North gets in line with the Ontario Cancer Plan

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Northern Ontario cancer care professionals are working hard to meet the standards set out by the Ontario Cancer Plan for 2008-2011.

Developed by Cancer Care Ontario, the plan aims to reduce the incidence of cancer and improve the health and quality of life of cancer patients. It is an update of the first such document, which set out a plan for the years 2004-2007.

The Ontario Cancer Plan for 2008-2011 has six goals:

• reduce the incidence of cancer.
• reduce the impact of cancer through effective

screening and earlier detection.

• ensure timely access to effective diagnosis and high

quality cancer care.

• improve the patient experience in every step of the

cancer journey.

• improve the performance of Ontario's cancer system
• strengthen Ontario's ability to translate cancer

research into improvements in cancer services and
control.

Reducing the incidence of cancer

It's no secret that Northern Ontario has a high incidence of cancer because of high smoking and obesity rates.

According to statistics compiled by Cancer Care Ontario, in 2004, women in the North East Local Health Integration Network (LHIN) had the second highest incidence of lung cancer among the 14 LHINs in the province, falling only behind North Simcoe and Muskoka.

Men living in the same area had the third highest incidence of lung cancer in the province. Those living in the North West LHIN seem to be doing better than their counterparts in the northeast, with both men and women having the seventh highest incidence of lung cancer in the province.

"In this part of the world, if you're a smoker and have higher-than-average exposure to environmental hazards, you're increasing your chances of getting lung cancer," said Bertha Paulse, vice-president of the Sudbury Regional Hospital's Regional Cancer Program.

"We have very high smoking rates in Northern Ontario. We're not as high as Quebec, but we're very high."

In the North East LHIN, both men and women had the highest incidence of colorectal cancer in the province. The picture was slightly better in the North West LHIN, with colorectal cancer incidence rates being the fifth highest in the province among men and twelfth highest among women.

The Ontario Cancer Plan has pinpointed two goals to reduce the incidence of cancer in the province - intensifying the efforts to support healthy eating and active living, and gaining a better understanding of the role that occupational and environmental carcinogens play in causing cancer.

Paulse said the northeast cancer program can't do much about reducing cancers caused by occupational and environmental carcinogens other than raising awareness and supporting stricter regulations.

The Cancer Prevention and Screening Network, which includes public health units and charities such as the Canadian Cancer Society and the Heart & Stroke Foundation, is responsible for ensuring there is a consistent message about the prevention of cancer through healthy lifestyles.

The northeast cancer program is also encouraging patients and staff at Sudbury Regional Hospital to quit smoking, said Paulse.

"We've found that 60 per cent of the patients coming in for cardiac surgery are smokers. Even on the oncology floor, the prevalence of smoking is really high," she said.

"We introduce them to the concept of smoking cessation, and if they're interested in quitting, then we link them up with home support services through either the public health units or a helpline. We also offer smoking cessation support for our staff. In excess of 45 per cent of our employees smoke," said Paulse.

Michael Power, vice-president of regional cancer services and diagnostics at the Regional Cancer Care Northwest program, said his organization is also working with regional partners to promote a healthy lifestyle.

The incidence of obesity, smoking and alcohol consumption in northwestern Ontario exceeds the provincial average.

One of the biggest impacts for cancer prevention is coming from the 2006 Smoke Free Ontario Act, said Power.

The latest part of the anti-smoking legislation came into effect June 1, and requires retailers to cover up their displays of cigarettes.

Screening and earlier detection

Northern Ontario is doing well when it comes to meeting the 2011 screening goals set out by the cancer plan.

One of these goals is to get 70 per cent of Ontario women aged 50 to 69 to receive mammograms every two years.

According to the Cancer System Quality Index (CSQI), in 2007, 65 per cent of women aged 50 to 69 in the area covered by the North West LHIN had received a mammogram in the past two years.

In the North East LHIN, in 2007, the CSQI showed that 63.7 per cent of women aged 50 to 69 had received a mammogram in the past two years. The provincial average for breast screening is just 62.8 per cent.

Many women choose to get mammograms at the Ontario Breast Screening Program, which offers mammography, clinical breast examination, instruction in breast self-examination and a systematic two-year recall for clients.

The second goal is to get 85 per cent of Ontario women aged 20 to 69 to receive cervical screening (or pap smears). The CSQI shows that in 2007, 67.9 per cent of women in the North West LHIN and 67.5 per cent of women in the North East LHIN received cervical screening.

The provincial average for cervical screening is 70.5 per cent.

Ensuring at least 40 per cent of both men and women between the ages of 50 and 74 have received colorectal cancer screening in the last two years is the plan's third screening goal.

The CSQI shows that in 2007, 18.3 per cent of those eligible in the North West LHIN received colorectal cancer screening. In the North East LHIN, 17.4 per cent received colorectal cancer screening.

Last year, the province introduced ColonCancerCheck, Canada's first province-wide colorectal cancer screening program. People over the age of 50 with no family history or symptoms of colorectal cancer are being encouraged to take a fecal occult blood test by their family doctors.

The program will also increase access to colonoscopies for individuals who have a positive FOBT, as well as those who have a family history of colorectal cancer.

Paulse said the northeast cancer program has a cancer screening and prevention division. Part of the division's role is to work with family doctors and nurse practitioners to ensure they are screening their patients for cancer, she said.

"The objective of the exercise is to change the risk factors and improve quality of life and survival rates. It has a tremendous impact."

Power said the northwest cancer program is very active in raising awareness of cancer screening. To that end, it even brought the Colossal Colon to Thunder Bay. The 40-foot-long, four-foot tall oversized model of the human colon was built by an American organization called the Colon Club.

As well, to offer more screening options for average-risk people, the northwest cancer program launched a pilot program with Dr. Gabriel Mapeso to have specially trained nurses perform flexible sigmoidoscopies to screen for colorectal cancer.

The Northern Cancer Fund of the Thunder Bay Regional Health Sciences Foundation also granted $300,000 for colonoscopy scopes in Thunder Bay, Marathon, Dryden, Fort Frances and Kenora to help increase access to colorectal cancer screening across the northwest.

"We've increased colonoscopy volumes by 25 per cent," said Power. "Clearly, detection of cancer at an earlier stage leads to better outcomes and reduces expense to the system. In the absence of prevention, patients would obviously want to be diagnosed with cancer at stage one as opposed to stage four."

Access to effective diagnosis and cancer care

The cancer plan also has four major initiatives designed to ensure timely access to effective diagnosis and high-quality cancer care.

These initiatives will ensure that adequate services are available to meet the needs of cancer patients and that every LHIN has a high-quality Regional Cancer Program. It also urges the streamlining of diagnostic assessment and the application of new knowledge emerging from molecular oncology research.

Paulse said the northeast cancer program has seen great improvements in recent years, with renovations to the Sudbury site that allowed the organization to increase the number of linear accelerators (radiation treatment units) from three to five.

By early 2011, when the new Sault Area Hospital is built, another linear accelerator will be available for use there, she said.

Chemotherapy is also available at many smaller hospitals in the northeast, said Paulse.
The northeast cancer program has one of the largest telemedicine programs in the country, with about 4,000 patients a year attending appointments with oncologists and other specialists by teleconference, she said.

Multidisciplinary case conferences, made up of several health care professionals caring for a patient, have been used for about two years, said Paulse. These conferences, which are also emphasized in the cancer plan, often include out-of-town health professionals attending by teleconference.

Another area of cancer care emphasized in the cancer plan is making intensity modulated radiation therapy (IMRT) available. IMRT allows oncologists to deliver radiation with precision right into the tumour, protecting healthy tissue and minimizing side effects.

"We're doing intensity modulated radiation therapy for most head and neck cancers, and certain prostate cases," said Mark Hartman, administrative director of the Sudbury Regional Hospital Regional Cancer Program.

"It will be expanded as evidence shows clinical need."

Paulse said the northeast cancer program keeps a close eye on radiation, chemotherapy and cancer surgery wait times, and the region is well within the parameters set by the province.

The northwest cancer program is making steady progress in improving wait times for pathology and diagnostic procedures, said Power.

Pathology turn-around times have decreased dramatically from a high of 23 days to five days, and diagnostic imaging has added after-hours CT clinics to meet increasing demand.

As of March 2008, IMRT is being used by the northwest cancer program, he said.

"It's a brand-new standard. The evidence was only out in January and February that we should go live with IMRT. We're one of the first sites in the province to do it," said Power.

Chemotherapy is also provided outside of Thunder Bay at hospitals throughout the northwest. Multidisciplinary case conferences are also used, with every patient having the opportunity to have their case reviewed by a multidisciplinary team before they begin treatment.

Improving the patient experience

Three goals for improving the patient experience are laid out in the cancer plan: moving towards a truly patient-centric system, improving psychosocial care for cancer patients and improving palliative and end-of-life care.

The northeast cancer program has a number of initiatives meant to improve the patient experience, said Paulse.

Cancer patients are able to access a supportive care team of health care professionals such as physiotherapists, nutritionists, social workers and speech language pathologists to help them deal with the side effects of their treatment and disease.

For example, head and neck cancer patients who have partially or completely lost their voices because of their condition would see a speech language pathologist to find ways to restore their voices.

The dental oncology program provides cleaning for radiation and chemotherapy patients, as well as prostheses for patients who have been left with defects due to cancer surgery, said Paulse.

Patients being treated at the northeast cancer program have access to a self-serve kiosk where they report the intensity of symptoms such as nausea and pain. They are tracked every time the patient goes to the cancer centre so physicians and nurses see how their condition is progressing over time.

As well, by late this summer, people in both Sudbury and Sault Ste. Marie will be able to receive end-of-life care at two new 10-bed residential hospices.

Power said the northwest cancer program has many innovative programs related to making the system more patient-friendly, including patient navigators who help breast cancer patients.

"Rather than tracking down your physician when you need results, or tracking down education information as you're moving through the cancer system, you call your patient navigator, and they will get the information for you. It's kind of a buddy system."

In Thunder Bay, a hospice is not yet under construction because community members feel they cannot raise sufficient operating funds.

Improve the performance of Ontario's cancer system

The cancer plan also identifies the goal of continuous quality improvement within the province's cancer system.

The CSQI is a valuable tool for administrators to use to look at where improvements need to be made, said Paulse.

According to the index, the northeast cancer program could be doing better when it comes to reducing wait times for diagnosis, she said. The answer to this problem is ensuring family doctors know what tests to order for their patients before they see a cancer specialist.

"If you're coming from your family physician, there will be specific diagnostic procedures that you will need for the confirmation of a cancer diagnosis," she said.

"We are working on providing family physicians with clinical pathways as to what diagnostic procedures patients should have. It will speed up the diagnostic process so we can get the patients in earlier for surgery and treatment."

The northwest cancer program is also committed to improving standards based on the CSQI results, said Power.

The program has some specific priorities for the next few years, including improving the patient journey for the most predominant disease groups (breast, lung, colorectal, prostate and gynae), replacing the current oncology patient information system and continuing to monitor wait times.

Translating cancer research into better cancer services and control

The cancer plan identifies research as "the engine that drives improvements in cancer prevention, detection and care when it is rapidly translated into the delivery of care."

Among the priorities in this area are research into the use of cancer imaging tools such as magnetic resonance imaging (MRI), positron emission tomography (PET), computerized tomography (CT) and ultrasound.

Other priorities are experimental therapeutics, including new drugs and device-based treatments, studying the ways in which cancer prevention, screening and care services are best delivered, and studying large groups of people to understand cancer risk factors, prevention and treatment.

Paulse said the northeast cancer centre's researchers are currently testing
chemotherapy drugs to have a better understanding of how the drugs interact with cells.

"We have a number of research initiatives looking at the relationship between the cellular function and the therapeutic impact of particular drugs."

The north's only PET scanner was recently introduced at the northwest cancer program.

The new Philips Gemini TF PET-CT unit, "the best, the fastest and the most accurate" diagnostic imaging device on the market, will be used for research purposes and clinical trials, said Power.

"We're going to be one of the most significant and successful research programs in molecular imaging in the country," he said.

"Molecular imaging is the revolution in health care and cancer care. The movement away from treating very sick cancer patients with very expensive drugs to treating more and more cancers at early stages of development is leading to less expensive health care and more optimal outcomes."

www.cancercare.on.ca
www.neorcc.on.ca
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