ontario cancer plan

8/8/2019 Ontario Cancer Plan

1/64

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


2/64

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


3/64O n t a r i O C a n C e r P l a n

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


4/64

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.


5/64

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


6/64

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.



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


8/64



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.


10/64

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.



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


12/640 < O n t a r i O C a n C e r P l a n

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.


13/64O n t a r i O C a n C e r P l a n >

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


14/642 < O n t a r i O C a n C e r P l a n

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


15/64

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


16/64

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.



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.


18/64

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.


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



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


20/64

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.



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


22/64

> 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.


Managing your health with a balancedmeal as shown by Clinical Dietician Paulina

Araujo can lower your risk o some cancers.


There has been limited

progress in ormally

addressing other cancer

risk actors such asobesity, physical activity,

and UV exposure.



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.


24/64

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.


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.



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


26/64

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




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.


28/64

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.


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.


Ontario has one o the highest incidences colorectal cancer. Colorectal cancer is

he second deadliest orm o cancer.


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.



> 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


30/64

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




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.


32/64

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.


Multidisciplinary Cancer Conerencesring together health proessionals to

make the best decisions or patients.

hoto courtesy o Juravinski Cancer Centreart o Hamilton Health Sciences.


33/64

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


34/64

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


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.



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.


36/64


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.


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.



> 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




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).


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.




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.


42/64

> 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

ontario cancer plan

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