It was a bold promise backed by billions of dollars in new government funding: Cancer patients should not have to wait longer than four weeks to obtain critical radiation treatment.
Four weeks. That's double the maximum waiting time oncologists recommend but still seemingly better than the cancer-care limbo many patients faced when Liberal health minister Ujjal Dosanjh and his provincial counterparts made the announcement last December.
One month later, a new Tory government was ushered in and waiting times became the centrepiece of Health Minister Tony Clement's health-care strategy.
But figures obtained by The Globe and Mail show a staggering 70 per cent of Canadian hospitals surveyed are unable to meet that standard for prostate cancer patients.
For breast cancer patients, the numbers are better but still fall short: Forty-seven per cent of hospitals surveyed are failing to radiate these patients within four weeks of being “ready to treat.”
“Overall for all of the tumour sites, 50 to 60 per cent of radiation oncology treatment centres are meeting that [four-week] guideline. That's not great,” said Michael Milosevic, president-elect of the Canadian Association of Radiation Oncologists, which conducted the survey.
“... There are lots of examples for patients who have really exemplary care, but there are others where patients are waiting long periods of time.”
In fact, the federal government's four-week standard is perplexing in itself: Radiation oncologists have long said patients should face a maximum two-week wait after being deemed “ready to treat.”
“In my view, it's the wrong target,” said Tom Pickles, president of the association of radiation oncologists.
With a new federal government at the helm, Dr. Pickles was charged with contacting officials in March to ask why they would select a benchmark twice as long as what radiation oncologists recommend. He said he never got a satisfactory answer, but was told it was a “done deal.”
Still, Dr. Pickles added, “Four weeks is better than no benchmark at all.”
That might have been the case if hospitals and other institutions providing radiation treatment across Canada were meeting that four-week standard. But not all of them are. And when oncologists applied their two-week treatment standard to the same institutions, the numbers were abysmally low.
Specifically, the survey found:
-- Sixty-five per cent of hospitals are meeting the four-week benchmark for rectal cancer patients; 24 per cent are meeting the two-week standard.
-- Seventy-five per cent of hospitals are meeting the four-week benchmark for patients with head and neck cancers, which can be fast growing; 19 per cent are meeting the two-week standard.
-- Little more than half, or 53 per cent, of institutions are meeting the four-week benchmark for breast cancer patients; 26 per cent are meeting the two-week standard.
-- Prostate cancer patients fared the worst, with only 30 per cent of institutions radiating them within the four-week benchmark and 15 per cent meeting the two-week standard.
-- Lung cancer patients fared reasonably well, with 82 per cent of institutions radiating them within the four-week benchmark and 53 per cent meeting the two-week standard.
-- Palliative or dying patients fared the best: Surveyed institutions said all of those patients were treated within the four-week benchmark; 94 per cent met the two-week standard. For these patients, radiation treatment can prevent paraplegia due to spinal-cord compression, relieve pain when cancer has spread to the bone and reduce neurological symptoms in a cancer that has invaded the brain.
It was almost a year ago when the provinces went to work on waiting times. They created clinical benchmarks for radiation cancer treatment for key medical procedures in exchange for signing a $5.5-billion Wait Times Reduction Fund, part of a $41-billion health accord created by the then-Liberal government.
Presented as the first step in a 10-year plan to repair a beleaguered health-care system, it tied federal money to results by urging the provinces to set benchmarks in five priority areas, including cancer services. Quebec opted to establish its own guidelines.
Under the accord, cancer services were defined by two groups — radiation oncology and screening. In the first group, provinces would “strive to provide” cancer patients with radiation therapy within four weeks of being deemed “ready to treat.” (The accord did not spell out a definition of “ready to treat,” but according to Dr. Pickles, doctors regard it as that time after which a patient has seen a radiation oncologist and had further tests ordered, and a treatment plan has been devised and agreed upon.) In the second group of services, breast cancer screening on women 50 to 69 was to be done every two years, and cervical cancer screening or a pap test was to be done on women aged 18 to 69 every three years, after two normal tests, Health Canada spokesman Paul Duchesne said.
Excluded from that list was surgery, even though 80 per cent of cancer patients will require it. That area is highly difficult to track, largely because it involves 6,500 different operations done by at least 10 different subspecialists, said Jonathan Irish, chairman of the expert panel for cancer surgery waiting times for Cancer Care Ontario. Ontario stands out as being aggressive in shaving down its waiting times for cancer surgery.
“Certainly we think that timely care is better,” said Dr. Irish, chief of surgical oncology at Toronto's Princess Margaret Hospital. “How long is too long is a matter of debate.”
But there seems little debate about the impact of delaying radiation treatment — a therapy half of all cancer patients require.
A systematic review of 70 clinical reports was done for the Canadian Institutes of Health Research by several teams of cancer researchers, including one led by Bill Mackillop, head of the community health and epidemiology division at Queen's University. That review, published last year, found there was strong evidence that delay in starting radiation therapy is associated with an increased risk of cancer recurrence in the primary tumour site for patients with cancers of the breast, head and neck.
“I think unnecessary delays in cancer treatment should always be avoided,” Dr. Mackillop said. “... It would go against everything we know about the biology of the disease if we were to pretend that delays were safe.”
Robert Pearcey, former president of the Canadian Association of Radiation Oncologists, said some prostate cancer patients are choosing treatments they would not have selected as a first choice — such as an operation, or being put on hormone treatment — because waits to see a radiation oncologist are so long.
“In a worst-case scenario, there may be the odd patient who is not cured who could be cured [due to delays],” said Dr. Pearcey, a radiation oncologist in Edmonton.
Prostate cancer patients, he said, are waiting 14 weeks in Edmonton for a first appointment with a radiation oncologist.
“There's a belief for which there is no good scientific evidence that prostate cancer might be a slower-growing cancer, therefore it's more reasonable for these patients to wait,” Dr. Pearcey said.
But while some prostate cancers grow slowly, not all of them do.
“At the time of referral we don't have a reliable way to determine which patients can safely wait and which ones can't,” Dr. Pearcey said. “What is wrong, in my opinion, is to assume that because many prostate cancers are slow-growing that it is safe for all prostate cancer patients to wait.”
In the survey, all 34 hospitals and other health-care institutions that provide radiation treatment across Canada were asked in April what the wait would be for the average patient with cancers of the breast, head and neck, prostate, rectum, lung and those requiring palliative care. Of those, 21 centres responded.
Survey results show centres providing radiation treatment were having the most difficult time meeting the four-week benchmark when it came to patients with cancers of the breast and prostate — two groups that comprise roughly half of all patients requiring radiation.
Dr. Milosevic stressed that this was a first look at how health-care institutions providing radiation oncology were performing since clinical health accord benchmarks were announced, calling it a baseline measurement. He said he was optimistic, adding that there's a “real push to improve those numbers.”
But others are not so certain; some doctors have taken issue with when that waiting-time clock begins to tick.
Under the federal government's health accord, the waiting time is not tracked until the patient is deemed “ready to treat.” Nor does it take into account the time it takes for patients waiting for that first appointment with a radiation oncologist, another queue that can be lengthy.
For example, late last month, prostate cancer patients faced a 4.5-week wait to see Dr. Pickles in his Vancouver office — something he and his institution have been working to correct. Two weeks ago, the time had been whittled down to 3.4 weeks, and it is expected to drop to under two weeks before Christmas, he said.
As part of the accord, provinces were expected to report to their constituents. Ontario provides current detailed listings of radiation waiting times by hospital name and cancer site on its Cancer Care Ontario website. Others, such as Alberta, show radiation waiting times on their website that are more than one year old.
Meanwhile, provinces and territories have a Dec. 31, 2007, deadline for submitting plans on how they'll meet the standards, but there is no enforcement mechanism if they fail to meet them.
Dr. Mackillop, renowned for his work researching treatment delays, wondered what safety valve was in place if patients were waiting longer than the benchmark times.
“It begs the question: What are you going to do if you don't meet them,” Dr. Mackillop said. “If there was some sort of action plan, the whole thing would make more sense.”
Yesterday, after giving a speech in Toronto, Mr. Clement told reporters his government is committed to waiting-time guarantees.
“You can't have benchmarks without eventually turning to guarantees,” he said, “because otherwise you are breaking a promise to Canadians.”