guidance.
Transfer: Knowledge transer through a coordinated program oclinician engagement.
Performance: A comprehensive system o perormance management
through the use o contractual agreements, nancial incentives and
public reporting.
Thoracic Surgery Standards
Lung cancer can be treated with a lung resection a surgical procedureto remove a damaged or diseased portion o a lung (lobectomy) or a whole
lung (pneumonectomy). This is called thoracic surgery. Thoracic surgery
is very complex. Successul outcomes, such as lower mortality and decreased
complications, are linked to the number o surgeries perormed (mini-
mum volumes), and to the availability o specialized surgical training and
hospital resources.
In 2005, Thoracic Surgery Oncology Standards were developed by an
expert panel and endorsed by CCO. The standards detail the best system
or delivering cancer-related thoracic surgery in Ontario based on hospitals
meeting three criteria: (1) high volumes o procedures; (2) necessary inra-
structure and (3) human resources to ensure high quality. The expert
panel included thoracic surgeons and administrative leaders. The stan-
dards were based on evidence compiled and presented by the Program in
Evidence-Based Care (PEBC), and the expert opinion o the panel.
In 2005, thoracic cancer surgery was being perormed in 40 centres. By
2009, this number was reduced to 15, each with the high volumes o pro-
cedures and the necessary inrastructure and human resources to ensure
high quality.
To accomplish this, CCO developed an implementation plan based on part-
nerships with the Regional Cancer Programs and their partner hospitals
where regional plans or compliance were established. Scenario planning
data outlining how reerrals might change due to the consolidation was
provided to assist the Regional Cancer Programs in their planning.
As the standards have been implemented, deaths associated with some
types o thoracic surgery have already declined.
8 < O n t a r i O C a n C e r P l a n
amily Physician Christine Tang andurgeon Don Jones mid-cancer surgery.urgery is one weapon in the ght
gainst cancer.
hoto courtesy o Carlo Fidani Peel Regional Cancerentre at The Credit Valley Hospital.
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Enablers
This quality ramework and improvement cycle is dependent on a
number o enablers. Some o these enablers are: engagement o clinical
and academic leaders; eective regional and local implementation; and
gathering and use o high-quality data through inormation manage-
ment and inormation technology. These enablers are described below.
Clinical Leadership and Engagement, and Evidence-Based
Standards: Provincial clinical leadership groups have been esta-
blished or each step o the cancer journey and or specic disease sites.
These groups work with regional clinical leaders to develop priorities
or improvement, share knowledge and drive quality improvements.
Elements o the Quality Framework are used to monitor and assess
perormance and drive change. Clinical leaders make use o standards
and guidelines developed by the PEBC to drive quality improvements
in all phases o the cancer journey.
Regional Leadership: Regional Cancer Programs are the primary
mechanism or implementing the Ontario Cancer Plan. They include
networks o stakeholders, healthcare proessionals, hospitals and
organizations involved in all aspects o cancer services rom pre-
vention through to survivorship within each o the provinces 14 Local
Health Integration Networks. Each Regional Cancer Program is led
by a Cancer Care Ontario Regional Vice President (RVP), who works
closely with regional clinical leads. Accountability or quality and
perormance across each region lies with the RVPs working with the
regional clinical leads.
Regional Cancer Programs respond to local cancer issues, coordinate
care across local and regional healthcare providers, and work to con-
tinually improve access to care, wait times and quality. Regional Cancer
Programs are responsible or implementing provincial standards and
programs or cancer control, and ensuring service providers meet the
requirements and targets set out in their partnership agreements with
Cancer Care Ontario. Progress is monitored through ormal quarterly
reviews with each RVP, through the Regional Cancer Program per-
ormance scorecard and through the Cancer System Quality Index, a
yearly public report.
This approach has led to signicant improvements in access and quality
in all steps o the cancer journey. Examples include better access to
radiation treatment and cancer surgery, improved quality o colorectal
cancer surgery and enhanced symptom management.
Information Management and Information Technology: CCO
has developed sophisticated and robust Inormation Management
and Inormation Technology (IM/IT) processes and systems that
Patient Usman Ali receives radiationtreatment rom Medical Radiation
Therapist Vanessa Barisic (L) andRadiation Therapist Jen Dewhurst (R
Photo courtesy o R.S. McLaughlin DurhamRegional Cancer Centre part o Lakeridge Hea
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collect and analyze data from across the cancer system. IM/IT
provides inormation that can be used by decision-makers to drive
quality while ensuring that the system is delivering value or money.
CCOs IM/IT systems and processes are now being extended into other
areas o healthcare. Today, our Access to Care Program provides
Ontario health system policy makers, planners and providers withinormation, knowledge and technology to support the system-wide
goals o accessible and high-quality healthcare services.
These and other enablers such as research, surveillance, and primary
care engagement have been critical to our progress to date. How these
will be applied to continue our progress is detailed later in this plan.
Partnering with hospitals The support and commitment o the government to und more cancerprocedures and inrastructure, the relationships the regional cancer cen-
tres have with our hospital partners and community stakeholders, and
the provision o necessary data, have allowed us to negotiate agreements
with hospitals or the ollowing:
> incremental unding to incent increased volumes o activity
> clear targets or volumes o activity
> the provision o data to CCO
> commitment to implement quality improvement initiatives
Dr. Bill Evans, RVP, Juravinski CancerCentre part o Hamilton Health
ciences. RVPs have accountabilityor quality and perormance acrosshe regions.
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The application o our guiding principles, quality ramework and im-
provement cycle and enablers has delivered tangible results.
The rst three-year Ontario Cancer Plan (OCP), introduced in 2005,
ocused on building capacity or the system the nuts and bolts o how
people, inormation and technology intersect to provide higher quality
cancer care. These are highlights o our progress:
> increasing the use o evidence to develop standards and guidelines
to infuence practice, investment and perormance management;
> establishing the 13 Regional Cancer Programs;
> opening three new centres at: Grand River Regional Cancer Centre
in Kitchener; Carlo Fidani Peel Regional Cancer Centre in Mississauga;
R.S. McLaughlin Durham Regional Cancer Centre in Oshawa and
expanding centres across the province at; London Regional
Cancer Program; Hpital rgional de Sudbury Regional Hospital
Regional Cancer Program; and the Juravinski Cancer Centre
in Hamilton;
> working with the government to develop and launch the Smoke-Free
Ontario Strategy and launch the HPV vaccination program.
The second three-year Ontario Cancer Plan, introduced in 2008, o-
cused on reducing wait times, improving the quality o care trans-
orming screening, diagnosis and treatment through the trajectory o
the care continuum, and building capacity. Highlights include:
> reducing wait times, particularly in surgery and radiation;
> construction continues in Niagara, Algoma, Barrie and Kingston;
> opened the Stronach Regional Cancer Centre at Southlake Regional
Health Centre;
> expanded The Ottawa Hospital Cancer Program at the Queensway
Carleton Hospital;
> consolidating complex surgeries (thoracic and HPB);
> launching ColonCancerCheck (CCC) to increase screening or
colorectal cancer;
> introducing primary and palliative care, cancer imaging and path-
ology leads or cancer services in every region;
> renewing our research program with the launch o the CCO re-
search chairs program;
> strengthening key partnerships or example, with the Ontario
Institute or Cancer Research (OICR); and
> beginning the Ontario Health Study (OHS).
Our record so ar: progressunder the rst two cancer plans
The Stronach Regional Cancer Centreat Southlake houses state-o-the-artradiation technology.
She enjoyed a milestonemoment in summer 2010.
On a amily vacation at
Killarney Provincial Park,
she paddled a canoe
3.5 kilometres into a head-
wind, hiked a trail with a
330-metre vertical drop
over one kilometre, and
then paddled back to her
cabin. It is no mean eat
or anyone at 56 years o
age. But or her, a ormer
smoker who the year
beore had the lower lobe
o her right lung removed
as a result o lung cancer,
it was particularly sweet.
Anonymous Patient
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priority 2-4
Priority targets:
Priority 2- 14 days
Priority 3- 28 days
Priority 4 -84 days
Pcg of Cc Sugy Css Compd wh tg fo Poy 2, 3 d 4
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
2008/09 2008/09 2008/09 2008/09 2009/10 2009/10 2009/10 2009/10 2010/11
90%
80%
70%
60%
50%
40%
30%
We have made signicant strides in reducing wait times or surgery and radiation, two o the
three main methods o treating cancer. We measure wait times by showing how many patients
are receiving treatment within the target wait time. Today, 76 percent o patients have surgery
within the recommended wait time, which takes into account the priority or each type o cancer.
Wait times or radiation treatment have also declined since 2008. There has been a 10 percent
increase in the number o patients seeing a radiation oncologist within the target wait time, and a
15 percent increase in the number o patients starting radiation treatment within the target wait
time. In the area o systemic treatment, there has been some improvement in wait times. All o
these improvements have been made in the context o rising incidence and prevalence o cancer
and growing demand or cancer services.
Reerralto Consultation(cases withconsult inthe period)
Consultto Treatment(cases treatedin the period)
Sysmc W tms: Pcg of Ps S/td wh tg
RAD Consult
Cohort-Reerral
to Consultation
(cases with consultin the period)
RAD Treated
Cohort-Ready to
treat to Treatment
(cases treated in
the period)
rdo W tms: Pcg of Ps S/td wh tg
90%
80%
70%
60%
50%
40%
30%Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
2008/09 2008/09 2008/09 2008/09 2009/10 2009/10 2009/10 2009/10 2010/11
90%
80%
70%
60%
50%
40%
30%Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
2008/09 2008/09 2008/09 2008/09 2009/10 2009/10 2009/10 2009/10 2010/11
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I have an amazing amily
mother, ather, brother,
sister, their spouses, my
children and a very special
gentleman in my lie
they have been with me
or every chemotherapy
session and surgery.
When we told my children,my entire amily was there.
We said, Mom has cancer
and shes going to beat
it. That was the only time
there were tears. >>
t
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I would tell someone just diagnosed to take a breath
because it will get easier. There is so much assistance
or us and there are so many people, doctors, nurses,
amily and riends, willing to help. When you rst get
diagnosed you eel like you are going into a black hole
and dont know i there is a way out. At that moment you
are aced with your own mortality. The next thing you
have to do is deal with the demands o cancer and it is
very, very draining. You have to take a step back, gather
all your inormation, process it all and then accept help...
and never be araid because there is always something...
there is so much being developed or cancer through can-
cer research.
Tina Radoslav, colorectal cancer patient
There are so many people,
doctors, nurses, amily andriends, willing to help.
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About this PlanThis Cancer Plan builds on our demonstrated progress and achieve-
ments. However, with the increasing burden o cancer, we know that
still more needs to be accomplished.
The 20112015 Ontario Cancer Plan
This Cancer Plan ocuses on cancer control rom the perspective o the
patient, and is driven by the need to ensure quality across the system.
Through this Plan, we will:
> strengthen our patient-centred approach to cancer control;
> continue to improve the quality o the system; and
> provide individuals with the knowledge they need to make inormed
decisions aecting their care.
This Cancer Plan details what we will accomplish by 2015 and how we
will accomplish it. Details on the Cancer Plan can also be ound online
at: ocp.cancerplan.on.ca
Goals and Strategic Priorities
This Cancer Plan has six goals:
1. Help Ontarians lessen their risk o developing cancer.
2. Reduce the impact o cancer through eective screening and early
detection.
3. Ensure timely access to accurate diagnosis and sae, high-quality
care.
4. Improve the patient experience along every step o the cancer journey.
5. Improve the perormance o Ontarios cancer system.
6. Strengthen Ontarios ability to improve cancer control through research.
While consistent with those in the previous cancer plan, our goals have
been rened based on our experience to date in order to meet emerging
challenges and continue improving the system. To move us closer to
realizing these goals, six strategic priorities have been identied or
20112015. These strategic priorities are described in detail on the
ollowing pages.The strategic ramework or this plan is illustrated
on the next page:
This Cancer Plan ocuses
on cancer control romthe perspective o
people and patients,
and is driven by the
need to ensure quality
across the system
Eugnia Prountzopoulos, colorectal casurvivor with her grandchildren.
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Building the Plan
This Cancer Plan is the product o an extensive review and consultation process.
Working groups were ormed and workshops conducted with clinical and administrative
leaders rom across the province, and other partners including the Canadian Cancer
Society, and the Ministry o Health and Long-Term Care. We reviewed evidence-based
best practices. We talked to experts across Canada and around the world. We involvedpatients through online discussion orums and advisory panels.
This Plan belongs to the entire cancer system. We all have ownership and everyone is
responsible or ensuring this Plans success.
A separate Inormation Strategy is being created, underscoring the importance o inor-
mation in delivering on our strategic priorities and realizing our goals. Other enablers
including research, surveillance, and evidence-based standards and guidelines under-
pin and are refected in each o the initiatives and strategic priorities detailed below.
6 < O n t a r i O C a n C e r P l a n
Goals
Help Ontarianslessen their risko developing
cancer
visionWorking together to create the best cancer system in the world
MissionWe will improve the perormance o the cancer system by driving
quality, accountability and innovation in all cancer-related services
Reduce theimpact o cancerthrough efective
screening andearly detection
Ensure timelyaccess to accurate
diagnosis andsae, high
quality care
Improvethe patient
experience alongevery step o thecancer journey
Improve theperormanceo Ontarios
cancer system
StrengthenOntarios ability
to improve cancercontrol through
research
strateGic priorities
Develop andimplement
a ocusedapproach tocancer riskreduction
Implement
integratedcancer
screening
Continue to
improve patientoutcomes throughaccessible, sae,
high quality care
Continue to
assess andimprove thepatient
experience
Develop and
implementinnovativemodels o
care delivery
Expand our
eforts inpersonalized
medicine
GuidinG
principles:
Transparency
Equity
Evidence-based
Perormance
oriented
Active
engagement
Value or
money
recovery
palliative
& end-of-
life care
prevention screeninG diaGnosis treatMent
The cancer journey
Better cancer services every step o the way
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My name is Theo Dosis.
I was born in October 1935
and am almost 75 years old
now. About 3-4 years ago,
I went to the bathroom and
ound blood in my urine. >>
tho
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I went to my amily doctor who sent me to the urologist.
The specialist did some tests and that is when I ound
out that I had cancer in my bladder. The eeling was one
where I couldnt believe it... I had cancer in my bladder and
I asked my doctor where it came rom and he said it was
rom the smoking. Very shortly ater that I had surgery and
was on medications. I didnt have too many side-eects.
The cancer was removed but it came back. I have had two
operations now. I know the cancer can still come back.
I learned early on that it is important to tell your doctors
everything so they can help you. I have condence in my
doctors. Today, I try to live healthier and take better care
o mysel. My advice to people is stop smoking and dont
be around second-hand smoke.
Theo Dosis, bladder cancer patient
I asked my doctor where it came romand he said it was rom the smoking.
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strateGic priorit y 1
Develop and implement a ocused approachto cancer risk reduction
Prevention strategies work in helping Ontarians reduce their risk odeveloping cancer.
While there is much we still do not know about the causes o cancer,
there is very strong evidence about a number o behaviours or exposures
that increase or decrease the risk o developing some types o cancer:
> Smoking is associated with a higher risk o developing cancers o the
lung, larynx, esophagus, kidney and bladder;
> Physical activity reduces the risk o colorectal and breast cancers,
while being overweight/obese increases the risk o colorectal, breast
and kidney cancer;
> Overexposure to ultraviolet radiation, whether rom the sun or articial
sources such as tanning beds, increases the risk o skin cancer; and
> Workplace and/or environmental exposure to carcinogens (e.g.,
asbestos, benzene and constituents o air pollution) increases the
risk o some cancers.
Accomplishments
CCO has played an important role in prevention, including eorts
directed at tobacco control, healthy eating, physical activity and healthyweight, ultraviolet radiation and occupational carcinogens. We have:
> worked closely with Ontario government ministries to advance
policies or the Smoke-Free Ontario Act and regulation and en-
hancement o the Smoke-Free Ontario Strategy;
> developed guidance documents or local Boards o Health or com-
prehensive tobacco control, healthy eating, active living, and other
health promotion issues;
> supported the implementation o the HPV vaccination program;
> conducted research and established resources that allow investi-gators across Ontario to produce studies that aim to improve cancer
prevention;
> established the Occupational Cancer Research Centre (OCRC)
in collaboration with the Workplace Saety Insurance Board, the
Canadian Cancer Society and the United Steelworkers to ll the
gaps in our knowledge o occupation-related cancers and to trans-
late these ndings into preventive programs to control workplace
carcinogenic exposures and improve the health o workers;
Prevention strategies
work in helping
Ontarians reduce their
risk o developing cancer
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> worked with the Canadian Cancer Society to lead production o
many Insight on Cancer reports on various cancer-related topics
(e.g., separate reports on colorectal, cervical and breast cancers,
environmental exposures and cancer, and sun-related behaviours
and strategies to reduce ultraviolet radiation exposure); and
> the Smoke-Free Ontario Strategy has demonstrated substantial
success in cancer risk prevention. Ontario is second only to British
Columbia in having the lowest rates o smoking in Canada.
The Opportunity
Despite our progress to date, the rates o smoking in Ontario remain
unacceptably high and considerable work remains to be done. As well,
there has been limited progress in ormally addressing other cancer
risk actors such as obesity, physical activity, UV exposure, alcohol,
occupational hazards and carcinogens in the environment. There is also
a lack o measurement and evaluation o cancer prevention activitiesat the provincial and regional levels, contributing to limited knowledge
o eectiveness, and inconsistent use o evidence-based practices.
We can build upon and make greater use o our expertise in research
and surveillance, management systems, knowledge and perormance
measurement to:
> collaborate with organizations involved in cancer prevention and
risk reduction to expand data capture, reporting and measurement
o perormance;
> encourage our partners to align reporting and perormance measure-
ment at the provincial, regional, provider and public levels, and
urther promote evidence-based prevention; and
> engage primary care physicians to promote cancer prevention
through cancer risk assessment or Ontarians.
There is an opportunity to address the dierences we see between
Aboriginal and non-Aboriginal populations in prevention, screening,
treatment and care.
Initiatives in this Plan
To help Ontarians reduce their risk o developing cancer, we will:
1. Build a cancer prevention perormance measurement ramework
that can serve as a resource or all partners who have a role
in prevention.
2. Develop and implement an online cancer risk assessment tool or
use by individual Ontarians.
0 < O n t a r i O C a n C e r P l a n
Managing your health with a balancedmeal as shown by Clinical Dietician Paulina
Araujo can lower your risk o some cancers.
hoto courtesy o Carlo Fidani Peel Regional Cancerentre at The Credit Valley Hospital.
There has been limited
progress in ormally
addressing other cancer
risk actors such asobesity, physical activity,
and UV exposure.
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3. Facilitate the implementation o a cancer risk reduction initiative in
each o the regional cancer centres.
4. Provide continued leadership on tobacco control through the
renewed Smoke-Free Ontario Strategy and the Provincial Training
and Consultation Centre.
5. Implement the second Aboriginal Cancer Strategy (2011-2015;
page 22).
These prevention-related activities will be done in partnership with
other organizations, and will be complemented by surveillance that
detects where disparities need to be addressed and research that
discovers cancer causes in the Ontario population.
By 2015
> Perormance measures or cancer prevention initiatives will be in
place and reported publicly.> Primary care providers will be given the tools that they need to
work with individuals to modiy their risks and link them to local
resources and screening where applicable.
> Every person in Ontario will be able to calculate their cancer risk
prole, based on personal characteristics and grounded in Ontarios
data. This prole will be delivered online and linked to local resources
that individuals can use to moderate their risk.
> Regional cancer centres will be models in implementing cancer
risk reduction initiatives.
>A new tobacco control strategy will be implemented.
Andrea Pitts uses exercise to maintaiher optimal health.
Photo courtesy o Carlo Fidani Peel RegionalCancer Centre at The Credit Valley Hospital.
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Aboriginal Cancer Strategy IICancer patterns dier signicantly between the Aboriginal population and
the general Ontario population. Cancer incidence and mortality rates are in-
creasing in the Aboriginal population and cancer survival is worse than or
all Ontarians. This underscores the need or a specic cancer control strategy
to reverse these trends. The rst Aboriginal Cancer Strategy (20042009) had
our strategic priorities:
1. Health promotion and prevention, including Aboriginal tobacco control.
2. Research and surveillance.
3. Relationship and capacity building within CCO, the regions and in
Aboriginal communities.
4. Treatment, including supportive and palliative care.
This strategy led to some key accomplishments, including a partnershipwith the Ministry o Health and Long-Term Care (MOHLTC) to develop
and implement the Aboriginal Data Indicator Pilot Project to enhance the
collection o cancer data on Aboriginal people in Ontario, and research to
understand why First Nations women had poorer breast cancer survival than
other Ontario women.
While progress has been made, there is a clear need or urther planning and
action to address the rising burden o cancer in the Aboriginal population.
The second Aboriginal Cancer Strategy is being developed and will be imple-
mented over the course o this Ontario Cancer Plan (20112015). A ew key
initiatives o this new Aboriginal Cancer Strategy include strengthening ourrelationships by engaging in more direct dialogue with First Nations, Mtis,
Inuit and O-Reserve Aboriginal people, and working with the health net-
works already in place among these groups. For example, we will continue
to work with the Chies o Ontario and other partners to develop a strategy
or an ongoing cancer surveillance system or First Nations people in Ontario.
We will implement the Aboriginal Patient Navigator and Lay Health Educa-
tor programs, which serve to improve the understanding o cancer among
Aboriginal people and increase their participation rates in cancer screening.
2 < O n t a r i O C a n C e r P l a n
A ew key initiatives o
this new Aboriginal
Cancer Strategy include
strengthening our relation-
ships by engaging in more
direct dialogue with First
Nations, Mtis, Inuit and
Of-Reserve Aboriginal
people, and working with
the health networks.
etting patients engaged in theirwn care is key to empoweringatients in the cancer journey.
hoto courtesy o Regional Cancer Care-orthwest at Thunder Bay Regionalealth Sciences Centre.
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Prevention and screening: working inthe workplace
As a long-time public health nurse, Elizabeth Dulmage was well versed in theconnection between awareness and action. Countless times, she had seen
how drawing attention to personal health matters, and the resources avail-
able to address them, had spurred people to take steps they might otherwise
have neglected.
This understanding was the impetus behind Your Health Matters, a compre-
hensive workplace cancer prevention and screening program that has grown
into a national success.
Each workplace session takes about 45 minutes. In addition to ocusing on
why prevention and screening are so important, the presentations also give
participants direction on where and how to take action, such as reerrals toclinics and liestyle modication programs.
It is important to motivate and inspire people, but it is equally important
to answer, now what? Dulmage says. The ability to immediately sign up
or programs, and ensuring the supports are in place oten within the
workplace itsel makes a big dierence in people ollowing through on
their commitments.
As manager o Cancer Prevention & Screening with the Windsor Regional
Hospital, Erie St. Clair Regional Cancer Program, Dulmage developed a pilot
program or healthcare workers within the local system.
Working with data expert Nicole Robinson to design baseline and monitor-ing surveys, Dulmage was able to denitively prove the programs eective-
ness not just in raising awareness about prevention and screening, but in
motivating people to act on what they had learned.
Within 12 months o the initial presentation, 78 percent o those due or a
mammogram and 70 percent o those requiring a Pap test had completed
the respective procedures.
Having proven its eectiveness, Dulmage with assistance rom various
agencies, including Cancer Care Ontario began developing templates, a
program manual and a step-by-step guide, building Your Health Matters into
an Ontario-wide program that is now being replicated across the country.
Dr. Neety Panu beside a mammograpmachine advising Grace Winter at
the Linda Buchan Centre or BreastScreening and Assessment at ThundeBay Regional Health Sciences Centre
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We have evidence or screening in certain can-
cers. The public may think we should screen or
everything all the time but there can be harm
associated with it. We have evidence or three
major cancers - breast, cervical, and colorectal
that shows screening can save lives. Our pro-
gram emphasizes screening or these three types
o cancers. We are working towards integratedscreening which involves screening or all three
o these cancers in eligible women, and conti-
nues to have men screened or colorectal can-
cer. When we try to get everyone screened we
know lives will be saved. Unortunately, there
are barriers to screening. These barriers may be
socio-economic, cultural, and educational, mak-
ing it difcult to screen everyone. We know or
example that marginalized populations as well as
the Aboriginal population get less screening. It is
really important to begin to address some o the
issues so all eligible populations get screened. It
is really critical to educate the primary care health
care providers because they are on the rontline
and have to encourage their patients to come
in and get screened. There are many strategies
to do this including providing specic inorma-
tion to primary care providers to support them in
improving screening rates.
Dr. Sandy Buchman, Regional Primary Care Lead
Toronto Central Regional Cancer Program
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strateGic priorit y 2
Implement integrated cancer screeningCurrently, CCO has three distinct screening programs: ColonCancerCheck,
the Ontario Breast Screening Program and the Ontario CervicalScreening Program. These programs are at dierent stages o develop-
ment and maturity and are supported by three dierent inormation
systems. In 2007, the provincial government made a commitment
to increase early detection and acilitate the eective treatment o
cancer with a ocus on improving screening rates or these cancers.
To accomplish this, we will implement an integrated screening strategy.
The three key elements o the Integrated Cancer Screening (ICS)
strategy are:
> Increase patient participation in screening;
> Improve primary care provider perormance in screening; and> Establish a high-quality integrated screening system and inormation
management and technology inrastructure.
Accomplishments
As o the date o this Plan, the Ontario Breast Screening Program
(OBSP) is celebrating its twentieth anniversary since being launched
in 1990. More recently, the ColonCancerCheck (CCC) Program was
launched in 2008. At present, the provincial CCC program has an elec-
tronic patient inormation system (InScreen) that collects colorectal
screening data or the purposes o screening evaluation, and or issuingpatient screening reminders. The Integrated Cancer Screening (ICS)
strategy will build on this IM/IT investment by integrating breast and
cervical cancer screening data into the inormation system.
With respect to ICS, the ocus to date has been on planning and laying
the oundation or implementation o a ully integrated cancer screen-
ing program or Ontario. A ew o the key accomplishments are:
>As a pilot, screening activity reports were produced or primary
care providers, giving amily physicians and nurse practitioners
colorectal screening inormation or their patients;
> Community-based initiatives were established to promote cancer
screening among hard-to-reach populations, in partnership with
Regional Cancer Programs;
> ICS business model and detailed implementation plan were developed;
> ICS support services delivery and unding model were developed;
and
> Key perormance measures were developed to monitor screening
perormance at local, regional and provincial levels.
Digital mammography oers severaimportant benets including bettercancer detection in women withdense breasts.
Photo courtesy o Princess Margaret Hospitalo University Health Network and Ontario BreScreening Program.
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The Opportunity
Breast and cervical cancer screening programs have relatively high
screening rates o 66 percent and 72 percent, respectively. However,
some breast cancer screening takes place outside the OBSP at
acilities not covered by CCOs quality management program, and there-
ore do not capture the inormation to regularly monitor perormance.ColonCancerCheck has much lower participation rates but these are
increasing rapidly. This is because o the introduction o the population-
based program to primary care providers, and public education cam-
paigns supported by new inormation and technology inrastructure.
With a single integrated screening strategy, primary care providers
and patients will have a more consistent and coordinated screening
experience. As well, eciencies will be realized in business operations
and inormation technology to provide the best value or money.
Initiatives in this Plan
To increase early detection and acilitate the eective treatment o
cancer with a ocus on improving screening rates, we will:
1. Implement the ICS strategy or breast, cervical and colorectal cancers.
2.Adapt and expand CCCs InScreen system to support the ICS strategy.
3. Establish ICS support services at the regional cancer centres and
implement regional accountability or screening in all 13 Regional
Cancer Programs.
4. Establish centralized administration support or all cancer screening,
including correspondence management and call centre unctions.
5. Produce integrated screening reports or primary care providers
to help them identiy which patients have been screened, which
patients require screening, and which patients need ollow-up.
By 2015
> Ontario will have one ICS strategy or breast, cervical and colorectal
cancer, supported by a single IM/IT system.
> Eligible Ontarians will receive invitations and reminders or the
appropriate cancer screens at correct time intervals.
> Primary care providers will receive reports, tools and supports to
enhance their screening perormance. Mentoring and support will
be provided to doctors as needed.
> Local and regional initiatives will be in place to encourage the under-
screened and/or never-screened to participate in cancer screening.
6 < O n t a r i O C a n C e r P l a n
Ontario has one o the highest incidences colorectal cancer. Colorectal cancer is
he second deadliest orm o cancer.
hoto courtesy o Carlo Fidani Peel Regional Cancerentre at The Credit Valley Hospital.
Medical Radiation Therapist HeleneCompeau (L) conducting a mammogram.
he screening rate in Ontario hasncreased seven percent since 2001-2002.
hoto courtesy o Stronach Regional Cancerentre at Southlake.
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> Support services will be in place to ensure individuals with abnormal
results receive appropriate ollow-up care.
> Evidence-based guidelines will be established or breast, cervical
and colorectal cancer screening.
>All breast cancer screening in Ontario will be consolidated into oneservice or all eligible women.
> Each o the 13 Regional Cancer Programs will be accountable or
screening programs in their region.
> Screening targets at the regional and provincial level will be reviewed
regularly to assist in perormance management, monitoring and
reporting to health system planners.
A 53 year old patient
o mine came to see me
today that I havent seen
or two years. She said shecame... because o the
letter you sent me. Her
husband died two sum-
mers ago o metastatic
colon cancer. He never had
any colon cancer screen-
ing and died within two
months o his diagnosis
Today, she received her
rst ever CCC kit... It
was the invitation pilot
letter that motivated
her to come in.
Dr. Marla Ash, Regional Primary Care
Lead, Central Regional Cancer Program
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The surgical oncology program at CCO has two
main missions, access to care and access to qual-
ity care. The whole concept o access to quality
care is to do it better. This can mean a range o
things including improved satisaction or the
patient, better outcomes, improved survival,
ewer complications, better margin resectionrates, and improved lymph node retrieval rates
or some cancers. Quality o care is about doing it
better or patients which translates to better out-
comes and better quality o lie or patients. The
quality improvement ramework is about estab-
lishing the current state o how we are doing it,
bringing in expert advisors/opinion leaders, es-
tablishing evidence-based practice around new
targets we want to achieve, engaging hospitals
regions and clinicians about how to implement
change, and monitoring how we are improving
over time. What we have realized at CCO is that
quality improvement occurs locally. Whatever
standard or guideline we establish, these things
mean nothing unless it is translated to the pa-
tients bedside, the operating room table, the
pathology bench or in the clinic.
Dr. Jon Irish, Provincial Head, Surgical Oncology, Cancer Care Ontario
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strateGic priorit y 3
Continue to improve patient outcomesthrough accessible, sae, high quality care
This Plan continues to ocus on quality, access to, appropriatenessand coordination o care and improving the patient experience. This
Cancer Plan takes our accumulated knowledge about how to improve
the quality o care and provide value or money and applies it across
the system.
Accomplishments
Since 2005, we have:
> reduced wait times or specialist consultation and treatment;
> improved the quality o cancer treatment;> improved the quality o perormance data;
> strengthened perormance indicators, measurement and reporting;
> instituted processes or regular review o data at the provincial and
regional level; and
> built a culture o continuous improvement, where standards o care
and guidelines or treatment are used across the system.
We hold cancer services providers accountable or meeting stan-
dards o quality and perormance, and these standards have been built
into all o our unding agreements. This approach has been the basisor a number o recommendations that are now included in Bill 46, the
Excellent Care for All Act.
Specic initiatives that are improving the quality o the cancer
journey include:
> Diagnostic Assessment Programs (DAP)that improve the coor-
dination o diagnostic testing, provide inormation and support
to patients, and help amily doctors access diagnostic tests and
results or their patients are being implemented. DAPs will reduce
wait times and delays in diagnosis. The Electronic Pathway Solution
(see page 35) is a tool that will be used as an integral part o theimplementation o DAPs.
> Pathology Reporting, which is a critical element in both the
diagnosis and treatment o cancer and is used to determine the
appropriate treatment or combination o treatments required.
Standardized (synoptic) cancer pathology reporting has been im-
plemented in more than 85 hospitals across Ontario. It is enabled
by eTools (new, electronic tools), resulting in over 90 percent
Dr. Som Mukherjee reviewing imaginscans. Cancer imaging plays an imporole in diagnosing and treating patie
Photo courtesy o Juravinski Cancer Centre paHamilton Health Sciences.
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completeness rates or synoptic reports submitted to CCO. The
next phase o the pathology reporting initiative will ocus on
expanding synoptic reporting to all cancer surgeries.
> Multidisciplinary Cancer Conferencing (MCC), which brings
together the entire team o cancer care proessionals to make deci-
sions about the best treatment or each patient are now happening
across the province. By the end o 2009/10, 69 percent o MCCs
adhered to provincial standards. We will continue to evaluate the
eectiveness o MCCs in infuencing care plans.
> Disease Pathway Management (DPM), which is a new approach
to improving the quality o care, processes and patient experience
or specic cancers (e.g., lung cancer) by examining the entire
cancer journey rom the perspective o the patient. Disease Pathway
Management identies the gaps along the cancer journey and in-
volves working with partners, patients and caregivers to set priorities
or improvement.
> Thoracic and hepato-pancreatic-biliary (HPB)surgery stan-
dards,whichare now almost ully implemented. They require that
lung and esophagus cancer surgeries and HPB cancer surgeries
be perormed in designated hospitals that perorm a high volume
o these procedures. Evidence shows that better patient outcomes
are achieved when surgeries are perormed at specialized, high-
volume hospitals.
> Intensity Modulated Radiation Therapy (IMRT), which is a
method o delivering high doses o radiation while signicantlydecreasing damage to surrounding healthy tissues and minimizing
side eects. It is now being provided by all radiation programs in
Ontario, and the number o eligible patients receiving this treatment
is steadily increasing. The Pharmacoeconomics Unit, whose man-
date is to conduct, evaluate and explain cost-eectiveness analysis
o cancer drugs and technologies under review or unding con-
sideration has begun studying the cost-eectiveness o IMRT to
guide our use o this technology; the PEBC has developed clinical
practice guidelines.
> The organization and delivery of systemic treatment (chemo-therapy), which is based on best practice standards. Each o the
13 Regional Cancer Programs has developed plans to meet the
standards and these plans have been rolled up into the Regional
Systemic Treatment Program (RSTP) provincial plan that is now
being implemented. Additional unding has been allocated or the
delivery o systemic treatment closer to home in community hospi-
tals, and 12 new medical oncology positions have also been allocated
in 2010 to meet the growing demand or systemic treatment.
30 < O n t a r i O C a n C e r P l a n
Multidisciplinary Cancer Conerencesring together health proessionals to
make the best decisions or patients.
hoto courtesy o Juravinski Cancer Centreart o Hamilton Health Sciences.
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Registered Nurse Kasie Penney helpcreate accurate records o symptom
and treatment regimens to improvethe patient experience during theircancer journey.
Photo courtesy o R.S. McLaughlin Durham ReCancer Centre part o Lakeridge Health.
O n t a r i O C a n C e r P l a n >
> Specialized training in oncology nursing, which is a specialty
area o practice requiring expert knowledge, clinical skills and cli-
nical judgment to meet the complex needs o cancer patients. The
number o nurses receiving specialized training in oncology is being
increased through the de Souza Institute, an innovative centre o
learning dedicated to supporting excellence in oncology nursing.
> Oversight of specialized cancer services, such as stem cell
transplant and neuroendocrine treatments, includes our key com-
ponents: expert advice; reviewing the latest evidence; provincial-
level planning; and unding care to ensure access. This helps to
avoid inappropriate use o costly services as well as out o country
services, and promotes care as close to home as quality permits.
Synoptic (Standardized)Pathology ReportingClinicians depend on pathology reports to conrm cancer diagnoses and
decide on the most appropriate course o treatment, making high-quality
pathology reporting essential.
Through CCOs Stage Capture and Pathology Reporting Project, undertaken
in partnership with Ontarios cancer-treating acute care hospitals, stan-
dardized reporting, also known as synoptic reporting, was introduced or
pathologists across Ontario. It is a rst or any jurisdiction o this size.
A survey o surgeons and oncologists showed overwhelming support or this
quality initiative. The survey showed synoptic reports made it easier to nd
the inormation required or clinical decision-making, and acilitated a con-
sistent approach to the interpretation o diagnostic and prognostic actors.
According to one survey participant, synoptic reporting reduces the chance
o error and/or orgetting to include a specic parameter signicant or a
cancer case. Another participant reported that it allows me to nd the inor-
mation I need quickly and efciently. These are all critical actors in making
accurate and timely treatment decisions or patients.
We have enabled the implementation o eTools to ensure consistency and
completeness o pathology reports ollowing an evidence-based standard
endorsed both provincially and nationally.
Hospitals now receive monthly reports on key surgical practice indicators.
By making health inormation data more accessible and usable, this large-
scale change in clinical practice has benetted direct patient care, research,
planning, and data quality.
A recognized world-leader in this area, CCO is now supporting the Canadian
Partnership Against Cancer and the Canadian Association o Pathology to
implement our synoptic pathology reporting across Canada.
A survey of surgeonsand oncologists showed
overwhelming support
for this quality initiative
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The Opportunity
While we have made signiicant headway in the development and
implementation o quality initiatives, there remain signicant oppor-
tunities to improve access to sae, high-quality care.
Traditionally, eorts to improve cancer care have ocused on individual
phases o the cancer journey (e.g., diagnosis, treatment) and the role
played by each healthcare provider. Disease Pathway Management is a
complementary approach that addresses the transitions between phases
o the journey and the coordination between healthcare providers. The
pathway rom screening through diagnosis and treatment and on to
ollow-up or end-o-lie care diers greatly rom one type o cancer
to another. The Disease Pathway Management approach ocuses on
improving the unique issues aced by patients with a particular type o
cancer.
Evidence has shown that there is a gap between the number o patients
who should be receiving radiation treatment and the number who are
getting it. By developing and implementing evidence-based plans or
delivering high-volume activities such as radiation treatment, surgery
and palliative treatment, we can work toward ensuring that all patients
have access to the appropriate treatment within an appropriate time.
We currently measure treatment outcomes such as survival, but to
improve the evaluation o our programs and services, we need to
better understand patient outcomes, such as quality o lie and the
recurrence o cancer. Strengthening our measures o quality to include
more patient outcomes will help us improve the cancer system.
New technologies can improve cancer care. The challenge exists in
determining whether a new technology oers signicant benets and
is cost-eective.
Building a culture o continuous quality improvement and putting
the inormation on perormance in the hands o those who can use
it will help to close the gap between what we know and what we
do. We now have the ability to capture and share clinician level data
to help clinicians understand their perormance against evidence-
based standards.
Certain treatments (e.g., stem cell transplant) are perormed in spe-cialized centres because o their complexity. A lack o oversight can
result in a gap in ensuring that all eligible patients have access to these
specialized services and that the quality o these services is consistent.
Provincial planning will ensure that these services are available in a
timely ashion to those who need them.
As the number o treatment guidelines continues to grow, it is in-
creasingly dicult or physicians to keep up-to-date, especially at
32 < O n t a r i O C a n C e r P l a n
echnology has become an importantnabler in the ght against cancer.ancer Care Ontarios systems androcesses are helping drive quality the ght against cancer.
hoto courtesy o Carlo Fidani Peel Regionalancer Centre at The Credit Valley Hospital.
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the point o care, where they need it most. We will leverage new
technology to ensure the evidence-based guidance is available in an
easy-to-use ormat at the point at which physicians need to use it to
inorm decisions.
Out-o-the-box thinkingOicially its a portable radiation suite, but everyone at Royal Victoria
Hospital simply calls it the bunker. By any name, it is saving lives close to
home or people in the Barrie area.
RVH is in the process o establishing a ull regional cancer centre, but it
is still some years away. In the meantime, Garth Matheson, Regional Vice
President, Cancer Services, North Simcoe Muskoka was aced with a challenge
in terms o radiation treatment. It was a concrete problem literally. Radiation
treatment acilities must be able to completely contain the radiation, which
is very intense. As such, they require very thick concrete walls and ceilings
that are constructed to meet Canadian Nuclear Saety Commission stan-
dards. With those kinds o specications, bunkers are expensive, and usually
permanent, structures.
The solution was to install a temporary radiation treatment suite the rst o
its kind in Canada.
It provides the same protection as a concrete bunker, and when our per-
manent acility is ready, this one can be moved somewhere else, helping
another community provide better care close to home, Matheson explains.
The temporary radiation acility is made up o more than 20 modules, or pods,
each about the size o a boxcar. They are lled with aggregate and joined
together to create the bunker. When the new Simcoe Muskoka Regional
Cancer Centre opens in 2012 and the temporary radiation acility is no longer
needed, the acility will be relocated.
It is not a building, it is a piece o equipment, Matheson says.
The state-o-the-art acility is the result o a partnership between RVH, the
Ministry o Health and Long-Term Care, Cancer Care Ontario and the Odette
Cancer Centre at Sunnybrook Health Sciences Centre. Cancer Care Ontario
owns the suite, and will determine where it goes next.
The solution was to instal
a temporary radiation
treatment suite the rsto its kind in Canada
Radiation Therapist Frough Balkhi-Yaand student Ashleigh Farmer (rear)prepare a patient or radiation treatm
Photo Courtesy o Juravinski Cancer Centrepart o Hamilton Health Sciences.
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Initiatives in this Plan
To improve patient outcomes, we will:
1. Develop disease pathway maps based on best practices, identiy
quality improvement targets, and embed these targets in our per-
ormance management process.
2. Develop provincial plans or the delivery o high-volume activities
such as surgery, radiation treatment and palliative care to provide as
much care as possible close to home, consistent with standards.
3. Strengthen quality assurance and best practices at the provider level
by ensuring hospitals and providers have the detailed inormation
and knowledge that they need to improve quality.
4. Develop measures and manage perormance with respect to patient
outcomes.
5. Make recommendations to healthcare providers and the MOHLTCwith respect to new technology that improves patient outcomes.
6. Provide oversight (including planning and quality management)
o very specialized cancer services and cancers, such as stem cell
transplant, neuroendocrine tumours and sarcoma.
By 2015
> Disease Pathway Management programs will be developed and imple-
mented or all major cancer types. This will result in improvements
in quality o care and the overall patient experience.
34 < O n t a r i O C a n C e r P l a n
For the more common types o cancers
shown at the bottom o the pyramid,
our approach is to use Disease Pathway
Management and guidelines to ensure
quality and access in regional cancer centres
and hospitals. Perormance targets are set
and unding is based on patient volumes.
As treatments or cancers become more
complex and specialized, we become more
directly involved to ensure patients have
access to appropriate care. These treatments
require centralized planning and delivery.
High-volume services provided in disseminated modele.g. most breast, colorectal, prostate cancer care
High-complexity services; centralizedregionally. e.g. head and neck cancers,
gynecology oncology
High-cost,high-complexity
services; highlycentralized/ew centres.
e.g. stem cell transplant
Our goal at the R. S.
McLaughlin Durham
Regional Cancer
Centres Breast Assess-ment Centre is to pro-
vide timely reassurance
to those patients with
a benign nding, and
those with cancer to
be diagnosed and
treated without delay,said Patti Marchand,
Clinical Nurse Specialist
and Nurse Navigator.
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> Cancer service plans will be in place or all high-volume activities
including but not limited to radiation treatment, surgery and palli-
ative care.
> Physicians involved in cancer care and control will have access to
their own perormance data.
> Evidence-based guidance will be more readily available and in a
more usable ormat at the point o care.
> Ninety percent o chemotherapy treatment visits will be supported
by computerized physician order entry, which will reduce errors
and increase patient saety.
> Specialized oncology nurses will be in place across the cancer
system, ensuring sae, high-quality patient-centered care as close
to home as possible.
> Specialized cancer services will have provincial service plans de-signed to ensure timely and appropriate access to specialized cancer
treatments, such as stem cell transplant.
The Electronic Pathway SolutionCCO is working in partnership with the Canadian Cancer Society to devel-
op and implement an electronic tool that will help to ease the stress and
uncertainty or patients as they go through the diagnostic phase o thecancer journey.
We know that this can be a time o great anxiety and we believe that this
experience can be improved i people have easy access to inormation and
answers to their questions. This tool will show patients and their amily
doctors where they are on the journey to diagnosis. They will be able to see
the tests they need, what comes next, the results o tests and the plan or
their care. Patients and caregivers will be able to access this web-based tool
at any time and will be able to get inormation specic to their own situa-
tions, as well as links to people who can provide support. This inormation will
help amily doctors stay connected to their patients as they go through the
cancer system, allowing them to support and care or patients when they
move to the survivor phase.
This is a very important initiative, primarily because it will help reduce the
anxiety that many patients eel during diagnosis, which is one o the most
stressul times o the entire cancer journey, said Martin Kabat, Chie Execu-
tive Ofcer, Canadian Cancer Society, Ontario Division.
This is a very important
initiative, primarily
because it will helpreduce the anxiety that
many patients eel during
diagnosis, which is one
o the most stressul times
o the entire cancer journey.
Martin Kabat, Chie Executive Ofcer
Canadian Cancer Society, Ontario Division
Nurses provide patients with navigatduring the cancer journey.
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Doug Gosling is more than a cancer survivor. Hes
a cancer warrior. He chronicles his cancer experi-
ence which continues to this day and his
eorts to navigate the cancer care system. Having
battled the disease twice, he is only too amiliar
with the challenges o a system he says is nally,
albeit slowly, recognizing that patients need
to be kept inormed about what is happening
to them. It is very difcult to be sitting around
waiting, with this terrible growth growing inside
your body, Gosling says. So many questions go
through your mind What are my chances o
recovery? Am I getting the right treatment? What
happens next? but its oten hard to nd any
answers. This lack o inormation exacerbates
what is already an arduous emotional experience
he says, adding that in many ways the emotiona
impact is worse than the physical toll. He believes
that keeping patients involved throughout the
process would help alleviate some o this anxiety
There is inormation available, but nobody tells
you where to start looking. From the moment o
diagnosis, what patients really need is someone
to take them by the hand and go with them every
step o the journey, he says.
Doug Gosling, prostate cancer patien
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strateGic priorit y 4
Continue to assess and improve thepatient experience
Accurate diagnosis and sae, eective treatment o cancer are clearlyimportant priorities in improving cancer care. These goals, however,
are not sucient when striving to create the best cancer system in
the world. Patients need to have more control over their own care
to improve satisaction and outcomes. Patients need access to tools
that enable them to assess and communicate their symptoms eec-
tively so that their symptoms can be better managed by healthcare
providers. They need access to resources and inormation that meet
all o their physical, emotional and educational needs throughout
the cancer journey.
Accomplishments
We have developed a better understanding o the patient experience
through a variety o activities such as Cancer Quality Council o Ontario
Signature Events ocused on the patient experience; engaging patients
through ocus groups and social media; and the Ambulatory Oncology
Patient Satisaction Survey.
With this increased understanding, we have launched several initi-
atives including:
>A Psychosocial Oncology Program to set guidelines and stan-
dardize care to meet the needs o cancer patients, including im-
proved emotional support, and helping cancer survivors return to
work and the regular routine o daily lie.
> The Ontario Cancer Symptom Management Collaborative
(OCSMC), which provides standardized symptom screening.
Patients report symptoms associated with their cancer, such as
anxiety or shortness o breath, to their healthcare proessionals,
online, by phone, or at kiosks in their regional cancer centres. Since
the programs inception in 2006/07 over hal a million symptom
sel screens have taken place. Forty-three percent o all cancer
patients seen at the 14 regional cancer centres are now routinelyscreened or symptoms each month. These symptoms are then com-
municated to the patients health care providers so that action can
be taken to reduce suering and address the patients needs.
> Our participation in an international collaborative, which
brings together healthcare proessionals rom around the world
andis aimed at measuring patient-reported outcomes, such as late-
eects o treatment, and vocational and sexual health. Collaborators
share ndings and learn rom each others experiences.
Bev Laontaine, nurse and Greg Barkepatient during a chemotherapy sessi
Photo courtesy o Juravinski Cancer Centre paHamilton Health Sciences.
For Aboriginal patients,
their amily and community
the cancer experience can
be overwhelming. The
multidisciplinary team can
help them by appreciating
their culture, health and
social issues, to teach,
explain and acknowledge
their concerns, in an
empathetic and supportive
manner as they guide
them through diagnosis
and treatment.
Dr. Darlene Kitty, Rural FamilyPhysician, Chisasibi Hospita
Board Member o the Indigenous
Physicians Association o Canada
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>A Patient Advisory Group has been established to engage cancer
patients and their providers with the goal o gaining their perspectives
on what can be done to improve the patient experience.
>A Provincial Palliative Care Program , which addresses a number
o the gaps in this vitally important stage o the patients journey
with cancer, has been established. Palliative Care Programs haveexpanded within each o the regions in the province. Engagement
o primary care practitioners to increase their knowledge, clinical
skills and collaborative practice is supported through education,
mentoring and consultation with palliative care experts. We have
developed recommendations or the organization and structure o
palliative cancer care programs in Ontario to ensure that the same
standard o care is provided across the province.
The Opportunity
We still do not have a complete understanding o the patient experi-ence. We need to know more to identiy the challenges and barriers
patients ace at every stage o their cancer journey. As a result o our
work with an international collaborative and patient advisory group, we
have identied the ollowing opportunities to develop new and better
ways to assess and improve the patient experience:
> Many more people are living longer with cancer, and we need to
measure and improve patient-reported outcomes or these long-
term survivors.
> There is a need or electronic tools or patients to enable sel-
management o their care.
Breathing made easierLung cancer patients have identied shortness o breath as one o the key
issues they ace on their journey.
To address this, we have established six one-year pilot projects to educate
and help lung cancer patients in managing shortness o breath, or dyspnea.
Projects ocus on early education and counseling or patients and amilies.
Others ocus on using the Edmonton Symptom Assessment System (ESAS) to
identiy patients who should be included in the program.
The projects are under way at the Odette Cancer Centre (Toronto), Carlo
Fidani Peel Regional Cancer Centre, the Ottawa Hospital Cancer Centre;
the Cancer Centre o Southeastern Ontario (Kingston), the Juravinski Cancer
Centre (Hamilton) and the Grand River Regional Cancer Centre (Kitchener).
38 < O n t a r i O C a n C e r P l a n
Health proessionals provide patientswith the psychological and emotionalupport to counter the impact cancer
as on individuals and their amilies.
hoto courtesy o Juravinski Cancer Centreart o Hamilton Health Sciences.
We are all about lie.
We are not involved inmedical management.
We are involved in meet-
ing the very dierent and
individual needs o each
patient that comes to us
or advice and support,
Holly Bradley, Managing
Director, Wellspring said.
For example, Wellspring
started Money Matters,
a program to provide
personalized nancial
advice to patients hit
by the unexpected
costs o the disease.
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Initiatives in this Plan
To improve the patient experience across the cancer journey, we will:
1. Improve the patient experience in the diagnostic phase, through
access to relevant inormation, coordination o care and implemen-
tation o the Electronic Pathway Solution.
2. Measure the patient experience during the treatment phase o the
cancer journey through improved survey instruments.
3. Expand symptom assessment through the Interactive Symptom
Assessment and Collection (ISAAC) system implementation, in-
cluding the increased use o ISAAC in regional cancer centres, the
expansion o its use to partner hospitals and in the community, and
the increased use o tele-ISAAC.
4. Continue to improve management o symptoms through better res-
ponse to elevated symptom scores using notication alerts.
5. Develop and implement a way to measure patient-reported outcomes
or the post-treatment phase through partnership in an international
collaborative.
6. Establish Regional Cancer Program accountability or improving
the patient experience through integration with our perormance
management process.
7. Increase patient support through expansion o regional psychosocial
oncology and patient education programs.
By 2015Every cancer patient in Ontario will:
> Have access to tools to help navigate the cancer system and manage
their own journey (e.g., through supportive resources such as care
pathways, patient navigators, and the Electronic Pathway Solution).
> Transition more smoothly along the care path and experience im-
proved continuity o care among cancer care service providers.
> Have the opportunity to give eedback on their experience throughout
their cancer journey.
> Have the opportunity to report their symptoms electronically to
support communication and the provision o care.
> Receive care in a timely manner or physical and emotional symptom
scores fagged through symptom screening.
> Have their perormance status, the clinical measure o the patients
ability to perorm normal daily unctions, collected to help in the
planning o their care.
Volunteer Dalia Halata using the com
puterized system at Princess MargareHospital to enter patient inormationComplete patient proles are vital in
designing the best cancer care plan.
Photo courtesy o Princess Margaret Hospitalpart o University Health Network.
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> Have their interests represented at a Patient Advisory Council
(a orum to advise on initiatives to improve the patient experience).
> Have access to psychosocial resources, standardized across the
province and based on international best practices.
Terms o engagement, andempowermentEngagement and empowerment are the two pillars o the Survivorship
Program at Princess Margaret Hospital, which provides consultation, advo-
cacy and education to patients at every phase o their cancer journey. The
program is designed to help rame the experience or patients, to ease their
conusion and ear and to give them a voice.
Our main message is, how can we help you? at a time when people oten
eel helpless, says Dr. Pamela Catton, Medical Director o the Breast Cancer
Survivorship Program. We help them understand and navigate the system,
so they dont eel overwhelmed by it. We provide direction on how they can
advocate and even negotiate their care. Ultimately, we show them its not
about the