Cancer surgical care, outcomes vary widely across Canada

Cancer surgical care and patient outcomes vary widely in Canada, depending on where you live, but could be improved through a set of national standards, a new report says.

The reportreleased Thursday, also has high praise for "regionalization," where high-risk, high-resources cancer surgery cases are grouped into specific centres, while the researchers acknowledge the limitations.

Five types of cancer were included in the report lung, ovarian, pancreatic, liver and esophageal for which the surgical route is often considered complex and high risk, although still the best chance for a cure or the management of the disease if it's caught in the earlier stages.

The report was based mostly on information gathered from 2004 to 2012 from the territories and nine provinces, not including Quebec, and looked at variances from 2010 to 2012.

It says Ontario has the most explicit regionalization policies and guidelines to fight lung, pancreatic, liver and oesophageal cancers. Still, Ontario joined Saskatchewan and Nova Scotia in having marginally higher mortality rates than the nine-year national average.

The bulk of research supports the regionalization of cancer care, based on measures such as in-hospital mortality rates and length of stay, according to the report.

Among the report's recommendations:

• Provinces should adopt more than just a simple consolidation of surgical services forregionalization. It encourages improvements in reporting and the development of clinical guidelines.
• Nationally implemented standards of care should be developed for each cancer surgery type.
• Surgical cancer care should be integrated into the spectrum of provincial cancer services, with the capacity for establishing systemic evaluation and the provision of sufficient resources to enact change.

Canada's low population density

One of the key problems in setting up systems with highly specialized diagnostic and surgical resources is population distribution. The report says at least some of the the disparities in care and outcomes can be attributed to low population density across Canada.

The report says the positive impact of regionalization on surgical cancer care is often expressed as a "volume-outcome" relationship, where larger volume centres have better patient-centred outcomes.

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Higher volume centres predicted a significantly lower risk of inhospital mortality and shorter length of stay.

The impact of hospital volume on the risk of inhospital mortality was most pronounced for esophageal and pancreatic cancers.

"There is a tremendous variance in inhospital mortality, resection (surgery)rate, and length of stay outcomes of highrisk cancer surgical care across Canada," the report says.

Esophagealcancer death rate in Manitoba

In many of the surgeries evaluated, there was a three to four times difference in mortality rates between the provinces.

One such difference was reported in the case of esophageal cancer, where patients in Newfoundland and Labrador saw a 2.72 per cent mortality rate over the period of 2004-2012, while those in Manitoba saw an 11 per cent risk of death.

"These results are both statistically and clinically significant, and are partly due to hospital and/or surgeon volumes," the report says.

New Brunswick had the highest rate for lung cancer surgeries, increasing from 43 to 58 surgeries per capita over the two time periods.

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The province also had an in-hospital mortality rate 1.4 per cent higher than the nine-year national average.

In Manitoba, the researchers found the three-year crude mortality rate for esophageal cancer surgeries was double that of the national average.

Some of that variation in the rate could be explained by the small total provincial case load. However, the report says the numbers could also be partially explained by other factors, including surgeon speciality and staff training.

B.C. with 4 large-volume centres

B.C. was singled out for managing an increasing volume of lung, liver, and esophageal procedures by consolidating surgical care into four large-volume centres. Overall, the three-year mortality rates were lower than the national average for all the procedures studied.

"Several participants from the Ontario and Alberta citizen panels acknowledged that they were lucky to live near a regional centre of excellence for cancer (in Hamilton or Edmonton)," the authors wrote.

Still, while those on the Ontario panel praised moves to improve the delivery of complex cancer surgeries, they noted a perceived lack of choice for local treatment options for example, the choice to be a patient at a high-volume hospital.

All of the citizen panels the third one made up of citizens from P.E.I. emphasized a preference for high-quality surgical are rather than convenience.

Researchers noted that an unintended consequence of regionalization is longer surgical wait times in high-volume centres. On the plus side, these systems offer the chance for partnering among staff with varying expertise.

Another challenge to improving care is the rising incidence rates for most cancers and an aging population, increasing demand for surgeries.