Northern Cancer Control Strategy Final Report March 3

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Northern Cancer Control Strategy Final Report

Northern Cancer Control StrategyA Joint Initiative of the

British Columbia Cancer Agency

and Northern Health

Final Report

March 2005


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Table of Contents

1. Executive Summary ........................................................................................................ 2

1.1. Approach to Planning ............................................................................................ 2

1.2. Data and Inventory Assessment ............................................................................ 21.3. Building a Northern Cancer Program --Recommendations................................... 5

1.4. Summary and Next Steps ...................................................................................... 8

2. The Northern Cancer Control Project ............................................................................. 9

2.1. Overview ............................................................................................................... 9

2.2. Project Participants and Roles ............................................................................... 9

2.3. Project Timelines................................................................................................. 10

3. Principles underlying cancer control in B.C. ................................................................ 11

3.1. The Organization of Cancer Control in B.C. ....................................................... 11

3.2. Delivering this Population Based Cancer Control Program ................................ 11

3.3. BCCA Strategic Plan 2004-2010......................................................................... 11

4. The FindingsHealth and Cancer in the North ........................................................... 12

4.1. The Data ..............................................................................................................12

4.2. Prevention and Promotion Findings .................................................................... 19

4.3. Screening Findings .............................................................................................. 21

4.4. Detection, Treatment, and Care Findings............................................................ 24

5. Analysis & Recommendations for Enhanced Cancer Control in the North.................. 31

5.1. Decision Criteria.................................................................................................. 31

5.2. Develop a Northern Cancer Program .................................................................. 31

5.3. Prevention, Promotion and Screening Priorities.................................................. 32

5.4. Detection and Diagnosis Priorities ...................................................................... 33

5.5. Treatment and Care Priorities.............................................................................. 33

5.6. Additional Considerations and Enablers of the Strategy..................................... 36

6. Appendices....................................................................................................................39

6.1. Data......................................................................................................................39

6.2. Prevention and Promotion ................................................................................... 53

6.3. Screening ............................................................................................................. 55

6.4. Detection, Treatment and Care ............................................................................ 56

6.5. Implementing the Priorities ................................................................................. 63

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1. EXECUTIVE SUMMARY

1.1. Approach to Planning

The Northern Cancer Strategy Project is a joint initiative between the BritishColumbia Cancer Agency (BCCA) and Northern Health (NH). The mandate is tocreate a plan to address the cancer control needs of Northerners into theforeseeable future in a way that responds to the epidemiology of cancer in the Northand the demographic and service delivery challenges that are unique to NorthernBC.

The mandate of the Project is to plan for a continuum of cancer related servicesfrom Prevention and Health Promotion, to Screening, Detection, Treatment,Rehabilitation, and Research. A framework is used to match the issues surfaced inthe Preliminary Findings Document with priorities for action around three maincategories of outcome:

Incidence of cancer,

Survival from cancer, and

Quality of life and Access to services for Northerners.

The information and ideas contained in this report rely primarily on the knowledgeand experience of Northern physicians, nurses, pharmacists and program staff fromthe Northeast, Northern Interior and Northwest Health Service Delivery Areas(HSDAs) and the clinical leaders and medical specialists from the BC CancerAgency. Through the invitation of the Northern Medical Advisory Committee, 15medical staff members from communities across the North contributed to theidentification of weaknesses in current services and offered many ideas forimprovements. Similarly, nurses, pharmacists, palliative care workers, diagnostictechnologists and public health professionals contributed their knowledge oflimitations in current clinic activities and prevention programs, including access andcommunication issues as identified by patients. Together, they made manysuggestions to strengthen and better link cancer services. Northern Healths recentpublic consultation process also contributed perspectives from many communitiesthat more needs to be done to prevent illness and foster better health as well as toimprove access to services. Representatives from the Canadian Cancer Societycontributed insights into areas where patients and the public had voiced a desire forimproved services. Through contributions of staff of the BC Cancer Agency, all ofthis information was considered within the context of a province wide program ofcancer control.

The primary focus of this strategy is to improve outcomes. Actions and projectsproposed will be monitored and measured to ensure the changes are improvingcancer control in the North.

1.2. Data and Inventory Assessment

Northern Health covers the northern two-thirds of the Province of British Columbia.The Northern population has significantly poorer health than other regions of BC.Over 300,000 people live within NH boundaries (7% of the population of BC), andthis is expected to increase to 348,000 by 2010.

The unique geography and demographicsof the North create challenges (andopportunities) for every aspect of planning for cancer-related services.

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The key characteristics of the Region include:

A small widely dispersed population with a higher proportion of youngpeople than the provincial average;

An expectation for rapid growth in the number of seniors;

An increase in the number of new cancer cases reported annually from1000 in 2005 to 1400 in 2015;

A high level of behavioral risk for cancer including high smoking rates, highlevels of alcohol consumption and high rates of obesity; and

The highest proportion of Aboriginal people in BC with numerous levels oforganization and differing models of health service provision. Datasuggests that the participation in mammography and cervical cancerscreening programs is less among aboriginal people and that smoking ratesare higher still than in the surrounding population.

The inventory of current services and programs shows that Northern Healthprovides a number of cancer control activities across the continuum of care in each

of the three HSDAs. Some of these programs are delivered in partnerships withother agencies such as the Canadian Cancer Society or are funded by the BCCancer Agency. For example, under the heading of Prevention and Promotion,Northern Health runs or supports a number of programs such as Hepatitis BImmunization, Viral Hepatitis C Clinic, Tobacco Control Program, Canadian CancerSociety Prevention Strategy, Sun Safety, Environmental Health, Nutrition Programs,Sexually Transmitted Disease Clinics, and the Primary Health Care Initiative.

Currently, the BC Cancer Agency partners with NH to provide cancer services incommunities across the region, including:

A Community Cancer Centre in Prince George providing a range ofsystemic therapy for cancer patients;

Five Community Cancer Services located in Fort St. John, Dawson Creek,Smithers, Terrace and Prince Rupert -- each has oncology-certified nursesproviding service to cancer patients such as chemotherapy administration,navigation (two sites), education and support; and

Traveling consultation services by Agency oncologists.

BCCA works with NH to deliver the screening mammography program and thecervical screening program. Screening for colorectal and prostate cancer throughprimary care physicians is available; however no formal population-based programsexist.

Northern Health citizens have access to clinical laboratory services and a variety ofdiagnostic imaging modalities including x-ray, CT, MRI, and Nuclear Medicine

scans.

General and sub-specialty surgery is offered in many Northern communities. Ageneral surgeon from Prince George is an executive member of the BCCA SurgicalOncology Network.

BCCA provides training to several Northern family practitioners in oncology. Thesepractitioners are linked through the Family Practice Oncology Network and aretrained to assess and support chemotherapy patients.

Supportive services are offered but there is no formal program to serve cancerpatients, resources are limited and not all communities can provide support across

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the continuum of care e.g. psychosocial support, nutrition counseling for cancerpatients etc. Palliative and hospice care is offered across NH but it is fragmented.The use of telehealth for cancer control is also limited in NH.

Some of the issues that have emerged from the data and inventory review include:

Significantly higher Standardized Mortality ratios for all cancers combinedand specifically Lung Cancer.

Poorer 5 year survival rates for breast, prostate, colorectal, and lung canceras compared to residents of other Health Authorities in B.C.

Surgical and chemotherapy treatment services and a range of preventionand screening services have been developed over time in the North, butare not well linked to ensure the best coordination of service to theclient/patient or to ensure optimal results.

While systemic therapy (chemotherapy) is offered in a number ofcommunities, resources are limited, demand is increasing and nosupporting structure exists to assist the communities with implementingquality improvements or guidelines, or provide relief nurse staffing and

training, etc.

Diagnostic testing is offered across the three HSDAs, however consistentorganization is limited and quality assurance occurs outside of an overallregional Health Authority framework. Reference group clinicians identified aneed to establish clear clinical guidelines and decrease the time required ofpatients for investigation in circumstances where multiple studies wererequired to reach a diagnosis.

More family practitioners in oncology are needed to improve patient accessto care within the Northeast, Northern Interior and Northwest Health ServiceDelivery Areas.

Patients referred for radiation therapy must travel outside of the region to

BC Cancer Agency sites or Alberta, which presents social and financialchallenges.

Variability exists across the 3 HSDAs in the use of radiation therapy forboth the initial treatment of cancer and palliative treatment for late stagecancer. Overall, Northerners have similar rates of curative treatment toother British Columbians, but rates of radiotherapy for palliative treatmentare lower for Northerners than for residents of the southern mainland.

Supportive care and palliative care services tend to be fragmented anddiffer by community.

Some important unanswered questions remain relating to gaps in the data:What specific cancer services are being provided in Alberta to people in the

Northeast Do Northerners present with more advanced cancer than theirprovincial counterparts?

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1.3. Building a Northern Cancer Program --Recommendations

1.3.1. Develop a Regional Cancer Program for NH

The North is the only region of BC without a Regional Cancer Program. The issuesclearly demonstrate the need for leadership and ongoing monitoring; therefore it isrecommended that Northern Health and the BCCA jointly establish a RegionalCancer Program. Program leadership will respond to patient service issues andassist with the coordination of services, programs, standards and guidelines acrossthe North.

In developing a strong Northern Cancer Program, a key challenge will be to find thebest balance between making services more accessible to Northerners in theircommunities, while also recognizing that treatment success for patients who needspecialized services such as cancer surgery, chemotherapy and radiotherapygenerally improves with the volume of care provided in any one sub specialty.

The following diagram outlines the mandate of the proposed Northern Cancer

Program as well as the current services and short term priorities for implementationacross the continuum of cancer control. The strategies are listed on the followingpages and discussed in greater detail in section 5. High level action plans for thepriorities are located in Section 6.5 of the Appendices.

The green boxes represent initiatives that NH would lead; initiatives in yellow boxeswould be lead by BCCA, while those in pink boxes would be joint initiatives of NHand BCCA.

Prevention&Promotion

Screening Detection&Diagnosis

Treatment SupportiveCare &Rehab

Palliative &End of LifeCare

Continuum ofCancer Control

Current NorthernService & Programs

Short Term Priorities

Surgical Oncology:Urology, General

Radiation Therapy:Must be referred toother Centres

Systemic Therapy:Available in allHSDAs in severalcommunities

TobaccoControl

Womens Health Program

Research & BestPractices to ImproveNH Health Status

RetrospectiveStaging Study

EnhancedConsultation

Telehealth

PalliativeCare

SurgicalOncology

Navigation, Primary Care/Diagnostic Coordination and Transportation

Hepatitis B & C

Heart Health

Tobacco Control

STD

Environmental Health

Chronic Disease Mgmt.

Primary Health CareInitiative

Breast

Cervical

Colorectal*

Prostate*

Women'sHealthProgram

Lab

DiagnosticImaging

Pathology

FPON

Nutrition

Pharmacy

Home Care

Rehab

Psychosocial

Palliative &Hospiceservicesavailable inall HSDAs

Program Leadership, Outcomes Measurement, and Quality Improvement

Chemo Review

*Not currently available as organized screening programs in BC.

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1.3.2. Short Term Priorities

Prevention, Promotion and Screening

The data demonstrated the need to support programs that would reduce theincidence of cancer. The three priorities are:

Develop a Comprehensive Tobacco Control Strategy.

Support the Womens Health Program to increase cancer screening rates.

Investigate known programs and best practices that reduce the incidence ofcancers amenable to preventive action.

Detection and Diagnosis

Complete a Retrospective Staging Study to better understand whereresources and effort should be focused to improve survival.

Link diagnostic testing processes with primary care practitioners to developa coordinated system from first encounter to screening, detection, treatmentand follow up. This priority will see the establishment of clear clinicalguidelines and will decrease the time required of patients for investigation incircumstances where multiple studies are required.

Treatment and Care

Develop travel assistance strategies to reduce the burden of travel forcancer patients.

Ensure that surgeons in the North have access to timely outcomesinformation and an opportunity to participate in a surgical oncology bestpractices program.

Increase capacity in systemic/chemotherapy services in the immediatefuture. An external assessment will be completed to provide guidance with

respect to clinic services and the integration of these services into a regionwide program.

The burden of travel for care planning, treatment and follow-up is verysignificant for patients requiring treatments such as radiotherapy. Inaddition to improvements in transportation, the following short term actionswill reduce the very significant burden of travel for patients:

o Enhance navigation services across NH to support patients in theplanning and organization of their treatment to minimize travelrequirements.

o Increase the accessibility of consultation for specialist care throughthe application of telehealth.

Explorehow consultative services to Northern family practitioners fromBCCA tumor site specific specialists in radiation, medical, and surgicaloncology could be enhanced.

Develop and implement a comprehensive Palliative Care Program that haslinkages with Home Care, Hospice Services and the BCCA Palliative CareNetwork.

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1.3.3. Additional Considerations and Enablers

Research and Education

Work in this area will be ongoing and will be an essential enabler of the NorthernCancer Program by improving recruitment and retention as well as throughevidenced based improvements to care. The BCCA is engaged in all aspects ofresearch at the provincial, national and international levels. Northern Health has anopportunity to build relationships with BCCA, UNBC, UBC and the Northern MedicalProgram to work collaboratively to expand research and teaching in the area ofcancer control.

Information Technology

Having the appropriate technical infrastructure will enable the Northern CancerProgram to improve patient care as well as monitor and share clinical information.There are several initiatives underway that will be essential enablers of thepriorities. For example:

The Clinical Information System (CIS) will interface with PHSA-BCCA,Cancer Information System (CAIS).

Telehealth is well established in the North and opportunities exist to linkthrough PHSA for the provision of diagnostic reports and interpretations.

The Physician Connectivity Project will connect all doctors across theNorth.

The BC Bycast Diagnostic Imaging Network will allow for effective, fast andefficient access to electronic diagnostic images to and from PHSA, otherHealth Authorities, and Northern Health.

The Private Network Gateway (PNG) initiative will provide a fully integratedand secure network for Health Authorities to access electronic clinical data.

Linkages with Yukon and Alberta

Areas with rural and remote populations often share similar characteristics in thatthey have low population density, greater unemployment, income inequality and ahigher proportion of Aboriginal persons. It will be important for the leadership of theProgram to engage jurisdictions with similar populations such as the Yukon todetermine areas for collaboration and shared learning.

It will also be important to develop ties with the Alberta Cancer Board to exploreborder issues around referral patterns.

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1.4. Summary and Next Steps

Northerners clearly face a burden of access to cancer care. The agreed upontreatment and care priorities reflect a short term approach to reducing this burdenby reviewing the systems, processes and supportive programs for cancer patients.

Many of the quality of life and access issues reflect a real service problemassociated with sub optimal patient education, communications, and coordination ofappointments, travel planning and navigation. These issues, in addition to asignificant number of anecdotal problems around specialist services, requireinterventions and improvements that ensure care planning, treatment and follow upactivities are done efficiently for patients and their care providers. This will requirereducing the uncertainty, unnecessary delays and travel hardships for patients andfamilies. NH and BCCA are committed to working together to improve the cancerservices and programs for Northerners.

The short term priorities for the Northern Cancer Program are designed to allowwork to begin immediately to improve outcomes with respect to the incidence ofcancer, survival, as well as access and quality of life. They will also build theessential foundation required to enable further development of cancer care in theNorth, including some additional elements of surgical, medical and radiationoncology services. As these short term priorities are accomplished, NorthernHealth and the BC Cancer Agency will seek out service models that can improveaccess to care in smaller centers without compromising service reliability andpatient outcomes.

The process for developing a Northern Cancer Program will be an ongoing anditerative one that will require strong, effective partnerships of medical staff andprogram leaders between NH and BCCA. It also needs to be an inclusive processinvolving internal and external stakeholders in the planning and implementation ofthe strategic priorities. It will necessitate fresh looks at existing data andinformation and the development of new data to answer emerging questions. Nextsteps include:

Due diligence/project planning and budgeting for each of the short termpriorities;

Quarterly meetings between BCCA and NH, to monitor progress andcontinue planning for the longer term initiatives; and

Yearly planning sessions with broad stakeholder input to review progresson the plans, determine outcome improvements, data requirements andbegin detailed planning on next priorities.

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2. THE NORTHERN CANCER CONTROL PROJECT

2.1. Overview

The British Columbia Cancer Agency, an agency of the Provincial Health ServicesAuthority (PHSA), and Northern Health are partnering to produce a joint cancercontrol strategy for Northern patients.

Project Vision: To strengthen the capacity to prevent, detect, and treat cancer andsupport patients in the North.

Project Goal: Develop a shared vision of short and long-term priorities for cancercontrol in the North that are patient focused, evidence and data driven.

This phase of the strategy is focused on opportunity definition. The teaminvestigated existing programs and services, analyzed data and maderecommendations for change. Subsequent initiatives will focus on detailedimplementation planning for needed changes.

2.2. Project Participants and Roles

The Executive Sponsors are Simon Sutcliffe, President of BCCA and MalcolmMaxwell, CEO of Northern Health.

The Steering Committee consisted of Cathy Ulrich, VP Clinical Services/CNO,Northern Health; David Butcher, VP Medicine, Northern Health; Barry Sheehan,Radiation Oncologist, Vancouver Centre, BCCA; and Sandra Broughton, RegionalAdministrator, Southern Interior, BCCA.

A Reference Group, based on the current Regional Cancer Committee, withadditional stakeholders included:

NHA: Dr. Winston Bishop (Internist), Dr. Phil Staniland (Physician, PalliativeCare), Dr. Gilbert Wankling (surgeon, NI), Dr. Zhou (Pathologist, NI), JudyFirth (Palliative Care, Community Services, PG), Gayle Magrath (RN,Cancer Care Unit, PGRH), Ladonna Fehr (RN, Cancer Care Unit, PGRH),Cindy Mueller (RN, Cancer Care Unit, PGRH), Corinna Werbecky (RN,Cancer Care Unit, PGRH), Dr. Dana Cole (Pharmacist, PGRH), AndreaLindsay (Director, Acute and Community Services, Quesnel), ElizabethZook (Pastoral Care, PGRH), Kerri McCaig (Tobacco ReductionCoordinator), Lynda Anderson (Public Health Nurse, Northern InteriorHealth Unit), Edna McLellan (Public Health Nurse Northwest), KathyMacDonald, Regional Director, Preventive Public Health, Lucy Beck,Regional Director, Public Health Protection, Dr. David Bowering (ChiefMedical Health Officer), Heather Tant (Dietitian), Val Stewart (Patient CareManager Pediatrics, PGRH), Mark Coulter (Regional Director, DiagnosticServices), Marshal Moleschi (Health Services Administrator), Judy Rea(RN, Prince Rupert Regional Hospital, Prince Rupert), Lynn Shervill (RN,Bulkley Valley District Hospital, Smithers), Jennifer Kennedy, (Manager,Special Projects, H&CC Palliative Care), Joanne Cozac, (Patient CareManager, PGRH Chair of Cancer Strategy Reference Group), MichaelMcMillan (COO-NI), Dr. Dan Horvat, (Medical Director, NI), Dr. John Mah(NI), Dr. Meredith Hunter (NI), Dr. Shannon Douglas (NI), Dr. Biz Bastian(NW), Dr. Warwick Evans (NW), Dr. Lorna Sandler (NE), Natalie Manhard(NE), Lynn Smiley (NE), Dr. Becky Temple (NE), Dr. Robert Newman (NE),

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Dr. Steven Ashwell (NE).BCCA: Marilyn Porter: Regional Systemic TherapyLeader, Dr. Joanne Stephen: Research Consultant for Cancer Rehab,Richard Doll: BC Cancer Agency, Jaya Venkatesh (Administrator of theProvincial Systemic Therapy Program) who will forward to Dr SusanOReilly (Professor and Head of Medical Oncology and leader for theVancouver Region (BCCA), Dr. Tom Keane, Provincial RT Program Leader

(BCCA).

Other Agencies: Donalda Carson (Prince George Hospice Society, PG),Steve Horton (Cancer Society), Joanne Snetsinger (Cancer Society),Stephanie Powell (Cancer Society), Judith Quinlan (Alliance for BreastCancer Information and Support), Joanne Fairlie, (Assist. Deputy Minister,Yukon Health & Social Services).

The establishment of a Reference Group enabled the sharing and vetting ofongoing learning and findings with a wide range of stakeholders.

The Project Manager was Maureen Knox, an independent health care consultantwith a background in cancer treatment.

2.3. Project Timelines

The project began in mid-October of 2004. A project charter was developed in earlyNovember and data gathering and inventory collection was completed in lateDecember. The issues were analyzed and priorities determined by the Sponsorsand Steering Committee in January. The findings and priorities were validated withthe Reference Group in January and the final report will be submitted to MalcolmMaxwell and Simon Sutcliffe in March of 2005.

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3. PRINCIPLES UNDERLYING CANCER CONTROL INB.C.

3.1. The Organization of Cancer Control in B.C.The BC Cancer Agency is responsible for delivering a program of cancer control tothe population of British Columbia. The vision of the BCCA is a cancer free society,which is reflected in the mission to reduce the incidence of cancer, to reduce themortality from cancer and to improve the quality of life of those living with cancer.

The BC Cancer Agency is a population-based cancer control organization with awell developed, stable platform for its service, education and research mandate.This population based program is used to deliver cancer control. The population ofBC is those who are healthy, healthy at higher risk population, asymptomatic withcancer, acutely ill with cancer, chronically ill with cancer, cured and dying of cancer.

3.2. Delivering this Population Based Cancer ControlProgram

Sites, programs, networks and services are the components required to deliveringthis population based program. There are four regional centres in Vancouver,Victoria, Surrey, Kelowna and one planned centre in Abbotsford (2008) that provideassessment, treatment, supportive care, pain and symptom management andpalliative care services. Chemotherapy and supportive care is provided through 26community cancer centres/clinics and chemotherapy by community cancer centrenurse in another six communities. Provincial programs include, prevention, earlydetection (Screening Mammography Program of BC (SMPBC) and CervicalScreening Program), diagnostics (imaging, pathology and laboratory), treatment(surgical, radiation therapy and systemic therapy), supportive, rehabilitation andpalliation, and end of life care. These programs include interventional services,research, education, information, communication and linkages. The goal of theProvincial Networks is to assist the BC Cancer Agency (BCCA) in its mandate toimprove cancer control in the province by providing support and connections in thecommunity. The Network includes Tumour Groups, SMPBC, Hereditary Cancer,Surgical Oncology Council/Network, Paediatric Oncology Council/Network, FamilyPractice Oncology Network, Palliative Care, Consultative Clinics and Psychosocial.Common services provide support across the sites, programs and networks andthey include the website (www.bccancer.bc.ca), Clinical Practice Guidelines,Priorities and Evaluation Committee, Professional Practice Standards, Registry,Surveillance and Outcomes and Professional Education.

3.3. BCCA Strategic Plan 2004-2010

Despite two decades of continuing improvement in age-standardized mortality rates(ASMR), the impact of interventions on death from cancer the population burdenof cancer continues to rise as a result of aging of a growing population. The BCCAStrategic Plan will sustain the provincial cancer control platform whilst transformingthe Agency into a "transactional research organization" directed to enhancingcancer control outcomes. In partnerships with the Health Authority in each region,BCCA works within the longer term framework set out in this document. The plan isavailable on the website noted above.

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4. THE FINDINGSHEALTH AND CANCER IN THENORTH

A process was undertaken in November and December of 2004 to collect relevant

data and inventory programs and services in order to provide an overview of cancercontrol in the North. The collection was completed using a framework that looks atthe continuum of cancer as described by the Canadian Cancer Control Strategyframework:

Prevention and Promotion

Screening

Detection, Treatment and Care (includes palliative care)

Data were collected from various sources including NH, BCCA, and the Ministry ofHealth etc. The inventory was developed from information submitted by programpersonnel.

(Additional data can be found in Section 6.1 of the Appendices.)

4.1. The Data

4.1.1. The Population of the North

The vast area served by Northern Health covers approximately 588,000 squarekilometers or two-thirds of BC and, with a population of approximately 299,446(2005) persons, it has the lowest population density per square kilometer of any BCHealth Area.

Administratively, Northern Health is divided into three Health Service DeliveryAreas: Northwest, Northern Interior and the Northeast. The vast geography, the

small widely distributed population and the differing needs of each communitypresent enormous challenges when it comes to promoting good health, preventingdisease and providing sustainable and integrated health services.

On average the population in the North is considerably younger than the rest of BCalthough, like the rest of BC, the northern population is growing older.

The average age of people in the North is 34 years of age whereas the average ageof the BC population is 38 years. The following chart demonstrates that thepopulation is aging and the percentage of those over 65 is expected to increasesignificantly over the next 10 years.

HA Name Year Gender 0 -19 20-54 55+ 65+ 75+

Total

Pop-ulation

Northern 2005 All 86631 156660 56155 25957 10092 299446

% 28.9 52.3 18.8 8.7 3.4 100.0

Northern 2015 All 77203 163582 82856 40331 14345 323641

% 23.9 50.5 25.6 12.5 4.4 100.

Source: BC Stats, Population Projections, PEOPLE 29, acquired through the Health Data Warehouse-Dec 22, 2004.

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Aboriginal, First Nations and Mtis peoples comprise a very significant andimportant part of the Northern population. According to the most recent Census,there are between 35,000 and 45,000 Aboriginal First Nations and Mtis personsresiding in the area served by Northern Health.

4.1.2. The Burden of Cancer in the North

At present it is estimated that there are about 1000 new cancer diagnoses inNortherners each year and it is estimated that about 8,000 Northerners are livingwith some form of cancer. By the year 2015, we can expect the number of newcancers to climb to approximately 1400 per year and there will be about 11,000persons living with a diagnosis of cancer in Northern BC.

The impact will be significant on all care providers including physicians, nurses,palliative care resources etc. It will be important to develop services such as theFamily Practice Oncology Network to ensure consistent follow up services.

Custom Data Analysis provided to NH by BCCA November 2004.

0

2000

4000

6000

8000

10000

12000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

People

th

nc

Livingwi

Ca

er

4.1.3. Morbidity and Mortality

Life expectancies for Northerners are from three to four years shorter than those forBC residents overall.

Cancers are a significant cause of death amongst Northerners second only todeaths from Circulatory and Heart Disease. Between 1991 and 2001, cancer

accounted for 3977 deaths in the North.

The Standardized Mortality Ratio (SMR) is an internationally recognized HealthStatus indicator. The SMR is a good measure for comparing mortality data that arebased on a small number of cases or for comparing mortality data by geographicalarea. The SMR is the ratio of the actual number of deaths to the expected numberof deaths. The area served by Northern Health is distinguished by having thehighest SMRs in British Columbia for many causes of death including all Cancersand Lung Cancer. If these ratios are adjusted for age and population structure (AgeStandardized Mortality Ratios demonstrated on the following graph) the North stillhas a death rate for cancer that is above the BC average.

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The graph below shows that the age standardized rate of death for all cancerscombined in Northern Health is 18.11 per 10,000 vs. the provincial rate of 16.05

Source: Data to support graphic obtained from BC Vital Stats, acquired through the HealthData Warehouse.

The data that describes the Incidence of cancer in the North appears to show agreat deal of variability between the 3 HSDAs for example, an age standardizedrate of 58/100,000 in the Northwest for colorectal cancer compared to rates of44/100,000 in the Northern Interior and a BC rate of 46.6/100,000. (See thefollowing 3 tables)

Age Standardized Female Cancer

Incidence Rates per 100,000 by

Selected Cancer Types 1999-2003

050

100150200

250300350400

Northwest Northern

Interior

Northeast BC Total

Breast

Colorectal

LungOther

Prostate

All Cancers

10 12 14 16 18 20

Interior

Fraser

Van.Coastal

Van. Island

Northern

Age Standardized Mortality Rate per 10,000

BC

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Females Breast Colorectal Lung Other Prostate All Cancers

Northwest 121.3 57.7 49.4 133.6 0 362.1

Northern Interior 97.9 42.2 56 157.3 0 353.4

Northeast 86.8 47.1 43.6 115.4 0 292.9

BC Total 105.1 44.4 46.9 153.2 0 349.6

p value vs. rest of BC

Northwest 0.015 0.02 0.52 0.11 0 0.16

Northern Interior 0.1 0.51 0.035 0.6 0 0.98

Northeast 0.055 0.48 0.83 0.00044 0 0.0013

Age Standardized Male Cancer

Incidence Rates per 100,000 by

Selected Cancer Types 1999-2003

050

100150200250300350400

Northwest NorthernInterior

Northeast BC Total

Breast

Colorectal

Lung

Other

Prostate

All Cancers

Males Breast Colorectal Lung Other ProstateAllCancers

Northwest 0 58.3 48.6 167.5 105.2 379.5

Northern Interior 0 46 60.9 146.2 120.2 373.4

Northeast 0 52.6 64.1 132.8 121 370.5

BC Total 0 48.8 52.5 154.5 115 370.8


Northwest 0 0.1 0.49 0.12 0.089 0.64

Northern Interior 0 0.23 0.067 0.28 0.79 0.78

Northeast 0 0.59 0.11 0.016 0.77 0.55

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Age Standardized All Cancer Incidence

Rates per 100,000 by Selected Cancer

Types 1999-1003

050

100150200250300350400

Northwest NorthernInterior Northeast BC Total

Breast

Colorectal

Lung

Other

Prostate

All Cancers

All Breast Colorectal Lung Other ProstateAllCancers

Northwest 0 58 49 150.4 0 370.7

Northern Interior 0 44.1 58.4 151.8 0 363.3

Northeast 0 49.8 53.7 124 0 331.4

BC Total 0 46.6 49.7 153.9 0 360.1


Northwest 0 0.0056 0.88 0.9 0 0.21Northern Interior 0 0.18 0.006 0.7 0 0.89

Northeast 0 0.38 0.28 3.50E-05 0 0.0092

Source: BCCA February 2005

While the statistical tests do not generally indicate that the variability between the3HSDAs and the BC incidence rates are statistically significant, the incidence datashould be interpreted with caution given that the numbers of cases in the North arerelatively small. The rates are highly dependent on the population denominatorsthat are used, which are based on projections from Census counts which may behigher than the truth due to the slowing of the economy in most of the North.

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The data that describes the 5-year survival rates also show a great deal ofvariability between HSDAs in the North. For example, the 5 year survival for lungcancer ranges from 16.4% in the Northwest to 11.7% in the Northern Interior to8.3% in the Northeast.

5-Year Survival Rates per 1,000 IncidentCases for Selected Cancer Types 1999-

2003

00.10.20.30.4

0.50.60.70.80.9

1

Northwest Northern

Interior

Northeast BC Total

Breast

Colorectal

Lung

Other

Prostate

All Cancers

Weighted

Breast Colorectal Lung Other ProstateAllCancers Weighted

Northwest 0.841 0.537 0.164 0.561 0.929 0.608 0.603

Northern Interior 0.794 0.592 0.117 0.493 0.803 0.543 0.548Northeast 0.811 0.604 0.083 0.527 0.875 0.58 0.573

BC Total 0.846 0.569 0.148 0.497 0.871 0.574 0.569

p values vs. rest of BC

Northwest 0.21 0.12 0.9 0.041 0.13 0.19

Northern Interior 0.098 0.86 0.023 0.87 0.0062 0.0065

Northeast 0.28 0.98 0.33 0.77 0.78 0.71

Source: BCCA Feb. 2005.

We can be confident in the tombstone data that indicate that the mortality rates of

lung cancers and all cancers combined are significantly elevated in NorthernHealth. More work will need to be done to ensure the reliability of our cancerincidence rates.

While 5-year survival rates are slightly lower than the BC rate when consideredacross all of Northern Health, there is a great deal of apparent variabil ity betweenHSDAs. Defining how cancer incidence and survival interact to produce theobserved mortality rates will be an important task for ongoing consideration as theproposed cancer strategy goes forward.

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Data Themes

The unique geography and demographicscreate challenges (and opportunities).The key challenges include:

Small widely dispersed population with a higher proportion of young people. Rapid growth in the number of seniors predicted.

The highest proportion of Aboriginal people of any BC Health Authority.

High Standardized Mortality Ratios for All Cancers and Lung Cancer.

Variable and somewhat poorer overall 5 year survival rates for breast, prostate,colorectal, and lung cancer.

Gaps still exist in the data

What type of cancer service does the Alberta Cancer Board provide to theresidents of the Northeast?

Do Northerners present with more advanced cancer than their provincialcounterparts, and if they do, what factors contribute to this?

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4.2. Prevention and Promotion Findings

Cancer prevention and healthy lifestyle promotion should be a key element in allcancer control strategies. Key elements of any cancer control plan generally includeprograms that focus on tobacco reduction, nutrition, sun safety, environmental, and

healthy lifestyles.

The North has many characteristics that require coordinated, comprehensiveapproaches to reduce the incidence of cancers:

Nearly 32 % of all Northerners are current smokers.

37% of Northerners permit smoking inside their homes.

In 2005, NH can expect 136 new lung cancers. By 2015, this number willhave climbed to 164 new cases per year.

Northerners have an average BMI that is higher than the average for therest of BC.

The rates of alcohol consumption are higher in the North.

The rates of STDs are higher in the North.

Northern residents are exposed to a number of environmental risk factorsincluding:

o Radon gas has been identified particularly in the Northern Interior;

o Arsenic levels in some water sources exceeds incoming nationalguidelines; and

o Sun exposure.

Efforts to reduce lifestyle related cancers require a comprehensive approach.

Northern Health runs or supports a number of Programs such as Hepatitis BImmunization, Viral Hepatitis C Clinic, Heart Health, Tobacco Control Programs,Canadian Cancer Society Prevention Strategy, Sun Safety, Environmental HealthPrograms, Nutrition Programs, Sexually Transmitted Disease Clinics, ChronicDisease Management Programs and the Primary Health Care Initiative.

While many programs and services are offered across the North, they arefragmented and rely on Public Health to partner with numerous other organizationsto assist with funding, initiation and implementation.

(See Section 6.2 in the Appendices for further program information by HSDA.)

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Prevention and Promotions Themes

NH has a population with a high level of behavioural risk.

Programs are offered across Northern Health, however given the importance ofthe modifiable risk factors in reducing cancer incidence, opportunities exist toenhance or expand services.

Public Health program resources and funding are limited.

Programs are often fragmented and differ by community or HSDA.

Prevention and Promotion programs and services are often the result of NHpartnering with other agencies and or responding to regulations, standards andguidelines e.g. BCCDC, School Districts, Ministry of Health Services, HealthyHeart Society, Canadian Cancer Society, and Health Canada etc.

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4.3. Screening Findings

The purpose of screening is to detect cancer at an early stage of development; priorto the development of symptoms. Screening can also identify precursors of cancer,the treatment for which can reduce the risk of cancer developing.

Although a number of cancer screening tests have been developed, only a fewhave been proven effective and therefore recommended for defined populations.BCCA operates two screening programs:

1. Screening Mammography Program of BC

2. Cervical Cancer Screening Program

Screening Mammography Participation Rates 2001-2002

0 25 50 75 100

East Kootenay

Kootenay Boundary

Okanagan

Thomp Cariboo Shus

Fraser East

Fraser North

Fraser South

Richmond

Vancouver

North Shore/Cst Garibaldi

S. Vancouver Is.

Central Vancouver Is.

N. Vancouver Is.

Northwest

Northern InteriorNortheast

Participation Rate (percent)

BC

47.1

Screening mammography is animportant strategy for the earlydetection of breast cancer.

Provincially, the screening programparticipation rate is 47.15 %.Participation rates in the North areas follows. Northwest 33.5 %,Northern Interior 46.9 % and theNortheast 38.5%.

Though participation is lower thanthe provincial rate, approximately20,000 women every 2 years

undergo Breast Cancer screening inNorthern BC

Screening Mammography Program of BC,

BC Cancer Agency published through the Health data Warehouse.

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Cervical Screening Participation Rates 2000 - 2002

0 50 100 150 200 250 300

East Kootenay

Kootenay Boundary

Okanagan

Thomp Cariboo Shus

Fraser East

Fraser North

Fraser South

Richmond

Vancouver

North Shore/Cst Garibaldi

S.Vancouver Is.


N.Vancouver Is.

Northwest

Northern Interior

Northeast

Rate per 1000 women

205

BC

Cervical cancer is the most commonlydiagnosed form of reproductive cancer.This is due to the development and

widespread use of the Pap (smear) test.

Each year approximately 21,000 Northernwomen undergo cervical screening in thearea served by Northern Health. Thistranslates to a regional programparticipation rate of 190.3 / 1000 womenages 20 69, which is lower than theProvincial average of 205/1000 women.One cancer is prevented for every 1500Pap smears.

Source: Cervical Cancer Screening Program acquired through theHealth Data Warehouse.

In addition to the BCCA Programs, a Women's Health Care Program is operatedby NH. This Program uses Primary Health Care Transition Funding to enhancereproductive health services and screening for cancers of the cervix and breast aswell as Sexually Transmitted Infections (HPV) in six rural communities. A keyfeature of this Program has been the training of Aboriginal service providers toincrease the use of services by this underserved population.

Prostate and Colon Cancer Detection:

Early detection is also important for prostate and colon cancer and consists of

specific symptom review, risk determination based on family and personal medicalhistory and physical examination, such as digital rectal examination. Follow-upstudies such as the Prostate Specific Antigen test (PSA), colonoscopy, or specialradiology should be done when history, physical examination, or the age and sex ofthe patient indicate they are needed. The value of these studies applied to thegeneral population rather than on an individual basis has not been validated.

There are currently no statistics available to compare the standards of practice withrespect to office-based screening for prostate and colon cancer in the North with therest of BC, but issues such as a relative shortage of primary care and specialistphysicians in some Northern communities would clearly affect the ability of Northerncitizens to access these important screening services.

(See Section 6.3 in the Appendices for further screening information by HSDA.)

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Screening Themes

Participation rates for breast and cervical screening fall slightly below provincialaverages.

Geography and road quality prevent mobile mammography units from visitingsome remote communities.

The First Nations population is known to have a higher incidence of cervicalcancer than the general population; however they have lower rates ofparticipation in screening programs.

The lack of coordinated primary care standards and scheduling for screening anddetection in some Northern communities negatively impacts citizens access toscreening and detection programs and services.

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4.4. Detection, Treatment, and Care Findings

Detection

Early detection means detecting cancer prior to the development of symptoms or as

soon as is practicable after the development of symptoms. Detecting a cancer earlymeans the likelihood of cure goes up as the cancer will be localized to the bodyorgan of origin. Early detection of cancer can involve education about signs andsymptoms and improved access to primary care.

Northern Health citizens have access to a variety of laboratory services anddiagnostic imaging modalities including x-ray, CT, MRI, and Nuclear Medicinescans. While diagnostic testing is offered across the three HSDAs, consistentorganization is limited and quality assurance occurs outside the Health Authorityframework.

Laboratory Services include in-patient and out-patient Clinical Pathology services:Hematology, Chemistry, Microbiology, Transfusion services and AnatomicPathology. Transfusion services include both blood and specific blood components

such as platelets. Also included is a fast track outpatient laboratory service forcancer patients.

Hematology services are closely tied to the cancer program as are bloodtransfusion services. Services performed range from complete blood counts (CBC),through peripheral smears for analysis of certain blood cell types, to bone marrowanalysis.

Limited cytology services are provided. Fluid screening and Fine Needleaspirates/biopsies are provided in some communities. The majority of cytology issent out to the BC Cancer Agency.

(See Section 6.4 in the Appendices for further diagnostic facility information.)

Treatment and Care

Treatment of cancer is complex, involving a range of therapies including surgery,radiation, chemotherapy, hormonal therapy, supportive services and palliative care.The aim of treatment is to cure or to prolong and improve the quality of the life ofthose with cancer.

A summary of NH treatment programs and services follows:

Surgery

Surgery is available in the North from a variety of general and sub-specialistsurgeons e.g. general, orthopedic, urology, oral maxillofacial, plastic, gynecology,ENT and pediatric ENT, ophthalmology, dental, and endocrine. General and sub-specialty cancer surgery is offered in many Northern communities but involvementwith the BCCA Surgical Oncology Network is limited and based on the individual

surgeon. This is likely a reflection of the creation of a regional medical staffstructure only within the last year. A general surgeon from Prince George is anexecutive member of the BCCA Surgical Oncology Network.

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Breast Conserving Surgery: The relative rate of breast conserving surgery isillustrative of the ability of patients to obtain current modes of treatment. Breastconserving surgery, or lumpectomy, is a less disfiguring option for the surgicaltreatment of breast cancer than mastectomy. However, a percentage of womenundergoing lumpectomy will require further surgery, which may include mastectomyif surgical staging of their disease indicates spread of the cancer. Women may be

offered a choice of surgeries and their ability to choose may be contingent onaccess to adjuvant therapies or to rapid laboratory confirmation of the presence orabsence of tumor spread. The relative number of breast cancer patients beingoffered and choosing breast conserving surgery is used here as an indicator ofNortherners access to current standards of surgical oncology.

Lumpectomies as a Percentof all Breast Surgery

0 10 20 30 40 50 60 70 80 90 100

Breast-conserving surgery (lumpectomy),followed by radiation treatment, is therecommended procedure for most womenwith early stage breast cancer.Guidelines produced by the Canadian

Medical Association and Health Canadasuggest that four out of five women withearly breast cancer may be treatedsuccessfully with breast conservingsurgery rather than a radical mastectomy.Lumpectomy is commonly combined withthe excision of lymph nodes from the axilla(armpit) to determine the potential forspread of the cancer

The graph to the left shows that the ratesof Breast Conserving Surgery at slightlyabove the Provincial average in Northern

Interior (NI) and Northwest (NW). Therates for Northeast (NE) are lower butfurther investigation will be necessary todetermine if it is due to referral patterns toAlberta.

East Kootenay

Kootenay Boundary

Okanagan

Thomp Cariboo Shus

Fraser East

Fraser North

Fraser South

Richmond

Vancouver

N. Shore/Cst Garibaldi

S. Vancouver Is.


N. Vancouver Is.

Northwest

Northern Interior

Northeast

Percent of all Breast Surgeries

BC

63.4

Source: Morbidity Database, BC Ministry of Health acquiredthrough the Health Data Warehouse.Breast ConservingSurgery reflects hospitalization data for fiscal 2000/2001.

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Radiation Therapy

Radiation therapy or radiotherapy is one of the most important types of non-surgicaltreatment prescribed for patients with common cancers. Radiotherapy is giventhrough repetitive treatments, usually on a daily basis, provided over an extendedtime period. The proportion of cancer patients treated by radiotherapy at some time

during their illness has risen steadily to about 50%.

There are no radiation therapy facil ities in NH. Therefore, patients referred forradiation treatment must travel to one of the BCCA sites in Vancouver, Victoria,Kelowna or Fraser Valley for an extended period of time, which typically rangesfrom three to six weeks. This presents travel and social challenges for patients andtheir families. In 2003, 357 people from NH were referred to BCCA radiationfacilities. Most of those patients went to the Vancouver Centre (309) while asubstantial minority went to the Southern Interior Cancer Centre in Kelowna (44). Ahandful of patients went to the Fraser or Island facilities.

The table following indicates the number of Northeast residents accessing servicesof the Alberta Cancer Board. At this time data is not available on the type ofservices accessed, but some portion of these numbers would include radiotherapy.

Region Township CountNorth Eastern BC Chetwynd

Dawson CreekFort NelsonFort St. JohnTete Jaune CacheTumbler Ridge

217823664

14

Source: BCCA February 2005

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The table following indicates that people living in NH are referred for radiationtherapy less often than those living near radiation facilities e.g. Okanagan, FraserValley, Vancouver or Vancouver Island.

Data from at least one year indicates that initial radiation treatment rates in theNorth (i.e., cases referred within 12 months of diagnosis) are comparable to the rest

of the province with relatively high rates in the NW, slightly lower rates in the NI,and low rates in the NE.again, probably due to referrals to Alberta. Overall,Northerners have similar rates of curative treatment to other British Columbians, butrates of radiotherapy for palliative treatment are lower for Northerners than forresidents of the southern mainland.

Referral Patterns: BC Cancer Agency New Cases, Referred Cases andRadiation Cases by Health Authority and Health Service Delivery Area

Years 2000-2002 Years 1995-1997New

CasesReferralCases

RadiationCases

NewCases

ReferralCases

RadiationCases

HealthAuthority

Health ServiceDelivery Area

# # % # % # # % # %

East Kootenay 901 423 46.9 141 15.6 899 259 28.8 65 7.2

Kootenay/Boundary 1184 608 51.4 255 21.5 1238 456 36.8 180 14.5

Okanagan 5195 3545 68.2 1408 27.1 4856 1755 36.1 717 14.8

Interior

Thompson/Cariboo 2955 1456 49.3 788 26.7 2480 938 37.8 378 15.2

Fraser East 3174 2042 64.3 860 27.1 2986 1830 61.3 848 28.4

Fraser North 6179 3705 60.0 1702 27.5 5350 2882 53.9 1547 28.9Fraser

Fraser South 6848 4471 65.3 2049 29.9 5905 3677 62.3 1824 30.9

Richmond 1819 1003 55.1 468 25.7 1596 843 52.8 459 28.8

Vancouver 6518 4381 67.2 1827 28.0 6330 3844 60.7 2033 32.1VancouverCoastal

Nrth Shore/Garibaldi 3642 2019 55.4 935 25.7 3343 1620 48.5 870 26.0

South Vanc. Island 6646 4700 70.7 1838 27.7 5917 3947 66.7 1800 30.4

Central Vanc. Island 4076 2730 67.0 1162 28.5 3476 2095 60.3 947 27.2VancouverIsland

North Vanc. Island 687 456 66.4 215 31.3 632 412 65.2 178 28.2

Northwest 777 487 62.7 180 23.2 650 368 56.6 146 22.5

Northern Interior 1393 638 45.8 276 19.8 1255 511 40.7 230 18.3Northern

Northeast 467 157 33.6 69 14.8 501 124 24.8 53 10.6

Blank Blank 528 292 55.3 128 24.2 296 103 34.8 45 15.2

Grand Total 52989 33113 62.5 14301 27.0 47710 25664 53.8 12320 25.8

Key: All Cases: Cancer cases in this table include all invasive cancer diagnosis in BC residentsand exclude non-melanoma skin cancers. Health Authority / Health Service Delivery Area:Includes Health Authority / Health Service Delivery Areas at time of diagnosis. Non-ReferredCases: Diagnosis Date = 1995-1997 and 2000-2002 Referred Cases: Site Admit Date =1995-1997 and 2000-2002. Percentage is of total new cases. Radiation Cases: RadiationStart Date within 6 months of the Site Admit Date (Referred Cases). Percentage is of totalnew cases. SOURCE: CAIS (Patient Information) DATE RETRIEVED: 02 November 2004

Travelling to access radiation therapy services is clearly a burden for cancerpatients in the North. This strategy will reduce some of this burden through therecommendation of several short term priorities namely transportation, navigation,telehealth and enhanced consultation.

Systemic Therapy/Chemotherapy

Chemotherapy is one of the most common treatments for cancer. It is the maintreatment for some types of cancer, such as leukemia, Hodgkin's Disease and Non-Hodgkin's Lymphomas. Cancers of the lung, breast, testes, colon, ovary, andstomach are also treated with chemotherapy. For some patients, chemotherapymay be the only treatment they receive.

BCCA operates one Community Cancer Centre in Prince George and fiveCommunity Cancer Services in Dawson Creek, Ft. St. John, Prince Rupert, Terraceand Smithers. The Community Cancer Centre provides a full range of systemic

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therapy for cancer patients. Partial funding and training for nurses are provided byBCCA. Chemotherapy is also administered by nurses or physicians in other smallercommunities that do not have a formal BCCA program e.g. Kitimat, Quesnel, andQueen Charlotte Islands.

The table following demonstrates the numbers of chemotherapy cases managed

directly by BCCA medical oncologists by community for the years 2002 and 2003.Differing data capture for other sites make complete comparison of historicalchemotherapy activity difficult.

Current Local

Health AreaV CC Pr. Rup ert CCSI Terr ace Daw son Crk VI CC FVCC Tota l Cases VCC Pr. Rupert CCS I Terra ce VICC FV CC Kam loops Total Cases

Burns Lake 6 0 1 1 0 1 0 9 6 0 1 0 0 1 0 8

Fort Nelson 2 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0

Kitimat 6 0 2 1 0 0 0 9 10 0 0 0 1 0 0 11

Nechako 12 0 0 0 0 0 0 12 7 0 3 0 0 0 0 10

Nisga'a 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 1

Peace River North 6 0 5 0 0 1 0 12 10 0 6 0 0 0 0 16

Peace River South 11 0 1 0 1 0 1 14 8 0 1 0 2 1 0 12

Prince George 57 0 10 0 0 1 2 70 59 0 18 0 0 1 1 79Prince Rupert 11 5 1 0 0 3 2 22 19 5 0 0 2 0 0 26

Queen Charlotte 7 0 0 0 0 0 0 7 4 0 0 0 0 0 0 4

Quesnel 6 0 30 0 0 1 1 38 14 0 10 0 1 2 0 27

Smithers 13 0 0 1 0 0 0 14 11 0 2 2 1 0 0 16

Snow Country 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0

Stikine 3 0 0 0 0 0 0 3 1 0 0 0 0 0 0 1

Telegraph Creek 1 0 1 0 0 0 0 2 3 0 0 0 0 0 0 3

Terrace 27 0 0 6 0 0 0 33 21 0 2 2 1 2 0 28

Upper Skeena 4 0 1 0 0 0 0 5 3 0 0 0 0 0 0 3

Grand Total 174 5 52 9 1 7 6 254 177 5 43 4 8 7 1 245* BCCA Fully Admit Northern Health Authority Cases:

Cases assessed or treated by a BCCA Oncologist (excludes cases referred for lesser service, eg conference only, special procedure, nutrition only, etc).

Current address postal code is in Northern Health Authority catchment.

** Prescribed Chemotherapy:

Chemotherapy includes IV or oral chemo or hormone therapy. First chemotherapy prescription date on pharmacy database is on or before BCCA site admit date.

*** Referral Treatment Centre:

Patient referred to a BCCA treatment centre or just to a BCCA Communities Oncology Network (CON) clinic.

Chemotherapy may or may not have been administered at the BCCA centre or clinic.

SOURCE: CAIS(Patient Information)

DATA RETRIEVED: 27 January 2005

PREPARED BY: Wendy Robb, Data Analyst - Surveillance & Outcomes Unit, P&PO

DATE PREPARED: 27 January 2005

FILENAME: q05601.xls

BCCA Site Admit Year and BCCA Referral Treatment Centre***

2002 2003

BCCA Fully Admit Northern Health Authority Cases* With Prescribed Chemotherapy**

By BCCA Site Admit Year and BCCA Referral Treatment Centre***

Site Admit Date Between 01 January 2002 and 31 December 2003

The NH chemotherapy program does not provide high dose intensive therapy forleukemia and does not participate in clinical trials. There is only one internist withexpertise in medical oncology available for consultation in NH. In general, there isno formal organization for chemotherapy administration across the North, demandis increasing, resources are limited and standards and guidelines may not beuniformly applied across the communities.

Family Practice Oncology Network

The Family Practice Oncology Network (FPON) is a partnership between the BritishColumbia Cancer Agency and family physicians. The impetus for developing theFPON has been the recognition of the need for enhanced capability in B.C.scommunities to care for cancer patients. The FPON promotes understanding anddevelopment of the supports necessary for family physicians to engage in thelongitudinal care of patients with complex, and frequently chronic, health concerns.The FPON has established a two-month preceptorship program for familyphysicians. A number of Northern physicians have completed the preceptorshipprogram; however more practitioners are needed in the North to support patientsand programs.

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Support Services

Coping with cancer and its treatment involves a range of issues for patients,families and caregivers. In order to meet their physical, social, emotional, nutritional,informational, psychological, sexual, spiritual and practical needs throughout thespectrum of the cancer experience a number of supportive and rehabilitative

services need to be developed. (Canadian Strategy for Cancer Control, 2002).

Pharmacy, nursing and medical consultation is provided in NH. Psychosocial,nutritional and emotional support is provided by professionals where available, but itis fragmented and only two communities offer navigation services. Some areashave support groups and the chemotherapy nurses provide services wheneverpossible.

Palliative & Hospice Care

Palliative care is an essential support throughout the cancer journey to provideexpertise in pain management, psychological and spiritual support as well as end oflife care. There is no comprehensive, integrated Palliative Care Program in theNorth. Only NI has a full-time coordinator while the other communities access

home care and acute care nurses as the need arises. The Hospice Society workswith NH in several communities to provide palliative care including bereavementsupport. Several Hospice Societies exist in the North, such as: North PeaceHospice, Kitimat, Upper Skeena/Hazelton, Rotary Hospice House in Prince George,and Dawson Creek.

Canadian Cancer Society

The Canadian Cancer Society provides funding and organizes support groups withcancer survivors in each HSDA. A new initiative provided funding for a CommunityAction Coordinator for NH who will engage community leaders in the developmentand promotion of healthy policies and programs.

Telehealth

Telehealth is currently being used in a variety of ways to support cancer control inthe North:

Oncologists involved in provincial tumor groups regularly meet throughvideo conferencing to discuss and develop individual patient treatmentplans and revise treatment protocols. There are also educational roundsbroadcasted via videoconferencing.

BCCA offers weekly education sessions to oncologists, nurses and otherclinicians practicing within BCCA's cancer centres and communitiesinvolved with cancer care across the province. Clinicians working withinsites that are part of the communities' oncology program, deliveringchemotherapy to patients locally, are a key target audience to access thisspecialized education service.

The hereditary cancer program has provided genetic counseling serviceslinking Vancouver based practitioners with ten clients in Prince Georgeand will be implementing a similar project servicing Prince George andPrince Rupert.

The use of telehealth for cancer control is not fully optimized in NH. There arenumerous examples where telehealth has been used in other jurisdictions forpatient consultations, and patient or provider teaching etc. For example, the VictoriaCancer Centre completed a successful trial of clinical consultation with newlydiagnosed gastrointestinal cancer patients in Nanaimo. There is a plan to

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reintroduce this service between Victoria and Nanaimo and expand it to CampbellRiver. A similar service is being implemented between the Cancer Centre inKelowna and clients in Cranbrook and Kamloops.

Other

Complementary and alternative medicine, also referred to as integrative medicine,encompasses a broad range of healing philosophies, approaches and therapiese.g. massage therapy, mind body therapy, image enhancement, therapeutic touchand naturopathic treatments. Some of these services are available in thecommunities privately e.g. The Centre for Integrated Healing has expressed interestin developing a satellite centre in Smithers.

(See Section 6.4 of the Appendices for further treatment and care programinformation by HSDA.)

Detection, Treatment and Care Themes

Limited linkages with primary care and diagnostic departments in some Northerncommunities negatively impacts citizens access to some diagnostic services.

Diagnostic testing is offered across the three HSDAs but consistent organizationand quality assurance are limited.

General and urology surgery is offered in many Northern communities but thereare limited ties to the BCCA Surgical Oncology Network.

Chemotherapy is offered across Northern Health in many communities.

Resources are limited e.g. One internist with expertise in medical oncology,limited trained nursing staff, many sites are challenged to provide reliefnurses skilled in chemotherapy administration.

Demand is increasing.

There is no formal NH regional organization for chemotherapy.

Funding for chemotherapy nurses is partially funded by BCCA.

Education, standards and guidelines for chemotherapy administration areprovided by BCCA.

Radiation Therapy services are not available in the North, which presents traveland social challenges for patients. Some NE residents are referred to Alberta forconsultation and treatment. Initial referrals for radiation treatments fall withinprovincial averages, however referrals for subsequent courses e.g. palliativeradiation therapy, are below provincial averages.

BCCA has trained several family practitioners in oncology but more are needed.These practitioners are trained to assess and support chemotherapy patients.

Supportive services are offered but there is no formal program to serve cancerpatients, resources are limited and not all communities can provide supportacross the continuum of care e.g. psychosocial support, nutrition counseling forcancer patients.

Palliative and hospice care is offered across NH but it is fragmented.

The use of telehealth for cancer control is limited in NH.

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5. ANALYSIS & RECOMMENDATIONS FOR ENHANCEDCANCER CONTROL IN THE NORTH

In early January, the Northern Cancer Control Strategy Preliminary Findings Report

outlined relevant health and cancer data and contained an inventory of cancerservices and programs operating within NH. This Report was used to determine thekey cancer control issues in the North. The list of priorities for change wasdeveloped by the Sponsors and Steering Committee and was subsequentlyvalidated by a Reference Group consisting of professionals from variousorganizations and communities involved in cancer control in the North.

The priorities outlined later in this Section will address the key issues and are linkedto the outcomes of reducing cancer incidence, reducing mortality and/or improvingthe quality of life or access to services for cancer patients. This strategy takes apopulation health approach with a balanced focus on interventions at each of thefollowing stages; prevention/population health; early detection and screening; aswell as treatment and care.

5.1. Decision Criteria

The Sponsors and Steering Committee endorse the following criteria fordetermining priorities. The initiatives must be:

Supportive of the project vision To strengthen the capacity to prevent,detect, and treat cancer and support patients in the North;

Integrated and planned within the provincial BCCA program;

Based upon evidence for benefit of existing and proposed interventions;

Directed towards improving cancer outcomes;

Based upon interdisciplinary practice within existing professional practicestandards and provincial clinical practice guidelines;

Complementary to existing and proposed practice patterns for the North;and

Culturally sensitive to the issues that characterize the North.

5.2. Develop a Northern Cancer Program

The North is the only region of BC without a Regional Cancer Program. Improvingcancer control in the North requires new resources to address limitations in currentservices, better measurement to support quality improvement in all services, and a

structure to assist the many parts of the cancer services system to serve individualsand communities in a more coordinated way.

Northern Health and BCCA will jointly establish a Regional Cancer Program for theNorth with program leadership reporting at a senior level within both organizations.This leadership position will be accountable for the implementation of therecommendations of this report with a high priority given to the coordination ofservice to individuals with cancer throughout the system of care.

The Program will develop measurement systems, including ongoing capture oftumour staging data for improvement of cancer services to Northerners.

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Measurement systems also need to incorporate the patients experience of care in amanner which will enable problems with the planning or coordination of care to beidentified and addressed on an ongoing basis.

The following diagram outlines the mandate for the proposed Northern CancerProgram including current services and short term priorities for implementation.

The green boxes represent initiatives that NH would lead, yellow BCCA would leadand pink would be joint initiatives from NH and BCCA.

The following sections outline the short term priorities under the categories:

Prevention&Promotion

Screening Detection&Diagnosis

Treatment SupportiveCare &Rehab

Palliative &End of LifeCare

Continuum ofCancer Control

rrent Northernice & Programs

ort Term Priorities

Surgical Oncology:Urology, General

Radiation Therapy:Must be referred toother Centres

Systemic Therapy:Available in allHSDAs in severalcommunities

CuServ

Sh

TobaccoControl

Womens Health Program

Research & Best

Practices to ImproveNH Health Status

RetrospectiveStaging Study

EnhancedConsultation

Telehealth

PalliativeCare

SurgicalOncology

Navigation, Primary Care/Diagnostic Coordination and Transportation

Hepatitis B & C

Heart Health

Tobacco Control

STD

Environmental Health

Chronic Disease Mgmt.

Primary Health CareInitiative

BreastCervical

Colorectal*

Prostate*

Women'sHealthProgram

LabDiagnosticImaging

Pathology

FPONNutrition

Pharmacy

Home Care

Rehab

Psychosocial

Palliative &Hospiceservicesavailable inall HSDAs

Program Leadership, Outcomes Measurement, and Quality Improvement

Chemo Review

*Not currently available as organized screening programs in BC.

Prevention, Promotion and Screening;

Detection and Diagnosis; and

Treatment and Care.

5.3. Prevention, Promotion and Screening Priorities

5.3.1. Comprehensive Tobacco Control Strategy

Existing good smoking cessation programs will be expanded across the region todevelop a strategic comprehensive tobacco control strategy across NorthernHealth. The framework for this strategy includes four pillars:

1. Education2. Cessation/Stop Smoking

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3. Enforcement4. Policy Development

5.3.2. Womens Health Program

The Womens Health Program will continue to be supported and evaluated. This isa three year project supported by BC Womens & Childrens through their primaryhealth transition funds and involves reproductive screening by Pap tests and breastexams for women who do not access this service through medical practitioners.Also included is testing for STIs. This is an ongoing project that is still in thedevelopmental stages.

5.3.3. Investigate known programs and best practices that reduce theincidence of cancers amenable to preventive action

Public Health currently works in partnership with a number of other organizations inthe development of health promotion initiatives focused on healthy living. In general,these initiatives are community or program specific. For example, Northern Healthis involved in Chronic Disease Prevention activities in seven communities involvedin a Chronic Disease Prevention and Management Collaborative Process. This

priority will see NH working with other Health Authorities and BCCA to select andplan additional effective prevention strategies during next three years.

5.4. Detection and Diagnosis Priorities

5.4.1. Retrospective Staging Study

Examination of cancer five year survival rates, for the five health authority regions,shows Northern rates to be a little below the provincial average. BCCA willcomplete a retrospective staging study to determine if there are delays in diagnosisand to provide a better understanding of where resources and effort should befocused to improve survival.

5.4.2. Diagnostic TestingCurrently in the North, patients who present with signs or symptoms may not alwaysfollow the most expedited path to a definitive diagnosis. This not only delaysdiagnosis but causes stress for the patient and wastes NH resources. This will beaddressed in an initiative that will improve primary care linkages to develop acoordinated system from first encounter to screening, detection, treatment andfollow up. BCCA and NH will collaborate on the application of diagnostic protocols.HSDAs will work with the diagnostic departments to develop implementation plansto enable patients to obtain a diagnoses more rapidly through a well coordinatedseries of investigations linked with Primary Care physicians and providers.

5.5. Treatment and Care Priorities

5.5.1. Transportation

This priority will see the development of travel assistance strategies, both within theRegion and with southern centers, to reduce the burden of travel for cancerpatients. This recommendation applies to the assessment, treatment, rehabilitationand palliative components of care. Travel assistance strategies should:

Assist patients being investigated or treated for cancer and their care giversin accessing information about travel and accommodation options;

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Create additional alternatives and reduced costs for individuals facingextensive or frequent travel whether by ground or air; and

Improve availability and reduce costs when accommodations related tocare are required.

5.5.2. Surgical Oncology

BCCA will ensure that, through the Northern Cancer Program and SurgicalOncology Network, surgeons in the North have access to timely outcomesinformation and an opportunity to participate in a surgical oncology best practicesprogram. The regional medical staff structure within Northern Health will provide aforum for the surgical community to bring forward requirements for serviceimprovement.

5.5.3. Systemic Therapy (Chemotherapy)

Chemotherapy is growing in importance in cancer therapy and will expand at asignificantly greater rate than the forecasted growth in incident cases due to theincrease in new drugs and new protocols. BCCA and NH will increase capacity inthis service in the immediate future through the recruitment of additional oncologynurses.

An external assessment of the delivery of chemotherapy in the North will beconducted by an expert team (e.g. medical oncologists experienced in broadlydistributed service systems) to provide guidance with respect to clinic services andthe integration of these services into a region wide program.

5.5.4. Radiotherapy

Any discussion of radiation oncology services in the North requires an appreciationof the scope of radiation oncology practice and an understanding of the essentialelements required to provide a quality service. The scope of radiation oncologypractice spans the entire continuum of cancer care from diagnosis, clinicalassessment and treatment decision making to treatment planning treatment and

follow-up. The complex nature of radiation oncology requires the recruitment ofmany specialists and the establishment of appropriate infrastructure.

In recognition of the increasingly complex nature of oncology management,radiation oncology practice has become increasingly sub specialized by anatomicaltumor site. As such, a radiation oncologists practice is typically limited to two orthree tumor sites. It is no longer possible for a single radiation oncologist to dogeneral practice radiation oncology and maintain expertise for all cancers. Thecomplexity of cancer management also recognizes that oncology management ismultidisciplinary in nature and involves close collaboration with both surgical andmedical oncology specialists.

In addition to the medical management requirements, the practice of radiationoncology has been dramatically altered by improvements in technology, bothhardware and software, which have fully integrated the quality assurance,dosimetry, treatment planning and simulation with the final treatment deliveryprocess. The maintenance and operation of this multi-system infrastructure andprocess requires highly skilled technical personnel (medical physicists, electronicstechnicians, dosimetrists and radiation therapists). In summary, the modernpractice of radiation oncology requires significant concentration of medical andtechnical expertise to support and maintain a high quality service. These specialistsare in short supply across Canada.

The increasingly tertiary nature of a radiation oncology consultation and treatmentservice is a reality which must be considered in planning any enhancement of

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services in the North. BCCA guidelines for a radiation service would require thefollowing:

A population of oncology cases large enough to support and justify aconcentrated resource (BC has typically considered a catchment ofapproximately 750,000 to justify a radiotherapy centre. Other jurisdictions

have recommended population estimates of 600,000 to 1,000,000 or aminimum population to support four linear accelerators and the associatedinfrastructure.).

Accessibility through transportation links.

The recruitment of a critical mass of radiation oncologists.

The associated development of a critical mass of surgical and medicaloncologists.

The development of minimum staff numbers for medical physics,electronics, dosimetry and radiation therapy technologists.

The necessary infrastructure for quality assurance, radiation dosimetry,

treatment planning and simulation.

The necessary treatment capacity (number of linear accelerators) withsufficient redundancy to accommodate machine downtime on any individualunit such that patients requirements for uninterrupted treatment are not

jeopardized.

Preceding and concurrent with the development of Northern Healths CancerStrategy, there has been considerable public discussion about, and support for, theestablishment of a Prince George based radiation therapy service. When the abovecriteria are examined it does not appear that the catchment area for the North islarge enough to support a service at this time. Feedback from Northern physiciansindicates that patients in the Northeast and Northwest are better served by currentarrangements than they would be through a service located centrally in the North

because of the established referral links, full range of specialized care in tertiarycentres, and relative ease of North South travel. It is also likely that the trend torefer some of the cancer patients from the Northeast to Alberta will continue. Whilethe population of NH is close to 300,000, given the referral and travel patterns, anorthern radiation service at this time could respond, at most, to a population of175,000 or about 25% of the current minimum recommended guideline. A serviceof this size would only allow the available sub-specialized radiation oncologists totreat a portion of the anatomic tumour sites requiring other patients from within thisarea to be referred to larger centres.

Population growth, development of other cancer services in the North, adequateplanning for oncology human resource specialists, improvements in East Westtransportation links within the Region, and developments in clinical technology maycombine to improve the feasibility of a Northern service in the future. In particular,the advancements in digital linkages and the implementation of clinical informationsystems may enable new models of service to be feasible. However, somestrategies can be implemented in the short term, which will reduce the demands onpatients and families who face multiple appointments, require information andsupport, and face significant travel and accommodations requirements duringinvestigation, treatment and follow up care.

5.5.5. Navigation

The Northern Cancer Program will provide patient navigation services across thethree HSDAs through registered nurses knowledgeable in all aspects of cancer

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care. Patients who receive several types of treatment will be supported to ensurethat the planning and organization of their treatment minimizes travel requirements.Assistance will be available when patients encounter difficulties in the oftencomplex series of consultations, examinations and treatments required by theirillness. This navigation service requires strong communication links within bothBCCA and NH to address process and scheduling issues.

5.5.6. Enhanced consultation

Northern family practitioners will have easier access to BCCA tumor site specificspecialists in radiation, medical and surgical oncology. This will foster improvedand timelier care while reducing travel for patients.

5.5.7. Telehealth

The well-developed infrastructure in telehealth in both the No

Documents

Northern Cancer Control Strategy Final Report March 3