Cancer care discrepancies found

The quality of surgery for cancer patients is inconsistent across Ontario, and some patients are not getting the surgeries they need to survive, a new report has found.
A detailed map of cancer surgery in Ontario has revealed the type, quality and number of cancer surgeries varies across the province. It also found the incidence of cancer varies from region to region, an indication that some patients may not be getting proper diagnoses.
Cancer patients in the Greater Toronto Area are largely getting better surgical care than those in other regions in the province. Many patients from other regions travel to Toronto for surgeries.
Experts say the report, released yesterday by the Institute for Clinical Evaluative Sciences, highlights the need to standardize cancer care across the province's 14 Local Health Integration Networks.
The report found, for example, large inconsistencies across health regions in the number of lumpectomies performed to treat breast cancer. In the Mississauga Halton health region, 75 per cent of patients had lumpectomies – 20 per cent higher than the provincial average – while only 46 per cent of patients in the Erie St. Clair health region had the procedure.
"The goal is to offer equal care as close to home for patients as quality permits," said Terry Sullivan, president and CEO of Cancer Care Ontario, the provincial agency charged with improving cancer care and which commissioned the report.
In a forward to the 200-page report, Sullivan called the discrepancies in surgical care across health regions "somewhat perplexing." However, he was quick to point out in an interview yesterday with the Star that many of the report's recommendations have already been implemented.
The report examined data collected from more than 31,000 newly diagnosed cancer patients over a one-year period in 2003 and 2004. The patients had been diagnosed with either breast, lung, prostate or colorectal cancer, or a cancer of the female genital tract.
Dr. Jonathan Irish, the provincial head of the surgical oncology program at Cancer Care Ontario, said the report provides valuable information to help plan cancer services and implement best practices. But, he cautioned, "It's not a snapshot of the present, so it might not exactly reflect current practice," pointing out the data was collected during the SARS crisis, which could have changed how doctors across the province referred patients.
Irish said researchers need to continue collecting data on cancer surgeries – an often under-reported aspect of cancer care – and put out a similar report every other year.
Many of the recommendations in the current atlas have already been implemented over the past three years, Irish said. His program at Cancer Care Ontario has brought together surgery experts to form "communities of practice" for lung, colorectal, breast and prostate cancers, which have already initiated improvement programs.
"Not only does the atlas raise some possible areas of improvement, but it also really validates some of the things we're already doing over the last four years," he said.
Since the report's data was collected, the province has adopted standards for how to biopsy lymph nodes during breast cancer surgeries. That was one of the key gaps in care identified in the report, which found 24 per cent of breast cancer patients in Ontario did not have underarm lymph nodes sampled during surgery, although it helps determine whether the cancer has spread.
Efforts are also underway to consolidate lung cancer specialists in centres of excellence around the province, said Sullivan. The report found only 19 per cent of lung cancer patients had a surgical procedure to remove their tumours.
Studies have shown concentrating expertise raises standards of care and improves a patient's overall outcome, Sullivan said.
"We have gone from more than 40 hospitals that do a few cases a year to a smaller number of hospitals that do many more cases," he said, pointing out physicians who rarely treat lung cancer may not be as up-to-date as those who regularly treat the disease. "We are looking for 12 or 13 or 14 hospitals as designated thoracic surgery centres."
One of the report's more troubling findings pinpointed discrepancies in care for prostate cancer. The report found men who lived in the poorest neighbourhoods were least likely to be diagnosed with prostate cancer and were also least likely to undergo a radical prostatectomy, known as curative surgery, after diagnosis. The discrepancy was greatest between Central West region, which had the highest incidence, and the Toronto Central region, which had the lowest.
Researchers know patients of lower socioeconomic status do not regularly see a doctor and so may get diagnosed too late for surgery. Irish said this a key area for future study.

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