• 2,300 women
    women were determined to be at high risk for breast cancer by the High Risk Screening Program in Ontario in 2015
  • 86%
    of cancer patients saw a registered dietitian at a regional cancer centre within 14 days of referral in 2016
  • 71%
    of stage III colon cancer patients received chemotherapy within 60 days of after surgery in 2014
  • 86%
    of all cancer surgery patients received their consult within the recommended wait time in 2016, and 87% received their surgery within the recommend wait time
  • Over 43,000
    patients were discussed at comprehensive multidisciplinary cancer conferences (MCCs) in fiscal year 2016/2017
  • About 13%
    of patients who undergo lung, prostate and colorectal surgery have an unplanned hospital visit following surgery
  • 79%
    of breast cancer patients had a guideline-recommended mammogram in the first follow-up year
  • 74%
    of colorectal cancer patients diagnosed in 2013 had a surveillance colonoscopy within 18 months of surgery
  • Over 100
    patient and family advisors, who vary by their type of cancer and experiences, represent diverse regions and work with Cancer Care Ontario to ensure a person-centred cancer system
  • 383,023
    unique patients were screened for symptom severity using Your Symptoms Matter – General Symptoms (YSM-General) in 2016
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Unplanned Hospital Visits During Chemotherapy

Measure Desired Direction As of this Report
Percentage of breast, colon and lymphoma cancer patients visiting the hospital at least once during a course of chemotherapy treatment Black Arrow Down Yellow Arrow Level
See Methodology and Approach to find out how the ratings are calculated.

Key findings

Forty-four (44%) percent of breast cancer patients, 47% of colon cancer patients who received IV, 37% of patients who received oral-chemotherapy and 51% of lymphoma patients who receive chemotherapy visit the emergency department (ED) or are admitted to hospital at least once within 4 weeks of receiving chemotherapy. A high number of patients visit a second or third time. Side effects do occur and patient education resources are needed for patients to self-manage complications where appropriate, while also having a place where they can call or go when they require evaluation or a prescription.

In my words

I had a number of problems with chemo – lots of side effects – none of which anyone prepared me for or much assistance how to cope with them - I struggled through.

Joanne M.
Patient/Family Advisor

What are chemotherapy, adjuvant chemotherapy and neutropenia?

  • Chemotherapy are drugs that slow or stop cancer cells from growing, multiplying or spreading to other parts of the body1. Chemotherapy is administered in the form of pills (oral), injection or intravenously (IV).
  • Chemotherapy is often given in cycles to allow the body to rest and recover.
  • Adjuvant chemotherapy means that chemotherapy treatment is given after removal of tumours through cancer surgery. Adjuvant chemotherapy has been shown to increase the chance of killing any remaining non-visible cancer cells, to prevent recurrence (return) of cancer, to prolong life and to improve the chance of curing a patient’s cancer.
  • In addition to destroying cancerous cells, chemotherapy drugs can suppress bone marrow function by killing white blood cells, which are essential for protection against illness and disease. As a result, patients may be more likely to develop infections in patients receiving chemotherapy treatment.
  • A decrease in neutrophils, a type of white blood cell, is called neutropenia. If accompanied by a fever, it is called febrile neutropenia, and it can be a sign of an underlying infection.
  • In treating lymphoma, the most common combination of drugs that are used is a regimen called CHOP, which includes the drugs cyclophosphamide, doxorubicin, vincristine and prednisone. CHOP is often combined with immunotherapy, which aims to stimulate the immune system to fight the cancer2. Often, the antibody rituximab (Rituxan®) is used in combination with chemotherapy drugs (where it is known as R-CHOP).

What is the New Drug Funding Program?

  • The New Drug Funding Program (NDFP) provides equal drug access for all Ontarians by paying for chemotherapy regimens that have been evaluated and approved for coverage by the Ministry of Health and Long-Term Care.
  • This section measures how many breast, colon and lymphoma cancer patients being treated with NDFP drugs—either after surgery or as a primary treatment—visited the ED 1 or more times for care and/or needed to be admitted to hospital within 4 weeks of receiving adjuvant chemotherapy, over the total duration of their treatment.

What is an unplanned visit during chemotherapy?

  • An unplanned visit occurs when a patient returns for an emergency department (ED) visit or is admitted to the hospital during a course of treatment because of a side effect or adverse event.
Figure 1. Percentage of breast cancer, colon and lymphoma cancer patients (diagnosed in 2010 to 2014) receiving provincially funded drugs who visited the hospital during treatment

Unplanned Hospital Visits During Chemotherapy

Percentage of breast cancer, colon-IV, colon-oral and lymphoma cancer patients (diagnosed in 2010 to 2014) receiving provincially funded drugs who visited the hospital during treatment

The figure is a flow chart with 11 labeled boxes linked by lines. Here the flow chart is described as lists in which the connections are listed beneath each box label. Each box label includes the relevant number and percentage of cancer patients.

  • Cancer patients receiving chemotherapy:
    • Breast: N= 14068
    • Colon-IV: N = 1885 Colon-Oral: N = 656
    • Lymphoma: N= 3210
  1. Connects to No ED/admission visit:
    Breast: N= 7603 (54%)
    Colon-IV: N= 957 (51%)
    > Colon-Oral: N = 401(61%) Lymphoma: N= 1253 (39%)
  2. Connects to Visited ED:
    Breast: N = 6196 (44%)
    Colon-IV: N = 882 (47%)
    Colon-Oral: N = 241(37%)
    Lymphoma: N = 1648 (51%)
    1. Connects No admission:
      Breast: N = 4839 (78%)
      Colon-IV: N = 713(81%)
      Colon-Oral: N = 161(67%)
      Lymphoma: N = 946 (57%)
    2. Connects to Admitted:
      Breast: N = 1357 (22%)
      Colon-IV: N = 169 (19%)
      Colon-Oral: N = 80 (33%)
      Lymphoma: N = 702 (43%)
  3. Connects to Direct admission to hospital:
    Breast: N = 269 (2%)
    Colon-IV: N = 46 (2%)
    Colon-Oral: N = 14 (2%)
    Lymphoma: N = 309 (10%)
    Under 2 and 3 (that is, patients who had ED/admission visit)
    1. Connects to No ED Revisit/Re-admission:
      Breast: N = 3402 (53%)
      Colon-IV: N = 491(53%)
      Colon-Oral: N = 157(62%)
      Lymphoma: N =782 (40%)
    2. Connects to Revisited ED:
      Breast: N = 2906 (45%)
      Colon-IV: N = 402 (43%)
      Colon-Oral: N = 87 (34%)
      Lymphoma: N = 937 (48%)
      1. Connects No admission:
        Breast: N = 2289 (79%)
        Colon-IV: N = 314 (78%)
        Colon-Oral: N = 59(68%)
        Lymphoma: N = 560 (60%)
      2. Connects to Admitted:
      Breast: N = 617 (21%)
      Colon-IV: N = 88 (22%)
      Colon-Oral: N = 28(32%)
      Lymphoma: N = 377 (40%)
    3. Connects to Direct admission to hospital:
      Breast: N = 157 (2%)
      Colon-IV: N = 35 (4%)
      Colon-Oral: N = 11(4%)
      Lymphoma: N = 238 (12%)

Report date: October 2016
Data source: OCR,NACRS, DAD, ODB, eClaims, and CSI
Prepared by: Analytics and Informatics, Cancer Care Ontario

Note: Numbers shown are for Ontario. Groups are mutually exclusive. If patients admit through ED on the same day, or on the following day, it is counted as a single visit.

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What do the results show?

ED visits and hospital admissions are common (Figures 1 to 4).

  • Forty-four (44%) percent of breast cancer patients, 47% of colon cancer patients who received IV chemotherapy (colon-IV), 37% of colon cancer patients who received oral chemotherapy (colon-oral) and 51% of lymphoma patients visited the ED at least once.
  • Of those patients who visited the ED at least once, 22% of breast cancer patients, 19% of colon-IV cancer patients, 33% of colon-oral cancer patients and 43% of lymphoma patients were admitted to hospital (Figure 1).
  • In addition to the patients who visited the ED, 2% of breast cancer patients, 2% of colon-IV cancer patients, 2% of colon-oral cancer patients and 10% of lymphoma patients were admitted directly to hospital.
  • There is some regional variation in patients who visited the hospital during treatment, ranging from 32% to 67% for breast cancer patients, 36% to 70% for colon-IV cancer patients, 33% to 75% for colon-oral cancer patients and 53% to 71% for lymphoma patients.
  • Time trend data indicate that unplanned hospital visits have remained relatively stable from 2010 to 2014 for breast, colon and lymphoma cancer patients (Figures 3 and 4).
  • Unplanned hospital visits are also reported after cancer surgery and during radiation treatment.

Almost half of patients with breast or colon-IV cancer visited the ED a second time during a course of treatment. Percentages were even higher for lymphoma patients (Figures 5, 6 and 7).

  • About 47% of breast and colon-IV cancer patients who visited the ED returned for a second ED visit, and approximately 24% returning for a third visit; 38% of colon-oral cancer patients and 60% of lymphoma patients returned a second time, while 16% and 36% returned a third time, respectively.
  • For breast and colon-IV cancer patients, 7% returned to the hospital 5 or more times (compared to 1% of colon-oral patients and 13% of lymphoma patients).
  • Hospital visits differed by age and type of cancer. Breast cancer patients ages 18 to 29 had the highest rates (61%) of visiting the hospital, compared to breast cancer patients ages 80 and over (34%).
  • Lymphoma patients and colon cancer patients who received IV chemotherapy had the highest unplanned hospital visits for patients aged 65 and older.
  • Colon cancer patients aged 80 and over who received oral chemotherapy had the highest rates (43%) of unplanned hospital visits during chemotherapy compared to other age groups (Figure 6).
  • These differences in age could be related to younger breast cancer patients being treated with more aggressive regimens of chemotherapy drugs than lymphoma and colon cancer patients, who all would receive the same regimen.

Many hospital visits are happening during the day, with hospital admissions varying by type of cancer and time of day (Figures 8 and 9).

  • Approximately one third of hospital visits took place during weekday business hours. About 33% of breast cancer, colon-IV cancer, colon-oral cancer and lymphoma patients returned on the weekend.
  • The weekday overnight time period had the highest rate of hospital admission for breast cancer, colon-IV cancer, colon-oral cancer and lymphoma patients.
  • Lymphoma patients had the highest rate of admission to hospital for any time of day—particularly the weekday overnight time period, when 66% of patients were either admitted directly to hospital or via the ED.
  • The differences seen among the types of cancer and the time of visit may reflect that some patients experience more serious symptoms.
  • This analysis helps identify which visits may be preventable with better symptom management supports in the cancer system.

Why is this important to patient care?

Managing treatment-related side effects.

  • While adjuvant chemotherapy for breast cancer, colon cancer and lymphoma patients has helped improve outcomes, the potential for drug-related side effects must be taken into account when balancing improvement in survival with aggressiveness of treatment.
  • There is no standard for an acceptable rate of chemotherapy side effects.
  • These drug-related side effects are potentially predictable, and they should be taken into account when setting individual treatment plans and planning for appropriate system resources to care for these patients.
  • By measuring the frequency of hospital visits resulting from the effects of chemotherapy treatment, Cancer Care Ontario aims to improve patient management and care in the following ways:
    • by ensuring patients know who to call for side effects; and
    • by eliminating unnecessary visits to the ED.
  • In the 2014 Ambulatory Outpatient Patient Satisfaction Survey (AOPSS), 83% of breast and colorectal cancer patients and 82% of lymphoma patients responded that someone had either “yes, completely” or “yes, somewhat” told them how to manage any side effects of chemotherapy (data not shown).
  • This suggests that the problem is not whether information is being provided, but how and what information is being provided and how it is being used by patients. The hospital may be the appropriate place to evaluate and help certain patients, but there may be other acceptable options as well.
  • Provision of alternative strategies and clinics to deal with these patient issues outside of normal working hours would seem to be an appropriate goal.

Neutropenia, fever and infection may be preventable.

  • Growth factor (e.g. G-CSF) has been shown to decrease the rates of neutropenia after intravenous chemotherapy3.
  • Using growth factor preventively after some adjuvant chemotherapy regimens may help reduce the rates of neutropenia and its complications.

Appropriateness of using the emergency department and hospital care.

  • Medical oncologists instruct patients to go to the emergency department if they experience serious side effects (such as fever) outside of normal clinic hours because fever after chemotherapy needs to be evaluated quickly, and no other appropriate health care settings exist to receive the patients (when clinics are closed).
  • From the point of view of cancer patients, emergency departments may not be the most appropriate care setting for support, treatment or management of all side effects. Other models of care could be considered, such as management of low-risk patients by urgent care centres.

Find out more

For more information on the Systemic Treatment Program, visit Cancer Care Ontario’s website.

View Notes

  1. Zanke B, Evans WK. Systemic therapy: building on a strong base. In: Sullivan T, Evans W, Angus H, Hudson A, editors. Strengthening the quality of cancer services in Ontario. Ottawa: CHA Press; 2003.
  2. Cancer.org [Internet]. American Cancer Society; 2015. Immunotherapy for non-Hodgkin lymphoma; [cited 2016 Feb 29]. Available from: http://www.cancer.org/cancer/non-hodgkinlymphoma/detailedguide/non-hodgkin-lymphoma-treating-immunotherapy.
  3. Wingard JR, Elmongy M. Strategies for minimizing complications of neutropenia: prophylactic myeloid growth factors or antibiotics. Oncol Hematol. 2009; 72:144–154.