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Cancer as a chronic disease:
Implications for Cancer Services in Ontario
Cancer Care Ontario
Annual General Meeting
April 26, 2007
Metropolitan Hotel
108 Chestnut Street
Toronto, ON
Overview
1.
Cancer Care Ontario: 2006-2007 in Review
2.
Cancer as a chronic disease
3.
Implications for the cancer system
1. Cancer Care Ontario: 2006-2007
in Review
How Are We Doing on
Volumes of Service?
Actual
20052006
Screens for OBSP
Actual
20062007
Growth
290,959
333,016
14.45%
New Radiation Cases
37,375
38,386
2.70%
New Systemic Cases
32,022
36,462
13.86%
4,186
5,116
22.22%
Additional Surgical Cases
Source: Cancer Care Ontario ICMS (OBSP), iPort (Radiation, Systemic), MoHLTC MIS (Systemic – non ICPs),
PMH (Radiation, Systemic)
How Are We Doing Financially?
2006/07 Annual Operating Budget:
531M
Funding to Healthcare Facilities
317M
New Drug Funding Program
141M
38M
MOHLTC Wait Times Strategy
CCO’s Financial Position (000s)
Net Position
Projected
Actual
March 31, 2007
500
March 31, 2006
851
Growth in MOHLTC Revenue
2004 - 2005
MOHLTC Funding
$
409,952
Projected
2006 - 2007
2005 - 2006
$
460,090
12%
$
530,919
15%
Ontario Cancer Plan
The final installment of the first 3 year
Ontario Cancer Plan released in
January 2007
– Roadmap for improving cancer
prevention and services
– Annual progress report and action
plan for year ahead
06-07 Highlights At-a-Glance
Significant Progress
 Smoke-Free Ontario
 First Colorectal Cancer
Screening Program
 Radiation and Surgery Wait
Times
No Improvement
 Overall Breast Cancer
Screening Rates
Overall Cervical Cancer
Screening Rates
Needs Attention
 Access to Chemotherapy
 Colorectal Cancer Screening
Rates
 Gaps in Patient Journey
 Healthy weights
 Local Cancer Service
Integration
 Quality and safety
•
•
•
Computerized Drug Ordering
Clinical guidelines
Organizational standards
 Data capture across continuum
Joint Oncology Drug Review
2. Cancer as a chronic disease
Number of newly diagnosed cancer cases
Aging & Growing Population are
Driving Increased Cancer Incidence
Source: Cancer Care Ontario, iPort.
Prevalence
10 Year Prevalence count and rates for all cancers,
Ontario, by age group
300,000
200
275,000
180
250,000
160
Age-standardized rate per 10,000
225,000
Number
200,000
175,000
150,000
125,000
100,000
75,000
140
120
20-44
100
45-74
75+
80
60
50,000
40
25,000
20
0
0-19
0
1984
2004
1984
Source: CancerYear
Care Ontario (Ontario Cancer Registry, 2007)
2004
Year
Cancer Care Then and Now
2004
1984
124,119 individuals alive within 10 years of
diagnosis
260,045 individuals alive within 10 years of
diagnosis
Single cancer drug costs $2,500
Single cancer drug costs $25,000
Number of cancer screening programs = 0
Ontario Breast Screening Program
Ontario Cervical Screening Program
Smoking allowed in workplaces,
restaurants, bars, airplanes
Smoke-Free Ontario introduced
–
100% ban on smoking in public spaces and
workplaces
Source: Cancer Care Ontario, Ontario Cancer Registry, New Drug Funding Program (iPort)
Transformation of Cancer
1936
1973
1994
2004
Long-Term Cancer Survival
Age Standardized Relative Survival Ratios for Major Cancers
Colorectal, Male
Colorectal, Female
Prostate
Female Breast
5 year relative survival ratio (%)
100
80
60
40
20
0
1975-79
1977-81
1979-83
1981-85
1983-87
1985-89
1987-91
Year of Diagnosis
Source: Cancer Care Ontario (Ontario Cancer Registry, 2007)
1989-93
1991-95
1993-97
1995-99
Age Standardized 5 Year Relative Survival Ratios for Two
Periods of Diagnosis (1977-79 vs. 1997-99)
All sites
Pancreas
1977-1979
Trachea, bronchus and lung
1997-1999
Stom ach
Leukem ia
Non-Hodgkin lym phom a
Colon and rectum
Kidney and other and unspecified
Oral cavity
Prostate
Fem ale breast
Melanom a of skin
Body of uterus
Thyroid gland
0
20
40
60
Percent
80
100
What is Behind the Transformation
of Cancer Survival?
• Better Prevention and Detection
•
•
•
•
Lifestyle
Infection control
Regulation
Screening
• More Precise/Effective Treatment Methods
• Image guided surgery
• IM/IG radiation
• Molecular/Biologic systemic therapies
• Population-Based Disease Prevention and Management
• Evidence based protocols
• Quality management
• Shorter knowledge transfer gap in use of evidence
Cancers Today
Cancer is over 200 different diseases, some of which are
chronic
• Cancers with poor survival growth – lung,
esophageal, pancreatic
• Chronic cancers – breast, prostate, colorectal
• Cancers with long shadows – childhood and young
adult cancer
Intensification of Systemic
Treatment in Canada
240,000
200,000
160,000
120,000
80,000
1997
1998
Incidence
1999
2000
2001
2002
2003
2004
Patients Receiving Drug Therapy
2005
After Effects of Cancer
Cancer treatments are improving but still dangerous:
•
260,000 10-year cancer survivors in Ontario
–
•
Second primary malignancies now account for 16% of all cancer incidence in this group
After Effects
–
Late effects on normal tissues
–
Radiation-induced second malignancies
–
Endocrine and reproductive effects
–
Cardiac toxicity
–
Cognitive effects
–
Anxiety, depression, psychosocial effects
Implication: need safer treatments, evidence-based treatment standards
Facts About Chronic Diseases
• Chronic disease accounts for 89% of all deaths in
Canada; projected to rise 15% in next 10 years
• Account for approx. two thirds of Canadian health
care spending
• Chronic diseases (cancer, heart disease and stroke,
emphysema and diabetes) share common, often
man-made causes: poor diet, smoking and inactivity
• Require population-based approach
Population-Based
Chronic Disease Management
• Focuses on prevention and wellness across care
continuum
• Hospitals’ focus on acute patients
• Encourages patients to take control; community-wide
education key
• Health policy and delivery system realignment
3. Cancer System Implications
Cancer System Implications
1.
Move towards disease management models of care
•
•
•
Fill gaps
Prevention and detection
Colorectal, lung
2.
Integration across the “cancer patient journey”
3.
Patient self-care
4.
Changing our mindset about cancer
Move towards disease
management models of care
Patient Journey
Colorectal Cancer Patient Journey
Primary Care &
the Cancer Journey
Specialty Care
Primary Care
Primary Care
Primary Care Practices
with Advanced Information Capacity
Percent reporting seven or more out of 14 functions*
100
75
87
83
72
59
50
32
19
25
8
0
AUS
CAN
GER
NETH
NZ
UK
US
Count of 14: EMR, EMR access other doctors, outside office, patient; routine use electronic ordering tests, prescriptions,
access test results, access hospital records; computer for reminders, Rx alerts, prompt tests results; easy to list diagnosis,
medications, patients due for care. Canadian Primary Care Doctors = 578
•Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians
.
Patients Routinely Sent Reminder
Notices for Preventive or Follow-Up Care
Yes, using a manual system
Percent
Yes, using a computerized system
100
75
5
18
16
50
25
14
24
65
20
93
83
61
28
18
8
0
AUS
CAN
GER
32
NETH
NZ
UK
US
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Opportunities for Primary Care
Family Health Teams
• Aligning incentives for health promotion, prevention,
chronic disease management
• P-Prompt: promising innovation
• Biggest challenge: Digital Divide
• Effective electronic integration of office systems,
secondary, tertiary care
– prompts, reminders, call backs, interoperable systems
Opportunities for Primary Care
Partnership with the Ontario College of Family
Physicians, Family Health Teams
Colorectal Cancer Screening Program
– Opportunity: Trusted contact point for patients; opportunity to
test chronic disease management innovations
– Challenge: Family physicians have low awareness, lack of
consensus about colorectal screening; poorly linked to
cancer care system
Diagnostic Assessment
Programs (DAPs)
• The diagnostic phase of cancer care (Wait 1) has critical
impact on a patient’s anxiety, health and well-being
• One of least developed areas of “cancer journey”
• CCO created DAP standards
– All models include: multidisciplinary teams,
customized patient information, psychosocial support,
primary care or self-referral
Ottawa Diagnostic
Assessment Unit
Champlain Model for Improving Access to Quality Cancer Surgery
The Montfort Hospital
The Ottawa Hospital (TOH)
Satellite Cancer
Program
Cancer Hub
TOH Regional Cancer Centre
Cancer Assessment Centre
•
•
•
•
The Queensway-Carleton Hospital
Satellite Cancer
Program
Leadership in Quality Agenda
Central Coordination
Access to Integrated Cancer Care
Surgical Consultation for Ottawa
Patients and Complex Case
Renfrew Victoria Hospital
Cornwall Community Hospital
Satellite Cancer
Program
Pembroke Regional Hospital
Satellite Cancer
Program
Satellite Cancer
Program
Satellite Cancer
Program
Winchester District
Memorial Hospital
Satellite Cancer
Program
Hawkesbury District
General Hospital
Cancer Surgery Standards
Distribution of Thoracic Cancer
Surgery Index Cases in Ontario, 2004-2005
Distribution of Thoracic Cancer Surgery Index Cases in Ontario, 2004-2005
300
250
Lung
Number of cases
Esoph
200
150
100
50
0
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
Hospital
W
X
Y
Z
AA
BB
CC
DD
EE
FF
GG
HH
II
KK
LL
MM
NN
OO
Regional Model for Quality
Systemic Therapy
Regional Model for Quality Systemic Therapy
Level 1 or 2
Integrated Cancer Program
 Academic Leadership
 Complex Care
Level 3
Systemic
Systemic Therapy
Therapy
Satellite
Affiliate
Level 4
Systemic Therapy
Satellite
REGIONAL SYSTEMIC THERAPY PROGRAM
Level 3
Systemic Therapy
Affiliate



Standards and Clinical Pathways
Performance Data
Multidisciplinary Cancer Conferences
Level 4
Systemic Therapy
Satellite
Level 3
Level 3
Systemic Therapy
Systemic Therapy
Affiliate
Affiliate
Systemic Therapy
Systemic Therapy
Satellite
Satellite
Formal Agreement
Level 4
Level 4
End-of-life Care
85% of palliative
patients have cancer.
Most prefer to die in
community/home; 53%
died in hospitals
Palliative Care
Integration Project –
standard tool to
improve symptom
management, pain;
allow cancer patients to
die in setting of choice
CCO Research Program
Experimental
Therapeutics
Molecular
Epidemiology
Imaging
Health Services Research
Integration Across the “Cancer
Patient Journey”
CCO Model for Driving
Performance Improvement
1. Data/Information
2. Knowledge
•
•
•
•
•
•
•
•
Incidence, mortality, survival
analysis
indicator development
expert input
4. Performance
Management
•
•
•
•
institutional agreements
quarterly review
quality - linked funding
clinical accountability
research production
evidence-based guidelines
policy analysis
planning
3. Transfer
•
•
•
•
•
•
publications
practice leaders engaged
policy advice
public reporting
technology tools
process innovation
Cancer System Integration
There is
variation
across
several
dimensions
of cancer
services
integration.
Patient Self-Care
Patient-Centred Care?
Outcomes
Among the domains of
patient satisfaction
(coordination, respect for
patient preferences,
physical comfort,
communication &
education, access,
emotional support)
emotional support is
consistently ranked lowest
(57% in 2006)
Patient Self-Care
• Survivorship vs. thrivership
• Balancing professional and
informal supports
• Reaching out to vulnerable
populations
PMH Breast Cancer Survivorship Program:
Interventions for self-care of late effects
Memory, Weight loss and Fatigue
Clinics:
• Education strategies, tips and
coaching survivors for selfcare
• Disease self management
tools
Changing Our Mindset
About Cancer
“People everywhere are going over the cliffs, developing
cancers that could be prevented, dying of cancers that
could be cured. Some 700,000 Canadians have cancer
today, me included. Your job is to stop that happening.
Don’t leave here until you have a blueprint and a flow
chart. And your luggage bulging with determination.
I wish you well.”
- June Callwood, National Cancer Leadership Forum, 2003