J. Niu

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

Approximately 9200 people in Canada die from colorectal cancer each year1, and about 20% of those tumours involve the rectum2. Surgery is the first-line treatment for nonmetastatic rectal cancer; the goal is complete removal of the tumour with no residual cancer cells left behind. Rectal cancer care has become increasingly multidisciplinary. Most treatment guidelines suggest that neoadjuvant therapy, including chemotherapy and radiation, be considered in the treatment of stage ii and iii rectal cancer, both to shrink the tumour and to improve surgical and overall outcomes3. The circumferential resection margin (crm), also called the radial margin, is very important in rectal cancer surgery, being a prognostic factor in patients who undergo such surgery. As recorded in the pathology report, a positive crm has been defined as a margin of normal tissue that is 1 mm or less from the edge of the original tumour, a measurement that comes from evidence-based guidelines4. A crm of less than 1 mm has been shown to be a strongly negative prognostic factor: specifically, it predicts for subsequent locoregional recurrence and poorer overall survival4. Guidelines recommend negative margins (>1 mm) for all rectal cancer patients who undergo resection5,6, and the rate of crm positivity is widely used as a quality indicator in rectal cancer care. Two major changes in rectal cancer treatment since the early 1990s are recognition of the importance of surgical technique (and specifically the adoption of total mesorectal excision) and increased use of neoadjuvant therapies. Those changes have contributed both to a reduction in positive crm rates and in local and regional recurrences. However, despite best efforts, concern remains about potential variations in rectal cancer treatment and outcomes. The System Performance Initiative at the Canadian Partnership Against Cancer regularly reports on standardized indicators at a national level to help identify opportunities for pan-Canadian system improvements. Recognizing that surgical resection is generally recommended as first-line treatment for nonmetastatic disease, the first indicator presented in this rectal cancer surgery–focused report is the rectal cancer resection rate. The second indicator is the rate of crm positivity among patients undergoing rectal cancer resection. A better understanding of the data can help to identify best practices, which in turn can inform quality improvements.

Provincial rates and time trends in pancreatic cancer outcomes

Pancreatic cancer, often called the “silent killer,” is the twelfth most common cancer in Canada, with an estimated 4600 new cases in 20121. Surpassing prostate cancer, pancreatic cancer is also the fourth leading cause of cancer-related death in Canada, with an estimated 4300 deaths in 20121. Smoking, obesity, diabetes, and genetic predisposition are all known risk factors for pancreatic cancer. Currently, no early detection method and no effective treatment are available for pancreatic cancer2. Of all patients diagnosed with pancreatic cancer, 75% die within the first year, most within the first 3–6 months2. The objective of the present article is to highlight the outcomes of this highly fatal cancer. Further details on the results and on the methodologies used can be found in the 2012 Cancer System Performance Report released by the Canadian Partnership Against Cancer as part of the system performance initiative.

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

BACKGROUND Communication with health care providers during diagnosis and treatment planning is of special importance because it can influence a patients emotional state, attitude, and decisions about their care. Qualitative evidence suggests that some patients experience poor communication with health care providers and have negative experiences when receiving their cancer diagnosis. Here, we use survey data from 8 provinces to present findings about the experiences of Canadian patients, specifically with respect to patient-provider communication, during the diagnosis and treatment planning phases of their cancer care. METHODS Data from the Ambulatory Oncology Patient Satisfaction Survey, representing 17,809 survey respondents, were obtained for the study. RESULTS Most respondents (92%) felt that their care provider told them of their cancer diagnosis in a sensitive manner. Most respondents (95%) also felt that they were provided with enough information about their planned cancer treatment. In contrast, more than half the respondents who had emotional concerns upon diagnosis (56%) were not referred to services that could help with their anxieties and fears. Also, 18% of respondents reported that they were not given the opportunity to discuss treatment options with a care provider, and 17% reported that their care providers did not consider their travel concerns while planning for treatment. CONCLUSIONS Measuring the patient experience allows for an understanding of how well the cancer control system is addressing the physical, emotional, and practical needs of patients during diagnosis and treatment planning. Although results suggest high levels of patient satisfaction with some aspects of care, quality improvement efforts are still needed to provide person-centred care.

Geographic disparities in surgery for breast and rectal cancer in Canada

Overall, the results demonstrate that geographic location poses a potential challenge to access, although it is only one facet of access to care. Our findings suggest that there are opportunities to better understand and potentially to improve care for Canadians residing in areas remote from cancer treatment facilities. More information about this report can be found at http://www.cancerview.ca/systemperformancereport. Downloadable slides of the figures in this communication can be downloaded at http://www.cancerview.ca/downloadableslides.

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

The 2012 Cancer System Performance Report is the 4th annual report on the Canadian cancer control system produced by the System Performance initiative at the Canadian Partnership Against Cancer, in collaboration with its provincial and national partners. The 2012 report presents, for 4 provinces, the percentage of all resected stage ii and iiia non-small-cell lung cancer (nsclc) patients receiving adjuvant chemotherapy consistent with treatment guidelines from the National Comprehensive Cancer Network1 and the results of a chart review undertaken to validate the indicator results and to examine reasons for non-concordant treatment.

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

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

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

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

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

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

Recent trends in breast, cervical, and colorectal cancer screening test utilization in Canada, using self-reported data from 2008 and 2012

In Canada, self-reported data from the Canadian Community Health Survey 2008 and 2012 provide an opportunity to examine overall utilization of breast, cervical, and colorectal cancer screening tests for both programmatic and opportunistic screening. Among women 50-74 years of age, utilization of screening mammography was stable (62.0% in 2008 and 63.0% in 2012). Pap test utilization for women 25-69 years of age remained high and stable across Canada in 2008 and 2012 (78.9% in 2012). The percentage of individuals 50-74 years of age who reporting having at least 1 fecal test within the preceding 2 years increased in 2012 (to 23.0% from 16.9% in 2008), but remains low. Stable rates of screening mammography utilization (about 30%) were reported in 2008 and 2012 among women 40-49 years of age, a group for which population-based screening is not recommended. Although declining over time, cervical cancer screening rates were high for women less than 25 years of age (for whom screening is not recommended). Interestingly, an increased percentage of women 70-74 years of age reported having a Pap test. In 2012, a smaller percentage of women 50-69 years of age reported having no screening test (5.9% vs. 8.5% in 2008), and more women reported having the three types of cancer screening tests (19.0% vs. 13.2%). Efforts to encourage use of screening within the recommended average-risk age groups are needed, and education for stakeholders about the possible harms of screening outside those age groups has to continue.

Examining the use of PET scans in the diagnosis and management of non-small cell lung cancer patients.

311 Background: PET Scans are increasingly used in the diagnosis and management of non-small cell lung cancer (NSCLC) patients. However, uptake of PET at provincial level is not well studied. This project, led by the Canadian Partnership Against Cancer, established processes and indicators to describe utilization of PET in patients with NSCLC. These indicators support the monitoring of uptake and highlight areas for quality improvement strategies at the national and provincial level. METHODS Cases of NSCLC, diagnosed in the study period of 2009-2011, were identified from cancer registries and linked to PET utilization data. PET scans were identified as indicated for diagnosis/staging or treatment response, based on the timing of scans relative to diagnosis and treatment dates. Scans conducted three months prior to and up to four months post-diagnosis but before start of treatment (surgery or radiation) were identified as diagnosis/staging. Scans conducted after the start of treatment to ten weeks post-treatment were identified as management and follow-up of treatment. RESULTS A total of 27,984 cases of NSCLC were identified. Preliminary analysis revealed that 8,947 (32.0%) of NSCLC patients had at least one PET scan. Some variation was seen in age, with those 18 to 69 years more likely to receive a scan than those 70 years and older. PET scan use was higher among stages I and II (52.3% to 50.6%) compared to stage IV (17.98%). A majority of PET scans were performed for diagnosing/staging NSCLC (91.1%). PET scans for diagnosis/staging were highest for patients with stage I (36.7%) followed by stage IV (24.6%). CONCLUSIONS This study provided information on the current use of PET technology across Canada, allowing for identification of opportunities for increasing evidence-based use while decreasing extra-evidential use, and forming a baseline for future monitoring as evidence evolves.