Cancer Care Ontario Research Articles

Update on Practical Management of Early-Stage Non-Small Cell Lung Cancer (NSCLC): A Report from the Ontario Forum

Therapeutic strategies for early-stage non-small cell lung cancer (NSCLC) are advancing, with immune checkpoint inhibitors (ICIs) and targeted therapies making their way into neoadjuvant and adjuvant settings. With recent advances, there was a need for multidisciplinary lung cancer healthcare providers from across Ontario to convene and review recent data from practical and implementation standpoints. The focus was on the following questions: (1) To what extent do patient (e.g., history of smoking) and disease (e.g., histology, tumor burden, nodal involvement) characteristics influence treatment approaches? (2) What are the surgical considerations in early-stage NSCLC? (3) What is the role of radiation therapy in the context of recent evidence? (4) What is the impact of biomarker testing on treatment planning? Ongoing challenges, treatment gaps, outstanding questions, and controversies with the data were assessed through a pre-meeting survey, interactive cases, and polling questions. By reviewing practice patterns across Ontario cancer centers in the context of evolving clinical data, Health Canada indications, and provincial (Cancer Care Ontario [CCO]) funding approvals, physicians treating lung cancer voiced their opinions on how new approaches should be integrated into provincial treatment algorithms. This report summarizes the forum outcomes, including pre-meeting survey and polling question results, as well as agreements on treatment approaches based on specific patient scenarios.

An assessment of cancer centre level designation and guideline adherent care in those with rectal cancer: A population based retrospective cohort study

BackgroundInstitutions providing care to individuals with cancer are organized based on available resources and treatments offered. It is presumed that increasing levels of care will result in improved quality of care and outcomes. The objective is to determine whether Cancer Level Designation is associated with guideline adherent care and/or survival. MethodsThis is a retrospective study of individuals within the Ontario Rectal Cancer Cohort, a population-level database including all adults undergoing surgical resection for rectal cancer between 2010 – 2019 were included in Ontario, Canada. The primary exposure was Cancer Centre Level Designation as defined by Cancer Care Ontario (i.e., Level 1/2 = regional cancer center; Level 3 = affiliate cancer center; Level 4 = satellite cancer center). The primary outcomes were guideline adherent care and survival. Associations were determined using one-way analysis of variances and a multivariable Cox proportional hazards model. Results12,399 patients were included with 54 % from a Level 1/2 centre, 33 % from a Level 3 centre and 13 % from a Level 4+ centre. All assessed aspects of guideline adherent care were associated with cancer centre level designation. Unadjusted 5-year overall survival was associated with cancer centre level designation (Level 1/2 79.5 % vs. Level 3 79.1 % vs. Level 4/non-designated 75.4 %, P = 0.003). Adjusted Cox Proportional Hazard Analysis for overall survival found the following: Level 4/5 HR 1.11 (95 %CI 0.99 – 1.25); Level 3 HR 1.01 (95 % CI 0.93 – 1.11); Level 1/2 1 [Referent group]. ConclusionsIncreasing Cancer Centre Level Designation was associated with higher likelihood of receiving the appropriate investigations and treatments in those with rectal cancer and may also be associated with survival. Policy SummaryFuture work should consider the centralization of complex rectal cancer care as well as quality improvement initiatives aimed at enhancing guideline adherent care across all centres managing rectal cancer.

Long Term Impact of Regionalization of Thoracic Oncology Surgery

In 2007, Cancer Care Ontario created Thoracic Surgical Oncology Standards for the delivery of surgery including lobectomy, esophagectomy and pneumonectomy. These standards regionalized thoracic surgery into designated centers and mandated physical and human resources. This analysis seeks to identify the impact of these standards, hereafter referred to as "regionalization", on outcomes after thoracic oncology surgery in Ontario, Canada. Population-level analysis of patients undergoing lobectomy, esophagectomy or pneumonectomy, using multi-level regression models to compare 30- and 90-day mortality and length of stay length of stay, before, during and after regionalization. Interrupted time series models were used to assess for an impact of regionalization, controlling for ongoing trends. A total of 22,195 surgeries (14,902 lobectomies, 4,958 esophagectomies, and 2,408 pneumonectomies) were performed within the study period. >99% of cases were performed at a designated center post-regionalization. Mean annual volumes per designated center increased post-regionalization for lobectomy and esophagectomy, and decreased for pneumonectomy. 30- and 90-day mortality and length of stay improved for lobectomy and esophagectomy over the study period, as did 90-day mortality for pneumonectomy. However, the interrupted time series analysis did not demonstrate any statistically significant effect of regionalization on these outcomes, separate from pre-existing trends. Consistent improvements in mortality and length of stay in thoracic surgical oncology occurred on a provincial level between 2003-2020, although this analysis does not attribute these improvements to implementation of Thoracic Surgical Oncology Standards including regionalization.

Standardizing Multidisciplinary Case Conferences and Improving Communication Between Referring Physicians and Radiologists: A Quality Improvement Initiative.

Purpose: Assess the effectiveness of standardizing multidisciplinary case conferences (MDCs). Methods: Anonymous electronic surveys gauged opinions of abdominal radiologists engaged in recurring MDCs. A standardized Excel template, following Cancer Care Ontario guidelines and relevant literature, was distributed to MDC managers. Physicians were instructed to send cases 36 hours prior to MDC. Template adherence was assessed at 1.5 and 8 months. A follow-up survey at 4 months evaluated the intervention's effectiveness. Results: 27/34 abdominal radiologists provided 47 baseline responses, and 12 delegated radiologists provided 23 follow-up responses. "Often/always" being provided the image's location increased from 36% (17/47) at baseline to 70% (16/23) at follow-up. Non-adherence to the 36-hour cut-off decreased from 36% (16/45) to 17% (4/23). 72% disagreed that uploading remote imaging to hospital servers is easy (33/46), similar to follow-up (18/23, 78%). In assessing the intervention, 41% noted improved standardization (9/22), another 41% considered MDCs already standardized (9/22), and 18% reported no change (4/22). Those reporting no change experienced a higher frequency of non-adherence to the 36-hour cut-off (3/4, 75%) than others (1/18, 6%), and less frequent "often/always" ratings for image location being provided (3/4, 75%) than others (2/18, 11%). 89% (25/28) of MDCs adhered to the template. Issues regarding last-minute add-on cases may be mitigated through EPIC force functions. Artificial intelligence advancements may assist in retrieving external images and patient information. Conclusion: Adherence to MDC standardization was high, allowing for more efficient preparation, potentially reducing radiologist administrative burdens. Future force functions and artificial intelligence integration into electronic patient records may further augment this.

Developing Organizational Requirements to Standardize Delivery and Improve Quality of Acute Leukemia Care in Ontario.

Acute leukemia is a rapidly progressive cancer of the blood and bone marrow that requires a high degree of complex, specialized, resource-intensive clinical and supportive care. The aging Canadian population has introduced an unprecedented demand on the health care system for a variety of illnesses, including acute leukemia. The purpose of this work was to develop organizational requirements for service providers delivering care for patients aged 18 years and older with acute leukemia within a single-payer health care system in Ontario. This initiative was intended to support streamlining high-quality health care across Ontario. We worked collaboratively with an expert panel to conduct a review of the literature to synthesize the organizational requirements for delivering acute leukemia care. A total of 229 requirements were developed. The requirements were categorized into themes including (1) facility requirements, including infrastructure, data management, safety, policies and procedures; (2) availability of clinical services and service complexity; (3) personnel, including roles, responsibilities, and ongoing education; (4) patient care; (5) quality management; (6) clinical research; and (7) laboratory services. These requirements will act as a framework for the provision of service, complexity of care, safety, accessibility, and quality care across all levels from the patient, organization, and system perspectives. This framework will help support person-centred care, emphasizing providing care close to home, while optimizing the use of specialized resources. Moving forward, Ontario Health (Cancer Care Ontario) will continue to work with acute leukemia service providers in the province to determine compliance and focus improvement efforts in priority areas.

A153 IMPLEMENTATION OF THE CHAMPLAIN REGION GASTROINTESTINAL ENDOSCOPY CENTRAL INTAKE (GICI) PROGRAM

Abstract Background The Champlain region of Ontario is implementing a regional central intake triage program for screening colonoscopy services (FIT+, screening and surveillance indications). The aim of this program is to improve the delivery of regional endoscopy services, so that access to resource-intensive endoscopy procedures can be equitable, timely and evidence-based. We characterized the first phase of implementation of the Champlain Regional GI Central Intake (GICI). Aims The primary objective of this study is to identify program strengths and opportunities for quality improvement. Methods Prospective data was collected from August 1, 2022 to August 31, 2023. Descriptive statistics were analyzed. Discrete data were presented in terms of counts, percentages and means where appropriate. Results 1942 CIP referrals were received during the period of study. 1478(76.1%) referrals were submitted by fax, and 571(29.4%) were for positive FITs. 703(36.2%) referrals were declined, with 374(19.3%) not meeting Cancer Care Ontario (CCO) referral indications, 84(4.3%) being duplicates and 56(2.9%) being symptomatic. Prior to a policy change in March 2023, 23(1.2%) referrals were declined due to incomplete referral forms. 581(29.9%) referrals indicated a preferred physician or hospital site. On average, triage decisions were made within 11.4 hours of receipt of referrals for positive FIT, and 6.8 days for other indications. The average time from FIT positivity to referral receipt at CIP was 20.0 days. In the first quarter of 2023, 75th percentile wait times for colonoscopy were 35 days for FIT positivity, 150 days for symptoms, and 346 days for other screening indications. Conclusions GICI and the use of CCO evidence-based guidance reduces the need for colonoscopy in nearly 20% of referrals. It also decreases physician administrative burdens by eliminating duplicate referrals. Referrals should not be declined due to incomplete forms. Measures to improve timely access to colonoscopy for symptomatic patients should be explored. Most referred patients do not have a preferred physician or hospital site. Further primary care support and engagement is needed to encourage the use of the GICI as well as immediate referral for FIT+ colonoscopy. Funding Agencies None

An Ontario Health (Cancer Care Ontario) Clinical Practice Guideline: Surveillance Strategies in Patients with Stage I, II, III or Resectable IV Melanoma Who Were Treated with Curative Intent

AimsTo make recommendations on managing the surveillance of patients with stage I, II, III or resectable IV melanoma who are clinically free of disease following treatment with curative intent. Materials and methodsThis guideline was developed by Ontario Health's (Cancer Care Ontario's) Program in Evidence-Based Care and the Melanoma Disease Site Group (including seven medical oncologists, four surgical oncologists, three dermatologists, one radiation oncologist and one patient representative). The MEDLINE, EMBASE, Cochrane Library, PROSPERO databases and the main relevant guideline websites were searched. Internal and external reviews were conducted, with final approval by the Program in Evidence-Based Care and the Melanoma Disease Site Group. The Grading of Recommendations, Assessment, Development and Evaluation approach was followed, and the Modified Delphi method was used. ResultsBased on the current evidence (eight eligible original study papers and four relevant guidelines) and the clinical opinions of the authors of this guideline, the initial recommendations were made. To reach 75% agreement for each recommendation, the Melanoma Disease Site Group (16 members) voted twice and one recommendation was voted on three times. After a comprehensive internal and external review process (including national and international reviewers), 12 recommendations, three weak recommendations and six qualified statements were ultimately made. ConclusionsAfter a systematic review, a comprehensive internal and external review process and a consensus process, the current guideline has been created. The guideline authors believe that this guideline will help clinicians, patients and policymakers make well-informed healthcare decisions that will guide them in clinical melanoma surveillance and ultimately assist in improving patient outcomes.

Comparative genomic analysis to identify a signature of sporadic colorectal cancer development in young adults.

208 Background: Young-onset sporadic CRC is an important yet understudied heterogeneous group of aggressive cancers with distinct clinical and histopathological features. There is a steady increase in the incidence of cancer in this group of patients and currently, there are no screening guidelines to identify these patients due to a lack of understanding of the molecular mechanisms driving cancer in this patient group. Introduction: Despite screening guidelines and recent advances in cancer treatment, colorectal cancer (CRC) remains the second most diagnosed cancer and the second and third leading cause of cancer-related mortality in Canadian men and women, respectively [Canadian Cancer Statistics 2017.]. More striking is the rise in incidence of CRC in young adults in the United States [Siegel, R.L., et al, Bailey, C.E., et al., Dozois, E.J., et al., Deen, K.I., et al.], and the expectation that by the year 2030, the incidence rate will increase by 90% in this patient population. Data from the Surveillance and Cancer registry at Cancer Care Ontario shows a similar trend with increased rates in younger adults (ages 30 to 49) by 5.2 per cent per year between 2005 and 2012 [Ontario, C.C., Cancer Fact.]. Moreover, these younger patient groups are often diagnosed with aggressive forms and advanced stages of the disease [Ontario, C.C., Cancer Fact.]. Methods: In this study, using a total of 30 colorectal cancer patient samples from Windsor Regional Hospital Cancer Program, we performed comprehensive targeted gene sequencing to identify single nucleotide variants, small insertions/deletions, copy number variants in over 500 genes that are implicated in cancer. Mean age of the patients in this study was 44 years and only patients without any personal or family history of colon cancer /other malignancies or IBD were enrolled in the study. Results: While identifying previously known colorectal cancer associated genetic variants, our preliminary data shows distinct missense mutations in several genes potentially contributing to the development and progression of cancer in these patients. In addition to showing pathogenic mutations in colorectal cancers associated genes, such as PIK3CA (H1047R, E545K, E545G, R93W, V344A), KRAS (G12V, G12D, A146T) and APC, our study showed recurring missense mutations in several genes including AXIN2, ALK, CDKN1A, MAP3K1, ROS1, EPCAM, KDM5A and AURKA in over 50% of our samples. Conclusions: The genomic profiling performed using biopsies from young colorectal cancer patients through this study provides a unique ability to identify the potential “genomic triggers” for the development and progression of cancer in young sporadic colorectal cancer patients. This information can not only be used to develop targeted treatment options for these patients but also to design new screening protocols as well as optimal surveillance strategies.

LUNG CANCER SCREENING- THE ONTARIO? CANADA EXPERIENCE

Lung cancer remains the most significant cause of cancer death, accounting for about 20% of all cancer-related mortality. A significant reason for this is delayed diagnosis mostly related to lack of symptoms in early-stage disease. Low-dose computed tomography screening of high-risk, asymptomatic populations has been shown to reduce lung cancer mortality. Various approaches have been taken on the implementation of lung cancer screening programs. Ontario Health Cancer Care Ontario OHCCO believes that screening that is delivered through organized programs is more likely to reduce cancer incidence and mortality, minimize the potential harms of screening and be cost effective when compared to screening that happens outside of organized programs. Based on lessons learned from a pilot project the province has now transitioned to a full provincial Ontario Lung Cancer Screening program. The key objectives of this presentation are to: discuss the need for early lung cancer detection; to clarify the use of the word Screening; to outline the essential components or the foundations of a screening program; and to summarize the Ontario experience on implementation of a population-based lung cancer screening program.

Developing a Health Equity Impact Assessment ‘Indigenous Lens Tool’ to address challenges in providing equitable cancer screening for indigenous peoples

BackgroundIn spite of past efforts to increase screening uptake, the rates of screening-detectable cancers including breast, cervical, colorectal and lung are rising among Indigenous persons in Ontario compared to other Ontarians. The Ontario Ministry of Health has an equity framework, the Health Equity Impact Assessment (HEIA) Tool, that was developed to guide organizations in the provision of more equitable health and social services. Although the HEIA Tool identifies that the health of Indigenous persons may benefit from more equitable provision of health and social services, it provides very little specific guidance on how to apply the HEIA Tool in a culturally relevant way to policies and programs that may impact Indigenous peoples.DiscussionGuided by the Calls to Action from the Truth and Reconciliation Commission of Canada and the United Nations Declaration on the Rights of Indigenous Peoples, an Indigenous Lens Tool was developed through a collaborative and iterative process with stakeholders at Cancer Care Ontario and with representatives from Indigenous community-based organizations. The Indigenous Lens Tool consists of four scenarios, with supporting documentation that provide context for each step of the HEIA Tool and thereby facilitate application of the equity framework to programs and policies. The document is in no way meant to be comprehensive or representative of the diverse health care experiences of Indigenous peoples living in Canada nor the social determinants that surround health and well-being of Indigenous peoples living in Canada. Rather, this document provides a first step to support development of policies and programs that recognize and uphold the rights to health and well-being of Indigenous peoples living in Canada.ConclusionsThe Indigenous Lens Tool was created to facilitate implementation of an existing health equity framework within Cancer Care Ontario (now Ontario Health). Even though the Indigenous Lens Tool was created for this purpose, the principles contained within it are translatable to other health and social service policy applications.

Development and implementation of a patient reported experience measurement program to transform cancer care.

343 Background: Improving the patient experience is central to providing high-quality, value-based care. Patient reported experience measures (PREMs) are tools to evaluate and improve quality of care. Your Voice Matters (YVM) is a validated survey created by Cancer Care Ontario that captures patient experience in outpatient settings at Regional Cancer Centres across Ontario, Canada. While most hospitals actively collect patient experience data, few have moved to action feedback to improve outcomes. Princess Margaret Cancer Centre (PM) implemented a systematic approach to PREMs evaluation to advance operational excellence in an outpatient setting. Methods: PM distributes the YVM survey monthly to patients with outpatient visits via email using a Redcap survey platform (93% of patient emails are on file). In addition to the standardized YVM questions, the survey captures respondent comments in an open text field asking about one thing PM can improve and comments are thematically coded and trended monthly. Patients reporting a very poor experience with care (defined as an overall experience of 1/5) who wish to connect with PM are contacted to provide additional information. Key performance indicators (KPIs) were established and visualized in run charts in a Power BI dashboard. KPIs were disseminated to staff and leadership to identify opportunities for improvement. Results: Starting in 2022, approximately 10,600 surveys were disseminated monthly to patients and 1,100 surveys returned (10% response rate) with 10-15 patients contacted each month regarding their poor experience. Long wait times was the top concern across three main outpatient clinics; in the Gynecology clinics, in March 2022, only 45% (35/77) of respondents rated wait times as very good (5/5) and 32% (11/34) of comments were wait times complaints. A comprehensive root cause analysis found that the visit booking system, distribution of clinics across the weekdays, and supports in clinic were key contributors to long wait times. In response, Gynecology clinic resources were reorganized to launch a new Physician Assistant clinic on the underutilized Friday afternoon clinic timeslot, a new streamlined visit process was established, and the booking system was optimized. Within six months, there was a 39% improvement in wait times on weekdays, a 60% increase in the number of patients waiting less than 30 minutes, and a 37% increase in visit capacity on underutilized Fridays. The corresponding patient experience data over the same timeframe improved seen as an increase from 45% to 52% of patients who rated wait times to see the provider as 5/5. Conclusions: A programmatic approach to PREMs evaluation and response can drive improvement in practice. Facilitators include a data-driven methodologic approach to quality improvement, leadership engagement at all levels, and elevation of frontline staff as local experts and change agents.

Evolving models of care for ambulatory systemic treatment.

155 Background: Increasing demand for systemic cancer treatment in Ontario, Canada, due to an aging population and therapeutic advances, is compounded by resource shortages and provider burnout heightened by the COVID-19 pandemic. This landscape has led to longer wait times, reduced services, poorer patient experiences, and widened health inequities, particularly impacting marginalized populations. In response, Ontario Health (Cancer Care Ontario) developed recommendations to optimize ambulatory systemic treatment delivery from various perspectives, including patients, providers, cancer programs, and organizations. Methods: Evidence-based recommendations were derived from a targeted literature review, current state surveys, and follow-up interviews across 16 Ontario treatment facilities. Feedback was gathered via focus groups involving patients, families, care partners, and providers. Key informants from cancer agencies in Canada and internationally were consulted through jurisdictional scans. Furthermore, focused discussions with First Nations, Inuit, Métis, urban Indigenous (FNIMUI) communities, Francophone populations, and other equity deserving groups informed the unique needs, experiences, and barriers to care of these groups. Results: Twenty-six recommendations that span various aspects of systemic treatment delivery, including referral processes, scheduling, role integration, patient education, patient and provider experiences, virtual care, and care transitions were developed. Priorities include evidence-based, person-centred care, timely access, effective collaboration, provider well-being, and technological innovation. Additionally, we highlight partnerships with FNIMUI communities, and other equity-deserving groups as strategies to address additional barriers to care. Conclusions: These recommendations strive to address challenges faced by healthcare providers and patients, ensure equitable access to care, and improve provider well-being. Engagement with FNIMUI communities and other equity-deserving groups influenced these recommendations, emphasizing the need for system-level oversight and investment to realize equitable and sustainable service delivery province-wide.

A guide for the administration of oral antineoplastic in patients with swallowing disorders

ObjectiveTo review the available literature on the administration of oral antineoplastic drugs in patients with swallowing disorders and systematize the information obtained. MethodBetween September 2019 and April 2020, two hospital pharmacists drew up a list of the oral antineoplastic drugs available in Spain, which was then distributed to three hospital pharmacists, each of whom carried out a literature search and a review. An analysis was made of the prescribing information and searches were performed in Pubmed, Micromedex, Uptodate, the Cancer Care Ontario website, different pharmaceutical bulletins, feeding tube administration guidelines, and tertiary information sources. Lastly, the pharmaceutical industry was contacted. The group systematized the information obtained, after which a fourth hospital pharmacist and an independent physician reviewed the work carried out. ResultsA total of 64 oral antineoplastic drugs were reviewed. Relevant information was obtained for 48 drugs, of which 44 were amenable to administration to these patients (69% of the investigated drugs). A systema-tization of the information found was carried out. ConclusionsDespite having found different methods for preparing and administering most of the oral antineoplastic drugs reviewed, the information compiled was rather scarce and with a low level of evidence. Further studies, based on pharmacokinetic and stability studies, are necessary in this field as there is a sore need for oral liquid pharmaceutical forms or extemporaneous preparations allowing administration of oral antineoplastic drugs to these patients.

Systemic Therapy for Small-Cell Lung Cancer: ASCO-Ontario Health (Cancer Care Ontario) Guideline.

To provide evidence-based recommendations to practicing clinicians on the management of patients with small-cell lung cancer. An Expert Panel of medical oncology, thoracic surgery, radiation oncology, pulmonary, community oncology, research methodology, and advocacy experts were convened to conduct a literature search, which included systematic reviews, meta-analyses, and randomized controlled trials published from 1990 through 2022. Outcomes of interest included response rates, overall survival, disease-free survival or recurrence-free survival, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. The literature search identified 95 relevant studies to inform the evidence base for this guideline. Evidence-based recommendations were developed to address systemic therapy options, timing of therapy, treatment in patients who are older or with poor performance status, role of biomarkers, and use of myeloid-supporting agents in patients with small-cell lung cancer.Additional information is available at www.asco.org/thoracic-cancer-guidelines.

Defining Standards for Hepatopancreatobiliary Cancer Surgery in Ontario, Canada: A Population-Based Cohort Study of Clinical Outcomes.

In 2006, Cancer Care Ontario created Surgical Oncology Standards for the delivery of hepatopancreatobiliary (HPB) surgery including hepatectomy and pancreaticoduodenectomy (PD). Our objective was to identify the impact of standardization on outcomes after HPB surgery in Ontario, Canada. This study was a population-level analysis of patients undergoing hepatectomy or PD (2003 to 2019). Logistic regression models were used to compare 30- and 90-day mortality and length of stay (LOS) before (2003 to 2006), during (2007 to 2011), and after (2012 to 2019) standardization. Interrupted time series models were used to co-analyze secular trends. A total of 7,904 hepatectomies and 5,238 PDs were performed. More than 80% of all cases were performed at a designated center (DC) before standardization. This increased to >98% in the poststandardization era. Median volumes at DCs increased from 55 to 67 hepatectomies/year and from 22 to 50 PDs/year over time. In addition, 30-day mortality after hepatectomy was 2.6% before standardization and 2.3% after standardization (p = 0.9); 30-day mortality after PD was 3.6% before standardization and 2.4% after standardization (p = 0.1). Multivariable analyses revealed a significant difference in 90-day mortality following PD poststandardization (4.3% vs 6.3%; adjusted odds ratio, 0.7; p = 0.03). Median LOS was shorter for hepatectomy (6 days vs 8 days) and PD (9 days vs 14 days; p < 0.0001) after standardization. Immediate and late effects on mortality and LOS were likely attributable to secular trends, which predated standardization. Standardization was associated with a higher volume of hepatectomy and PDs with further concentration of care at DCs. Pre-existing quality initiatives may have attenuated the effect of standardization on quality outcomes. Our data highlight the merits of a multifaceted provincial system for enabling consistent access to high quality HPB care throughout a region of 15 million people over a 16-year period.

Access to Surgery for Endometrial Cancer Patients During the COVID-19 Pandemic in Ontario, Canada: A Population-Based Study

ObjectivesTo assess the impact of the COVID-19 pandemic on endometrial cancer stage and surgical treatment in Ontario, Canada. MethodsThis descriptive study identified cases from January 1, 2017 to December 31, 2021 from endometrial cancer hysterectomy specimens in the Ontario Health–Cancer Care Ontario, ePath system. Endometrial biopsy records from January 1, 2016 to December 31, 2021 were matched to surgical specimens by provincial health card number. Time to surgery and surgical stage were compared before (2017–2019) and during (2020–2021) the COVID-19 pandemic. ResultsThere were 10 446 women treated with hysterectomy for endometrial cancer in Ontario from 2017–2021. In April and May 2020, corresponding with the provincial state of emergency, there was a 56% relative reduction in endometrial biopsies. Despite this 2-month reduction in endometrial biopsy volume, there was no change in surgical volume for endometrial cancer treatment. The median time from endometrial biopsy to surgery was 56 days (IQR 40, 80) during the pandemic (2020–2021) compared to 58 days (IQR 43, 82) prior to the pandemic (2017–2019) (P < 0.001). There was no upstaging of endometrial cancer during the COVID-19 pandemic. ConclusionsThe Ontario healthcare system continued to prioritize service delivery to endometrial cancer patients during the COVID-19 pandemic, despite the increase in virtual care and decrease in operating room time. There were no significant surgical delays or upstaging of endometrial cancer.

A Cancer Care Ontario Consensus-Based Organizational Guideline for the Planning and Delivery of Spine Stereotactic Body Radiation Therapy Treatment in Ontario

The proposed recommendations are primarily based on the consensus opinion and in-field experience of the Ontario Health/Cancer Care Ontario stereotactic body radiation therapy (SBRT) for Spine Metastasis Guideline Development Group and published literature when available. Primary consideration was given to the perceived benefits for patients and the small likelihood of harm arising from recommendation implementation. Apart from the magnetic resonance imaging (MRI) follow-up strategy, all evidence was considered indirect and was provided by the working group in conjunction with their collective expertise in the field of SBRT.The application of an SBRT program requires a multidisciplinary team consisting of a radiation oncologist, spine surgeon, neuroradiologist, medical physicist, medical dosimetrist, and radiation therapist. In Canada, linear accelerators are the most used treatment delivery units and should follow technology-specific quality assurance procedures. Immobilization technique is location dependant. Treatment planning MRI sequences should be acquired no more than 14 days from the date of treatment. In the case of epidural disease, simulation MRI should be completed no more than 7 days from the date of treatment. After treatment, patients should be followed with routine clinical visits every 3 months for the first year, every 3 to 6 months during years 2 and 3, and every 4 to 6 months thereafter.The recommendations enclosed provide a framework for the minimum requirements for a cancer center in Ontario, Canada to offer SBRT for spine metastases.

Preoperative Breast Magnetic Resonance Imaging: An Ontario Health (Cancer Care Ontario) Clinical Practice Guideline.

The use of preoperative breast magnetic resonance imaging (MRI) after the diagnosis of breast cancer by mammography and/or ultrasound is inconsistent. After conducting a systematic review and meta-analysis comparing preoperative breast MRI versus no MRI, we reconvened to prepare a clinical practice guideline on this topic. Based on the evidence that MRI improved recurrence, decreased the rates of reoperations (re-excisions or conversion mastectomy), and increased detection of synchronous contralateral breast cancer, we recommend that preoperative breast MRI should be considered on a case-by-case basis in patients diagnosed with breast cancer for whom additional information about disease extent could influence treatment. Based on stronger evidence, preoperative breast MRI is recommended in patients diagnosed with invasive lobular carcinoma for whom additional information about disease extent could influence treatment. For both recommendations, the decision to proceed with MRI would be conditional on shared decision-making between care providers and the patient, taking into account the benefits and risks of MRI as well as patient preferences. Based on the opinion of the Working Group, preoperative breast MRI is also recommended in the following more specific situations: (a) to aid in surgical planning of breast conserving surgery in patients with suspected or known multicentric or multifocal disease; (b) to identify additional lesions in patients with dense breasts; (c) to determine the presence of pectoralis major muscle/chest wall invasion in patients with posteriorly located tumours or when invasion of the pectoralis major muscle or chest wall is suspected; (d) to aid in surgical planning for skin/nipple-sparing mastectomies, autologous reconstruction, oncoplastic surgery, and breast conserving surgery with suspected nipple/areolar involvement; and (e) in patients with familial/hereditary breast cancer but who have not had recent breast MRI as part of screening or diagnosis.

Abstract P2-02-05: Patterns of adjuvant bone modifying agent use in patients with early-stage breast cancer in the United States

Abstract Background: The bone modifying agents (BMAs), bisphosphonates, reduce risk of cancer recurrence after diagnosis of early-stage breast cancer (EBC), particularly in postmenopausal women, while another BMA, denosumab, has not been shown to improve EBC outcomes. The 2017 American Society of Clinical Oncology (ASCO) and Cancer Care Ontario (CCO) clinical guidelines recommended consideration of adjuvant bisphosphonates for postmenopausal women with EBC who are candidates for adjuvant systemic therapy. Despite this, small survey-based studies suggest that their prescribing is variable. The goal of this study was to evaluate prescribing of adjuvant BMAs in the United States before and after publication of the 2017 ASCO/CCO guidelines (ACGD). Methods: This retrospective cohort study used the nationwide Flatiron Health electronic health record (EHR)-derived de-identified database and included 11,740 patients diagnosed with stage I-III breast cancer from 2012 to 2019. We analyzed data on use of BMAs (bisphosphonates or denosumab) in the adjuvant setting, defined as receiving first dose of BMA within 24 months of breast cancer diagnosis and before diagnosis of metastatic disease. Any episodes of BMA use after a metastatic recurrence were excluded. We used Chi-squared test to compare the proportion of patients receiving adjuvant BMAs pre- and post-ACGD. We used univariable and multivariable logistic regression analyses with list-wise missing value deletions to identify predictors of adjuvant BMA prescribing. Results: Of 11,740 patients, 7,391 were diagnosed pre-ACGD and 4,349 post-ACGD. Of the pre-ACGD patients, 545 (7.4%) patients received adjuvant BMAs, and of the post-ACGD patients, 390 (9.0%) patients received adjuvant BMAs. Patients diagnosed post-ACGD were more likely to receive adjuvant BMAs compared with patients diagnosed pre-ACGD (OR 1.23; 95% confidence interval (CI) 1.08-1.42; p=0.002). Of patients age ≥ 50 (n=9,654), 522 of 6,027 (8.7%) and 360 of 3,627 (9.9%) received adjuvant BMAs pre- and post-ACGD, respectively (OR 1.146; 95% CI 0.996-1.319; p=0.0572). In multivariable analysis, age ≥ 50 years at diagnosis, post-menopausal status, having T2 or higher stage at diagnosis, adjuvant endocrine therapy, and coexisting bone loss diagnosis were significantly associated with receipt of adjuvant BMAs (Table 1). Of the 935 patients who received adjuvant BMAs, 615 (65.8%) had denosumab only, 305 (32.6%) had a bisphosphonate only, and 13 (1.4%) received both a bisphosphonate and denosumab during the course of adjuvant treatment. Two patients received an adjuvant BMA as part of a clinical trial. Conclusions: Adjuvant BMA prescribing in our cohort was overall low; there was a modest increase in uptake in patients with EBC diagnosed after the publication of the 2017 ACGD. Older age, higher T stage, endocrine therapy, and coexisting bone loss diagnoses were significantly associated with receipt of adjuvant BMAs. Despite the recommendations for bisphosphonates in the adjuvant setting in EBC, the majority of patients received denosumab only. Considering these findings, further research is required to determine barriers to BMA prescribing and factors that influence physician and patient decisions. There continues to be a need for improved implementation and dissemination of recent guidelines, including the updated 2021 ASCO/CCO recommendations which continue to endorse bisphosphonate use in the adjuvant setting. Table 1: Univariable and multivariable logistic regression analyses to identify predictors of receiving adjuvant BMAs sabs Citation Format: Nicole Odzer, Rachel Jaber Chehayeb, Maryam Lustberg, Cary P. Gross, Julia Foldi. Patterns of adjuvant bone modifying agent use in patients with early-stage breast cancer in the United States [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-02-05.

Hierarchical causal variance decomposition for institution and provider comparisons in healthcare

Disease-specific quality indicators are used to compare institutions and health care providers in terms of processes or outcomes relevant to treatment of a particular condition. In the context of surgical cancer treatments, the performance variations can be due to hospital and/or surgeon level differences, creating a hierarchical clustering. We consider how the observed variation in care received at patient level can be decomposed into that causally explained by the hospital performance, surgeon performance within hospital, patient case-mix, and unexplained (residual) variation. For this purpose, we derive a four-way variance decomposition, with particular attention to the causal interpretation of the components. For estimation, we use inputs from a mixed-effect model with nested random hospital/surgeon-specific effects, and a multinomial logistic model for the hospital/surgeon-specific patient populations. We investigate the performance of our methods in a simulation study and demonstrate them through analysis of administrative data on kidney cancer care in Ontario.