High-quality cancer surgery for Canadians, from start to finish: A Q&A with Dr. Christian Finley

Dr. Christian Finley, thoracic surgeon and Expert Lead, Clinical Measures, at the Canadian Partnership Against Cancer led development of the cancer surgery standards. Here he discusses why they were created and how they will help to improve the quality of cancer surgery in all parts of Canada.

Why were the standards created?

In Canada, cancer is the leading cause of all deaths (30 per cent)¹ and tremendously impacts the economy of the health system. In 2019 alone, there will be over 220,000 estimated new cancer cases² and over 82,000 projected cancer deaths.² In our fight against the disease, there are three pillars of treatment: chemotherapy, radiation therapy and surgery. In recent years, we’ve identified that surgery largely sat outside management of the traditional cancer system as it’s often delivered, resourced and evaluated under provincial ministries of health and territorial health authorities, not cancer agencies, which typically manage chemotherapy and radiation. For this and many other reasons, we’re seeing significant variations in the effectiveness of cancer surgery in different parts of the country. These observations were quantified in the Approaches to high-risk, resource intensive cancer surgical care report that we released in 2015. Seeing that these gaps existed, we needed to develop evidence-informed cancer surgical standards that could be applied to different types of the disease and adopted by any health care setting where cancer surgeries are taking place.

By setting standards for care delivery and promoting their adoption, we will improve surgical practices across Canada and deliver on a priority of the Canadian Strategy for Cancer Control (2019-2029). The Canadian Partnership Against Cancer is the steward of the Strategy working with provincial and territorial governments and others to make changes that ensure the our cancer system delivers high-quality care in a sustainable, world class system.

What issues are you seeing with cancer surgery in Canada?

The 2015 report looked at surgeries for breast, rectal, esophageal, pancreatic, liver, lung and ovarian cancers. The findings were startling as we saw significant variances in surgery outcomes for these cancers in different parts of Canada. Through advances in screening, many cancers can now be identified at an earlier stage, and surgery is often the optimal treatment choice to cure or manage the disease. While many patients fare well after surgery with no complications and are discharged home within expected timelines, some experience more complex post-surgical effects with extended hospital stays, adverse effects requiring additional care, re-admission to hospital, or in some cases, death. While cancer prevention, early detection and screening are important in the fight against cancer, surgery is often the only way to cure the disease. High-quality surgical practices, along with pathology and imaging, can mean up to a 55 per cent increase in chances of survival.³ As such, we need to make sure all Canadians are receiving high-quality cancer surgery.

Why are there variations among hospitals delivering cancer surgery in Canada?

There are many reasons why cancer surgery practices differ from province to province. The first is having the right resources and services in place, particularly before and after surgery. It’s vital that hospitals have physicians and nurses well-trained in identifying the specific signs and symptoms of complications following surgery, and that processes are in place to support timely action and “rescue” a patient should adverse events occur. There also needs to be 24-hour access to a radiologist and a hospital must have an operating room open at night to allow surgeons to go back and assess patients experiencing complications following a cancer surgery. We’re seeing that this is not the case with every hospital in Canada where cancer surgery is being performed. The other key factor is quality improvement practices. No surgeon, institution or province is the best at everything. There is tremendous value in knowing your performance compared to others across the country. That means getting hospitals to allow their data to be collected and compared with others. Routine data collection on the process and outcomes of a cancer surgery are needed in every facility that provides these procedures. Currently, that data is two to three years behind and its retrieval takes more than six months. This is a major obstacle in identifying and addressing problems in the cancer surgical practices at many hospitals across Canada.

What are the standards and what do they hope to achieve?

To increase the quality of surgery, it requires significant support from a multidisciplinary group of healthcare providers, as well as appropriate equipment and processes. Combining these factors will ensure that patients undergoing cancer surgery receive safe, timely and high-quality care. In August 2019, we released pan-Canadian standards for the practice of cancer surgery, including defining training and resource requirements. These standards seek to address the challenges affecting the quality of cancer surgery in Canada. They have been developed to elevate and standardize surgical practices in every part of the country where these procedures are performed. The standards include surgeon criteria and processes to ensure every hospital is providing training and routine re-certification for those operating on cancer patients. The standards can help hospitals in ensuring organizational resources are in place to support high-quality care at all stages of a cancer surgery. And importantly, the standards include data collection practices to encourage continuous quality improvement, particularly with feedback directly from patients following their surgery.

How will the standards benefit the patient and the cancer system?

Surgery is one of the greatest success stories in treating many types of cancer. Because of this treatment option, we have reduced deaths from the disease by 35 to 50 per cent over the last decade.³ It’s because of this effectiveness that we need to ensure that these types of surgery are being done at the highest quality possible. A cancer system with high-quality surgery practices from coast-to-coast-to-coast is in everyone’s best interest. For a patient, surgery is less invasive and has fewer physical post-treatment effects compared to chemotherapy and radiation therapy. For the system, surgery can remove tumours completely and if done effectively, you can see improved outcomes and minimal care required for the patient after treatment. From an economic standpoint this means fewer resources used in the cancer system. Getting these standards implemented in all relevant health care settings will mean all Canadians, no matter where the live in the country, will receive high-quality cancer surgery and are supported from end to end from diagnosis through to post-treatment care.

What’s next?

Through our National Surgery Standards Implementation Network, we have a conduit to provincial and territorial government policymakers and healthcare providers involved in the practice of cancer surgery. We are actively meeting with surgeons in all jurisdictions to present and promote adoption of the standards or identify if there are any barriers in their jurisdiction to adopting them. We are also starting a mentorship program whereby we connect leading cancer surgeons with other surgeons to share current practices and lessons learned. The goal is to have champions of the standards who can help in facilitating their adoption on the front lines of cancer surgery in every province and territory. The other big focus is on measurement. We are currently gathering data to show the effectiveness of surgery for breast, rectal, thoracic, gynecological and prostate cancer. We know that resources required to improve cancer surgery are limited in every province and territory. By obtaining the data in each jurisdiction and identifying which cancers are being treated effectively through surgery, and which are not, we can allocate our efforts and resources appropriately. This data will be featured in a report to be released to the public in spring 2020.

References
1- Government of Canada. Fact Sheet: Cancer in Canada. 2018. Available at: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/fact-sheet-cancer-canada.html
2- Canadian Cancer Society. Canadian Cancer Statistics. 2019. Available at: https://www.cancer.ca/en/cancer-information/cancer-101/canadian-cancer-statistics-publication/?region=bc
3- Canadian Partnership Against Cancer. Approaches To High-Risk, Resource Intensive Cancer Surgical Care In Canada. 2015. Available at: https://stg.partnershipagainstcancer.ca/topics/quality-high-risk-cancer-surgery/