Key findings
We have made significant progress at increasing the percentage of cancer cases in Ontario for which we have valid stage reporting – from both regional cancer centres and their affiliated hospitals. We have met our target of 90% for cases seen by regional cancer centres, and have achieved a 21% improvement over last year, reaching a 68% valid stage rate for new cancer cases overall.
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Goal |
As of this report |
| Reporting of cancer stage at diagnosis |
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What is cancer staging?
Staging is an internationally standardized process for determining how much cancer there is in a patient’s body and where it is located. Staging describes the extent or severity of a person’s cancer based on the size and/or extension of the original (primary) tumour and the degree of spread in the body 1. The stage values for invasive cancer range from Stage I, which indicates the disease is in early development (e.g., small tumor, no spread beyond primary site), to Stage IV, which indicates the cancer has metastasized (spread) to other sites in the body. Knowing the stage of the disease helps the physicians plan a treatment and determine a prognosis (likely outcome or course of the disease).
 Figure 1: Population-based stage capture rate, percentage of Ontario cancer cases with valid stage reported by year of diagnosis (as measured in CSQI that time period**)
 Figure 2: Population-based stage capture rate by disease site – new cancer cases diagnosed in January 2008
 Figure 3: Distribution of cancer cases by stage at diagnosis for top 4 volume disease sites – new cancer cases diagnosed in January 2008
 Figure 4a: Facility-based stage capture rate: percentage of regional cancer centre cases with valid stage, by fiscal year (2005-2006, 2006-2007, 2007-2008, and 2008-2009 April to June)
 Figure 4b: Facility-based stage capture rate: percentage of regional cancer program cases (regional cancer centre cases plus surgery-only cases in “host hospitals”) with valid stage (2007-2008)
What do the results show?
Population-based stage capture rate for Ontario is improving
The results show a substantial improvement in the percentage of Ontario cancer cases for which valid stage data are reported and available to use to support cancer care system improvement. Last year (in 2008) the stage capture rate for the latest period available, January to June 2007, was 47%. This year (in 2009), the stage capture rate for the latest period available, January 2008, is 68%. This represents a 21% improvement (Figure 1).
The population-based stage capture rate for 2007 is expected to improve as more staging data are received for that year. This will be shown in the 2010 CSQI.
The population-based rate for the top 5 disease sites ranges from 73% to 90%
The results show that for five common disease sites (breast, colorectal, lung, prostate, and gynecological), valid stage data are available for the majority of cases: 73% to 90% (Figure 2). Unlike previous years when staging was only available for patients seen by a regional cancer centre, we now collect stage data from all major Ontario hospitals treating cancer (accounting for 93% of all cancer cases). This means that, for the first time, we can use stage data to help analyze overall cancer activity across the province instead of only the activity at the cancer centres. This includes using stage data to calculate more meaningful indicators of cancer treatment patterns and outcomes.
We can now calculate reliable stage distribution for the high-volume disease sites
For the first time, we are able to show reliable information on the distribution of new Ontario cancer cases, by stage, for the major disease sites (Figure 3). The stage distribution for breast, colorectal, lung, and prostate cancers is representative of the overall population. One of the important uses of this type of information is to assess the impact of cancer screening programs. These programs aim to reduce the incidence of late stage cancers. The chart shows, for example, a relatively low incidence of late stage breast cancer (20% for Stage III and IV). This reflects the impact of Ontario’s formal breast screening program, which has been in place for many years. However, the incidence of Stage III and IV colon cancer is a relatively high 50%. A formal screening program for colorectal cancer was launched more recently, in January 2007. Figure 3 also underlines the ongoing worldwide challenge of diagnosing lung cancer early, with 75% of cases diagnosed at Stage III or IV.
Increase in stage reporting for regional cancer programs
There has been a substantial increase in the percentage of regional cancer centre cases for which valid stage data is reported and available to use to support cancer system improvement. The rate reached the 90% target in 2007-2008 and remains above it through the first quarter of 2008-2009 (Figure 4a). Ten of the 12 reporting cancer centres met or exceeded the 90% stage capture rate target in 2007-2008. This is a substantial improvement over 2005-2006, when only one centre was above 90%.
While Figure 4a shows the facility-based rate for cancer centre activity only, Figure 4b shows the combined rate, which includes patients visiting the cancer centre plus patients receiving surgery at the “host hospital” or the general hospital co-located with the cancer centre. Cases in the latter category are referred to as “surgery only cases” because the patients are not referred to a cancer centre after the surgery. The results show the overall combined rate for 2007-2008 at 85%, with 7 of the 12 reporting centres meeting or exceeding the 90% target. Some Regional Cancer Programs had not yet fully implemented the staging of surgery only activity, thus affecting their rate. Surgery-only cases are estimated to comprise 7% of all incident cancer cases in the province.
Why is this important to patient care?
Accurate cancer stage information can improve quality of care
Determining the stage (i.e., exact location, size and spread of disease) of a patient's cancer is essential for selecting the best treatment for that individual 2. By linking stage of cancer with outcome and treatment data, we gain valuable information to assess the quality of care provided and identify new ways to improve the delivery of that care.
Capturing stage of disease at the time of diagnosis for all new cases treated in Ontario's cancer care system is crucial in determining whether:
- Screening programs are finding cancers early;
- The right treatments are being given to the right patients (i.e., concordance with treatment guidelines); and
- Provincial and regional cancer care outcomes compare well with other jurisdictions.
How does Ontario compare?
Rates of stage capture in Ontario still need improvement
Ontario's ability to capture stage information is consistent with that of other provinces3 but lags behind American standards. The Surveillance, Epidemiology, and End Results (SEER) cancer registries of the National Cancer Institute in the U.S. collect stage at diagnosis data for 90%-95% of patients with stageable cancer (however, not all SEER registries are population based)4.
What is being done?
Ongoing initiatives to improve quality and rate of stage capture data
Cancer Care Ontario (CCO) has been working with the cancer centres to provide targeted education sessions for physicians and health information management professionals in the cancer centres to improve the quality and capture rate of stage data. Monthly stage data quality reports were also published in iPort™ (CCO’s online data reporting tool) and reviewed regularly with clinician mentors and health records leads at each cancer centre.
In 2007-2008, CCO and the 14 cancer centre hospitals (two new cancer centres began submitting data to CCO in June 2008) developed and implemented plans to expand stage data capture to include cases seen only at the host hospitals (i.e., cases that receive surgery in the hospital but do not get referred to the cancer centre clinic).
In 2008 and 2009, CCO engaged non-cancer centre hospitals through Cancer Surgery Agreements (CSAs). By mid 2008, collaborative stage data collection had begun in CSA hospitals in the following Local Health Integration Networks: Hamilton Niagara Haldimand Brant, Central West, Mississauga Halton, and Toronto Central. As of March 2009, collection is under way in all non-cancer centre CSA hospitals in the province, starting with cases diagnosed in 2007 for the most common cancers.
The ultimate target is to capture stage data on 90% of new cancer cases across all disease sites and hospitals, using electronically-enabled data capture tools. The 2009 interim target is to capture stage data on 77% of new cancer cases. Part of this effort involves the collection of an expanded range of relevant prognostic data (beyond stage) useful for research and quality measurement.
Notes
1 Adapted from “What is Cancer Staging?” American Joint Committee on Cancer. 14 March 2008. http://www.cancerstaging.org/mission/whatis.html
2 See the American Joint Committee on Cancer website at http://training.seer.cancer.gov/module_staging_cancer/unit03_sec03_part00_ajcc.html
3 Health Canada. Public Health Agency of Canada. Progress Report on Cancer Control in Canada, 2004. http://www.phac-aspc.gc.ca/publicat/prccc-relccc/index-eng.php
4 See the Collaborative Staging Task Force website at http://www.cancerstaging.org/cstage/index.html
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