Achieving the Achievable in Cancer g Control: Som e lessons from our radiotherapy system William J Mackillop William J. Mackillop (PMH RO class of 1980) Queen’s Cancer Research Institute, Kingston
The take hom e m essage Our best shot at reducing the burden of cancer in Canada within the next decade is to learn how to make better use of existing knowledge, technology and resources k l d t h l d We need to invest more in Health Services Research aimed at identifying and exploiting opportunities for improving the identifying and exploiting opportunities for improving the performance of our cancer control systems Active surveillance of the performance of treatment processes is Active surveillance of the performance of treatment processes is one of the keys to better outcomes
Health Services and Policy Research Health Services Research is the domain of health research that seeks to improve population health by research that seeks to improve population health by creating the knowledge required to improve the delivery of health services. Health Policy Research seeks ways of putting that knowledge to work knowledge to work. Lu Ann Aday
Cancer Control The WHA Declaration on Cancer Prevention and Control recommends that all nations should: – develop comprehensive cancer control programs through the systematic, stepwise and equitable g y , p q implementation of evidence-based strategies for prevention, early detection, diagnosis, treatment, rehabilitation and palliative care; rehabilitation and palliative care;
The W HA Declaration on Cancer The W HA Declaration on Cancer Prevention and Control recom m ends that all nations should: – develop comprehensive cancer control programs through the systematic, stepwise and equitable implementation of evidence-based strategies for implementation of evidence-based strategies for prevention, early detection, diagnosis, treatment, rehabilitation and palliative care;
Background to the W HA Declaration Background to the W HA Declaration on cancer prevention and control: � Recognizing that many of cases of cancer could be prevented, � Recognizing that the technology for treatment of cancer � Recognizing that the technology for treatment of cancer is mature and that many cases of cancer can be cured, � Recognizing the value of multidisciplinary management g g p y g and the importance of surgery, radiotherapy, chemotherapy, and palliative care � Mindful of the need for careful planning and priority- Mindful of the need for careful planning and priority setting in the use of resources
The W HA recom m ends that national cancer control strategies should: – frame policies for strengthening and maintaining frame policies for strengthening and maintaining equipment for diagnosis and treatment; equipment for diagnosis and treatment; – improve access to appropriate technologies improve access to appropriate technologies – determine minimum standards for cancer treatment determine minimum standards for cancer treatment (appropriate to local situations) (appropriate to local situations) (appropriate to local situations) (appropriate to local situations) – develop and strengthen health system infrastructure, develop and strengthen health system infrastructure, particularly human resources particularly human resources
CSCC CPAC Thanks to many people from across Canada, but in particular to Simon Sutcliffe (PMH RO class of ’81), Canada now has a a national cancer control strategy Canada now has a a national cancer control strategy and a federal funded national agency, CPAC, charged with implementing that strategy in collaboration with many governmental and t l d non-governmental organizations across the country across the country. “The engine for cancer control in Canada”
An ounce of prevention….. What is the right balance of investment between prevention and treatment in a cancer control program?
Cancer 2 0 2 0 : The Potential I m pact of p Prevention and Screening on Cancer in Ontario, Dr. John McLaughlin, CCO Cancer Prevention Targets Cancer Prevention Targets C Cancer Screening Targets S i T t • Tobacco use • Cervical cancer screening • Colorectal cancer screening • Diet and nutrition • Breast cancer B t • Healthy body weight • Alcohol consumption • Occupational carcinogens Occupat o a ca c oge s • Environmental carcinogens • Ultraviolet exposure • Viral infections • Viral infections Presented at: The future of radiation treatment in the 21 st century. Toronto, March, 2007 in the 21 century. Toronto, March, 2007 http://www.cancercare.on.ca/documents/2006Cancer2020Report-English.pdf
Impact of Cancer Prevention p Interventions Decreased incidence in 2020 incidence in 2020 females : -3.2% (1400 cases) males : -2 6% (1400 males : 2.6% (1400 cases) John McLaughlin CCO
A pound of cure… Mortality/ Incidence Ratios of Common Mortality/ Incidence Ratios of Common Cancers in Canadian women (2004) Breast 0.26 Lung 0.81 Colorectal 0.44 Uterus 0.10 Head & Neck 0.23 Non-Hodgkin Lymphoma 0.43 Thyroid 0.04 Ovary 0.71 Melanoma 0.16 Pancreas 1.00 All Cancers C 0.45 Chronic Disease Surveillance Division, CCDPC, Public Health Agency of Canada
How m uch does treatm ent contribute to the overall effectiveness of a cancer control program ? The appropriate balance of investment among the different components of a cancer control program is unknown We need to find that out! unknown. We need to find that out! At present, treatment has a much greater impact on p , g p mortality than primary prevention Cancer-directed treatment will inevitably remain the most important element of cancer control well into the middle of the middle of this century
How do w e better? How do we set about enhancing the effectiveness of cancer treatment programs? Step 1 is to consider the factors the limit the effectiveness of existing programs g p g
A hi Achieving the Achievable i th A hi bl The “ Achievable ” outcome: the best outcome we could possibly achieve within the limitations imposed the state of scientific knowledge/technology and availability of resources knowledge/technology and availability of resources. The “ Achieved” outcome: the actual outcome observed in the population, which may fall far short of the achievable… Attainment factor = Achieved/ Achievable (Value= 0 to 1) Achieved outcome = Achievable outcome × Attainment factor Achieved outcome = Achievable outcome × Attainment factor
A hi Achieving the Achievable i h A hi bl Biomedical/Clinical Research ↓ Achieved outcome = Achievable outcome × Attainment factor
A hi Achieving the Achievable i h A hi bl HSR ↓ Achieved outcome = Achievable outcome × Attainment factor
Aspects of Health System Aspects of Health System Perform ance Accessibility: Do patients get the care they Accessibility: Do patients get the care they need, when they need it? Quality: Do patients get the right care, delivered in the right way? – Technical/personal care Technical/personal care Efficiency: Are we getting the best value for money in terms of the accessibility and quality? – performance/allocation efficiency p y These quantities are not independent of one another!
Aspects of Health System Aspects of Health System Perform ance Accessibility: Do patients get the care they need, when they need it? Equity Quality: Do patients get the right care Quality: Do patients get the right care, delivered in the right way? – Technical/personal care Efficiency: Are we getting the best value for money in terms of the accessibility and quality? quality? – performance/allocation efficiency These quantities are not independent of one another
The PMH w aiting list crisis of 1 9 8 9 Cancer hospital short of staff, may shut doors to new patients: Kelly Toughill Toronto Star. Sep 7, 1989 g p , A desperate wait in cancer's grip. Richard J Doyle, The Globe and Mail Sep 12 1989 (RJD was Editor Mail. Sep 12, 1989. (RJD was Editor of the Globe 1963-83) Hospital to close doors to new cancer patients; Kelly Toughill, Toronto Star. Sep 13, 1989. Toughill Toronto Star Sep 13 1989 Patients are dying because their cancers have grown while they were waiting for treatment.“ said Dr. Alon D Dembo, – Toronto Star. Sept 9, 1989 b T t St S t 9 1989
St Stages in the acceptance of the diagnosis i th t f th di i of “diseases of the health system ” 1. Denial of the existence of the problem: • “D “Despite media reports to the contrary, the vast i di h h majority of patients receive timely and appropriate care” CCO, Toronto Star ,
St Stages of acceptance of the diagnosis f t f th di i of “diseases of the health system ” 1 Denial of the existence of the problem: 2 Denial that the problem is remediable: • OK, this is a problem, but it’s happening everywhere. It OK thi i bl b t it’ h i h It is beyond our control .
Waiting for radiotherapy in Ontario f O Int J Rad Oncol Biol Phys, 1993 Waiting times for RT for laryngeal cancer t 1 =Dx to referral f t 2 =referral to consult t 3 =consult to RT 3 t total =Dx to RT
St Stages of acceptance of the diagnosis f t f th di i of “diseases of the health system ” 1 Denial of the existence of the problem: 2 Denial that the problem is remediable: • OK, this is a problem, but it’s happening everywhere. It OK thi i bl b t it’ h i h It is beyond our control .
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