Technical Information

​Number of oncology PET/CT scans per 1000 total cancer incidence, by Local Health Integration Network (LHIN) of patient residence, 2011-2015

Figure 2

More PET/CT scans were performed in 2015 than in 2014; however, there continues to be significant regional variation across Ontario. This variation is likely driven by differences in physician referral patterns and knowledge of how to access PET/CT in the province.

1. PET Scans Ontario. PET scanner primer [Internet]. 2008 [cited 2013 February 22]. Available from:https://www.petscansontario.ca
2. Hastings, J., Adams, E.J. Joint project of the international network of agencies for health technology assessment – Part 1: survey results on diffusion, assessment, and clinical use of positron emission tomography. International Journal of Technology Assessment. 2006; 22(2): 143-148.
3. Canadian Partnership Against Cancer [Internet]. 2011. The 2011 Cancer System Performance Report; [cited 2013 February 26]. Available from: http://www.partnershipagainstcancer.ca/wp-content/uploads/2011-Cancer-System-Performance-Report.pdf.
4. The Organisation for Economic Co-operation and Development. 2013. Cancer Care: Assuring Quality to Improve Survival; [cited March 4, 2014]. Available from: http://www.keepeek.com/Digital-Asset-Management/oecd/social-issues-migration-health/cancer-care/positron-emission-tomography-scanners-per-million-population-2010-or-nearest-year-available_9789264181052-graph14-en#page1.

​(Total number of PET exams performed for oncology indications) / (Total cancer incidence) x 1000 = Number of oncology PET/CT scans performed per 1000 total cancer incidence

N/A

​PET/CT Scans per 1000 total cancer incidence

• PET/CT Access and Registry Database, Cancer Care Ontario
• Insured PET/CT Scans Database, OHIP
• Total Cancer Incidence estimates from Population Health at Cancer Care Ontario

​CY2011-2015

By patient LHIN of origin

Total Cancer Incidence estimates from Population Health at Cancer Care Ontario

​Total number of diagnostic exams (insured, access and registry) performed on cancer patients with PET/CT scanners

Exclusions

• Scans performed as part of clinical trials (OCOG or institutional/other)
• Insured and uninsured cardiac PET/CT scans
• Out of province patients
• Multiple scans per patient
• Patient LHIN or treatment facility information is null or unknown

​Total Cancer Incidence estimates from Population Health at Cancer Care Ontario are estimates for CY2014-2015 and actuals from CY2011-2013​

​Percentage of Non-Small Cell Lung Cancer Patients who had PET Scan prior to radical treatment such as radiation, surgery or combine with radical intent systemic treatment, in Ontario, by LHIN of Residence

Figure 3

NSCLC patient should receive a PET scan to confirm disease is localized before patient proceeds to any radical treatments (radiation, surgery or combined with radical intent systemic treatment were being considered)

N/A

​Rate of NSCLC patients who had PET scan prior to radical treatment =

(Number of NSCLC cancer patients who had PET scan prior to radical treatment(s)) / (Number of NSCLC cancer patients who received radical treatment(s))*100

N/A

​100

• Cancer Care Ontario, Ontario Cancer Registry
• Discharge Abstract Data (DAD)
• National Ambulatory Care Reporting System (NACRS)
• Registered Person Database (RPDB)
• Activity Level Reporting (ALR)
• Ontario Health Insurance (OHIP)
• Postal Code Conversion File (PCCF)
• PET Access
• PET Registry

​Patient diagnosed between January, 2011 to December, 2015

LHIN of residence

Number of Lung cancer (small and non-small cell) patients diagnosed between January, 2011 and December, 2015; was also receiving radiation/systemic treatment or surgery for curative intent:

1. Diagnosis Cohort:
   Inclusion Criteria
   • Use topography code = ‘C34’ to identify any patient who diagnosed as lung cancer
   • Patient diagnosed as lung cancer between January 01, 2011 and December 31, 2015
   • Use histology codes from Disease Pathway Management (DPM) to differentiate small cell carcinoma cancer, non-small cell lung cancer and unspecified malignant
   • Patient was diagnosed in their age of 19 or above
   • Postal codes for LHIN of residence in geographical variation analysis are based on postal codes found in RPDB
   
   Exclusion Criteria
   • patients with missing or invalid health card number
   • Method of confirmation code = 8 (Clinical Diagnosis only) and 9 (Unknown whether or not microscopically confirmed; death certificate only), similar to DPM lung concordance indicator
   • Patient with multiple primaries (regardless the second primary is lung related or other disease site, about 29% of lung patient was having multiple primaries)
   • Out of Ontario residence


2. Intervention Cohort:
   Inclusion Criteria
   • Use Lung Resection procedure codes list that was used for DPM concordance indicator to define lung resection
   • Patient who died after surgery WILL BE INCLUDED
   • Patient received surgery within 3 months prior to the diagnosis and within 6 months after diagnosis
   • If a patient received more than one surgery, only the first surgery was included
   • Patient also found in Diagnosis cohort


3. Radiation Treatment Cohort:
   Inclusion Criteria
   • Patient received radiation treatment within 3 months after being diagnosed
   • Clinical practice group = LUNG
   • Radical treatment intent only (i.e. adjuvant, curative and neoadjuvant)
   • Active treatment record (i.e. ALR methodology key = 4)
   • Patient also found in Diagnosis cohort


4. Systemic Treatment Cohort:
   Inclusion Criteria
   • Patient received systemic treatment within 3 months after being diagnosed
   • Clinical practice group = LUNG if record found in ALR
   • Radical treatment intent only (i.e. adjuvant, curative and neoadjuvant) if record found in ALR
   • Active treatment record (i.e. ALR methodology key = 4)
   • Patient had ICD10 code = Z51.1 if record found in National Ambulatory Care Report System (NACRS)
   • Patient had CCI code = 1.ZZ.35.^^ if record found in Discharge Abstract Database (DAD)
   • Patient also found in Diagnosis cohort
   
   Exclusion Criteria
   • Patient only receiving radical systemic treatment, but no other radical treatment (i.e. no radiation treatment and no surgery) will excluded

​Number of lung cancer patients who received radical treatment:

1. Patient diagnosed as lung cancer between 2011 and 2015 also receiving radical treatment(s)
2. Patient received PET scans that occurred before radical treatments when:
   • within 6 months before surgery
   • within 3 months before radiation treatment or
   • within 3 months before systemic treatment
3. If the patients had more than one PET scans, then the PET scan occurred closest to the date of first treatment will be used for analysis
4. All PET scans will be considering (the PET scan may have been OHIP encoded as esophageal, or SPN, etc., but – if it occurred prior to lung treatment, it would still have contributed to appropriate staging, there wouldn’t be any difference in technique)

Confidence intervals are based on the 95% upper and lower confidence limits for the rates

1. ​Certain LHINs have a relatively small number of study patients which may lead to large variations in the rates across the province.
2. The accuracy of these measures depends on accurate reporting of PET scans and any data source that used for defining treatment cohort.

​Since NACRS do not collect treatment intent information, the record found in NACRS will be assumed as

1. NOT a Radical Intent if the NACRS’s record was on or after a palliative intent systemic treatment in ALR
2. Radical Intent Otherwise

Assumed patient was receiving 2 PET scans when the PET scan date recorded in PET registry database is different from the service date in OHIP database

​Percentage of Esophageal cancer patients (diagnosed 2011–2015) who had PET Scan prior to radical treatment such as radiation, surgery or combine with radical intent systemic treatment, in Ontario, by LHIN of Residence

Figures 4 and 5

Esophageal cancer patient should receive a PET scan to confirm disease is localized before patient proceeds to any radical treatments (radiation, surgery or combined with radical intent systemic treatment were being considered)

N/A

​Rate of Esophageal cancer patients who had PET scan prior to radical treatment

=

(Number of Esophageal cancer patients who had PET scan prior to radical treatment(s))/(Number of Esophageal cancer patients who received radical treatment(s))*100

N/A

​100

• Cancer Care Ontario, Ontario Cancer Registry
• Discharge Abstract Data (DAD)
• National Ambulatory Care Reporting System (NACRS)
• Registered Person Database (RPDB)
• Activity Level Reporting (ALR)
• Ontario Health Insurance (OHIP)
• Postal Code Conversion File (PCCF)
• PET Registry
• PET Access

​Figure 4: Ontario percentage for CY2011, CY2012, CY2013, CY2014 and CY2015

Figure 5: 5 years percentage in CY2011, CY2012, CY2013, CY2014 and CY2015

Figure 4: Provincial

Figure 5: LHIN of residence

Number of Esophageal cancer patients diagnosed between January, 2011 and December, 2015; who also received radiation, surgery or combine with radical intent systemic treatment:

1. Diagnosis Cohort:
   Inclusion Criteria
   • Use SEER code = ‘21010’ to identify any patient who diagnosed as esophageal cancer
   • Patient diagnosed as esophageal cancer between January 01, 2011 and December 31, 2015
   • Patient was diagnosed in their age of 19 or above
   • Postal codes of LHIN of residence in geographical variation analysis are based on postal codes found in RPDB
   
   Exclusion Criteria
   • patients with missing or invalid health card number
   • Method of confirmation code = 8 (Clinical Diagnosis only) and 9 (Unknown whether or not microscopically confirmed; death certificate only), similar to DPM lung concordance indicator
   • Patient with multiple primaries (regardless the second primary is esophagus related or other disease site, about 32.8% (out of 4,154) of esophageal cancer patient was having multiple primaries)
   • Out of Ontario residence


2. Intervention Cohort:
   Inclusion Criteria
   • Patient who died after surgery WILL BE INCLUDED
   • Patient received surgery within 3 months prior to the diagnosis and within 6 months after diagnosis
   • If a patient received more than one surgery, only the first surgery was included
   • Patient also found in Diagnosis cohort


3. Radiation Treatment Cohort:
   Inclusion Criteria
   • Patient received radiation treatment within 3 months after being diagnosed
   • Clinical practice group = “GASTROINTESTINAL” and the SEER code description = “Esophagus”
   • Radical treatment intent only (i.e. adjuvant, curative and neoadjuvant)
   • Active treatment record (i.e. ALR methodology key = 4)
   • Patient also found in Diagnosis cohort


4. Systemic Treatment Cohort:
   Inclusion Criteria
   • Patient received systemic treatment within 3 months after being diagnosed
   • Clinical practice group = “GASTROINTESTINAL” and the SEER code description = “Esophagus” if record found in ALR
   • Radical treatment intent only (i.e. adjuvant, curative and neoadjuvant) if record found in ALR
   • Active treatment record (i.e. ALR methodology key = 4)
   • Patient had ICD10 code = Z51.1 if record found in National Ambulatory Care Report System (NACRS)
   • Patient had CCI code = 1.ZZ.35.^^ if record found in Discharge Abstract Database (DAD)
   • Patient also found in Diagnosis cohort
   
   Exclusion Criteria
   • Patient only received radical systemic treatment, but no other radical treatment (i.e. no radiation treatment and no surgery) after diagnosed as esophageal cancer will excluded

​Number of Esophageal cancer patients who had PET scan prior to radical treatment(s)
(i.e. radiation/systemic treatment or surgery for curative intent):

1. Patient diagnosed as esophageal cancer between 2011 and 2015 also receiving radical treatment(s)
2. Patient received PET scans that occurred before radical treatments when:
   • within 6 months before surgery or
   • within 3 months before radiation treatment or
   • within 3 months before systemic treatment
3. If the patients had more than one PET scans, then the PET scan occurred closest to the date of first treatment will be used for analysis
4. All PET scans will be considering (the PET scan may have been OHIP encoded as esophageal, or SPN, etc., but – if it occurred prior to esophageal treatment, it would still have contributed to appropriate staging, there wouldn’t be any difference in technique)

Confidence intervals are based on the 95% upper and lower confidence limits for the rates

1. ​Certain LHINs have a relatively small number of study patients which may lead to large variations in the rates across the province.
2. The accuracy of these measures depend on accurate reporting of PET scans and any data source that used for defining treatment cohort.

​​Since NACRS does not collect treatment intent information, a record found in NACRS will be assumed as

1. NOT a Radical Intent if the NACRS’s record was on or after a palliative intent systemic treatment in ALR
2. Radical Intent Otherwise

Assumed patient was receiving 2 PET scans when the PET scan date recorded in PET registry database is different from the service date in OHIP database

​​Percentage of PET/CT scans performed for staging of aggressive lymphoma, by lymphoma incidence, 2014-2015

Figure 6

In March 2015, Cancer Care Ontario in conjunction with the Program in Evidence-based Care published a recommendations report for the use of PET for the staging of lymphoma.

The lymphoma registries were opened to strengthen the evidence found in the recommendation report and tracking the utilization helps to ensure that patients who would benefit from the scan are receiving the scan.

1. Kouroukis CT, Cheung M, Sussman J, Hodgson D, Freeman M, Kellett S. The clinical utility of positron emission tomography in the diagnosis, staging, and clinical management of patients with lymphoma. Toronto (ON): Cancer Care Ontario; 2015 Mar 13. Program in Evidence-based Care PET Recommendation Report No.: 12.

​​(Total number of PET/CT Scans performed for the staging of aggressive lymphoma Registry indication*)/(Total related lymphoma Incidence*) x 100% = Percentage of PET/CT scans performed for staging of aggressive lymphoma per related lymphoma incidence*

N/A

% of aggressive lymphoma incidence that received PET/CT scan

• PET/CT Access and Registry Database, Cancer Care Ontario
• Lymphoma Incidence estimates from Population Health at Cancer Care Ontario

​CY2014-2015

Provincial

​Total related lymphoma incidence estimates from Population Health group at Cancer Care Ontario based on specific histology codes related to the indication

Total number of PET/CT Scans performed for the staging of aggressive lymphoma

Exclusions:

• ​Out of province patients
• Multiple scans per patient
• Patient LHIN or Treatment facility information is null or unknown

​​Lymphoma incidence are estimates developed by Population Health at Cancer Care Ontario for CY2014-2015​

​​​Point in time wait for PET/CT scans as reported by PET/CT centres on a monthly basis

Figure 7

​To ensure patients are receiving their PET scan in a timely fashion, PET Scans Ontario tracks wait times across the 12 PET scanners in the province.

1. Canadian Partnership Against Cancer [Internet]. 2011. The 2011 Cancer System Performance Report; [cited 2013 February 26]. Available from: http://www.partnershipagainstcancer.ca/wp-content/uploads/2011-Cancer-System-Performance-Report.pdf.

• Median wait time calculated from 12 data points (1 per PET/CT centre) on a monthly basis
• Minimum wait time from 12 data points (1 per PET/CT centre) on monthly basis
• Maximum wait time from 12 data points (1 per PET/CT centre) on monthly basis

​​Median, min and max values are taken from the first available appointment the institutions report each month

N/A

N/A

PET/CT centre (hospital and independent health facility [IHF]) self-reported, first available appointment date, submitted monthly, given a standardized date (once per month) as a referral

​Analysis for January 2011 to December 2016

Provincial

​N/A

N/A

Point in time wait for PET/CT scans does not provide patient level wait times; the wait time reflects a point-in-time for each month, and may not be reflective of the wait time for the entire month each centre reports their institutional wait time by providing the first and second available appointment, given a standard date of referral

Exclusions:

• ​Patient level data
• Second available appointment institutions report each month

• Complete data available only for 2011, 2012, 2013, 2014, 2015, and 2016; start date for reporting varies by centre, according to start date of participation in the provincial program
• Data reflects availability at PET/CT centres (hospitals and IHFs), and does not reflect patient level wait times

The wait time reflects a point-in-time for each month, and may not be reflective of the wait time for the entire month