• 2,500 women
    were determined to be at high risk for breast cancer by the High Risk Screening Program in Ontario in 2014
  • 84%
    of cancer patients saw a registered dietitian at a regional cancer centre within 14 days of referral in 2015
  • 72%
    of stage III colon cancer patients received chemotherapy within 60 days after surgery
  • 84%
    of all cancer surgery patients received their consult within the recommended wait time in 2015, and 88% received their surgery within the recommend wait time
  • 29%
    of patients with oropharynx cancer and 20% with cervical cancer visited the emergency department while undergoing a course of curative radiation therapy between 2012 and 2015
  • 44%
    of breast cancer patients, 48% of colon cancer patients and 62% of lymphoma patients visited the emergency department or were admitted to hospital at least once while receiving chemotherapy
  • About 25%
    of patients who undergo lung, prostate and colorectal surgery have an unplanned hospital visit following cancer surgery
  • 64%
    of cancer patients had a first consult with an outpatient palliative care team within 14 days of referral in 2015
  • 40%
    of cancer patients visited the emergency department in the last 2 weeks of life in 2012
  • 361,991
    unique patients were screened for symptom severity using ESAS in 2015, representing 60% of patients
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Symptom Assessment and Management

Measure Desired Direction As of this Report
Percentage of cancer patients screened at least once per month for symptoms
 Black Arrow Up  Yellow Arrow Down
Percentage of patients who report that their healthcare team talked to them about symptoms of concern on their ESAS  Black Arrow Up  Yellow Arrow Down
See Methodology and Approach to find out how the ratings are calculated.

Key findings

Cancer Care Ontario collects data on patient symptom screening and the patient experience with symptom management using the Edmonton Symptom Assessment System (ESAS).

The percentage of patients who are screened for symptoms using ESAS has increased from 50% in 2011 to 60% in 2015. Four of 14 regional cancer centres are exceeding Cancer Care Ontario’s target ESAS screening rate of 70%. In total, 361,991 unique patients were screened using ESAS in 2015.

Fifty-five percent (55%) of patients surveyed in 2015 said that their healthcare team always discussed their ESAS scores with them (compared to 51% in 2014).

What is symptom screening?

  • Symptom screening is the identification and triage of patient symptoms. ESAS is a tool designed to help patients identify and report their symptoms to their healthcare team. It asks patients to rate the severity of 9 symptoms commonly experienced by cancer patients including physical symptoms (such as pain, shortness of breath, appetite and fatigue) and emotional symptoms (such as depression and anxiety). It also assesses the overall well-being of patients.
  • The ESAS screening rate is an indicator that measures the uptake of ESAS amongst cancer patients.

How does the Symptom Management Program monitor the patient experience with symptom screening and management?

  • A new Symptom Management Patient Experience Survey was launched through the Ontario Cancer Symptom Management Collaborative (OCSMC) in December 2014. The revised survey was developed in response to clinician and patient feedback requesting that questions be refined to elicit data that would help better support symptom management quality improvement efforts.
  • A multiphase, rigorous and consensus-building process was employed to identify key domains and indicators for the symptom management patient experience survey.
  • From December 2015 to January 2016, 4,379 patients from the 14 regional cancer centres were surveyed.
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What do the results show?

Regional variation in ESAS uptake continues across Ontario, with several regions screening a lower percentage of patients than in previous years (Figure 1).

  • The proportion of Ontario cancer patients using ESAS has increased from 50% in 2011 to 59% in 2015.
  • In total, there were 513,275 screenings using ESAS with 361,991 unique patients screened in 2015.
  • In 2015, the screening rate of cancer patients completing ESAS ranged from approximately 37% in the Juravinski regional cancer centre to 81% in the North East regional cancer centre.
  • From 2011 to 2015, ESAS use increased substantially at University Health Network/Princess Margaret Hospital and Sunnybrook regional cancer centres, up from 14% in each to 71% and 57%, respectively.
  • From 2013 to 2015, the screening rate of patients completing ESAS at the Carlo Fidani, Grand River, London, Ottawa, Simcoe-Muskoka and Stronach regional cancer centres all decreased. Despite this, rates at the Grand River, Ottawa and Stronach regional cancer centres remain above the provincial average.
  • Symptom screening rates for cervical cancer patients are similar to those for all types of cancer (data not shown).

Patients reported that they experienced higher symptom severity for tiredness, wellbeing and anxiety (Figure 2).

  • Patients reported moderate severity scores (ESAS 4–6) and high severity scores (ESAS 7–10) for tiredness (moderate: 23%; severe: 12%), well-being (moderate: 22%; severe: 8%) and anxiety (moderate: 14%; severe: 7%) in 2015. These results are consistent with symptom profiles reported in previous years.
  • Consistently high symptom severity for fatigue and anxiety led to the decision to test patient-reported outcome tools specific to these symptoms.
  • Symptom severity responses for patients with cervical cancer is highlighted in the “Special Focus on Cervical Cancer”.

The majority of patients surveyed said their healthcare team discussed their ESAS scores with them. They felt that their physical symptoms were managed and their worries, concerns and feelings of sadness were addressed. Patients also felt they were involved in discussions of how to treat and manage their symptoms (Figures 3–10).

  • Figures 3, 5, 7 and 9 display the 2014 and 2015 provincial breakdowns by response to the question asking patients whether their healthcare team:
    • talked to them about symptoms reported on their ESAS;
    • treats and manage their physical symptoms;
    • responds to their worries, concerns or feelings of sadness; and
    • includes them in decisions about how to treat and manage their symptoms.
  • In 2015, 16% of all participants indicated that they had never filled in an ESAS or they had no symptoms to report (compared to 17% in 2014). Of those participants who did have symptoms to report in 2015 (Figure 4), 65% indicated that their healthcare team always talked to them about concerning symptoms reported on their ESAS. Regional variation exists regarding patients responding that their healthcare team always talks to them about their symptoms from their ESAS scores, ranging from 52% (North East) to 87% (Southeastern) (Figure 4).
  • In 2015, 20% of all participants indicated that they usually do not have concerning symptoms to report, which was similar to 2014. Of those participants who did have symptoms to report in 2015 (Figure 6), 83% indicated that their healthcare team always managed their physical symptoms (compared to 82% in 2014).
  • In 2015, 26% of all participants indicated that they usually do not have worries, concerns or feelings of sadness, which remained steady from 2014. Of those participants who did have worries, concerns or feelings of sadness, 77% indicated that their healthcare team always responds. This was unchanged from 2014 (Figure 8).
  • In 2015, 11% of all participants indicated that they usually do not have symptoms, and 5% reported that they prefer their healthcare team to make decisions (Figure 9). Of those participants who wanted to be included in decisions about how to treat and manage their symptoms in 2015 (Figure 10), 85% reported that their healthcare team always includes them, with regional responses ranging from 76% (Northwestern) to 94% (Windsor).

Why is symptom screening important to patients?

  • In a 2010 study of more than 45,000 Ontario patients, at least 57% reported that they experienced anxiety, 53% reported pain, 49% reported shortness of breath and 44% reported depression 1. These results demonstrate that patients have multiple symptoms throughout their cancer journey, and it is important for the cancer system to consider these symptoms when identifying gaps in care and opportunities for improvement.
  • A 2013 study of 45,118 Ontario patients who completed an ESAS found that worsening symptoms contributed to emergency visits. Poor overall well-being was associated with the highest odds of a subsequent emergency department (ED) visit2. These findings support the need for detailed assessment to support improved patient outcomes and optimized resource use.
  • Similarly, a 2014 study of more than 8,000 breast cancer patients found that screening with ESAS was associated with decreased ED visits. The rate of ED visits was 43% lower among patients previously screened with ESAS compared to those not previously screened3.

Increasing autonomy and responsiveness to care is important to patients’ symptom assessment and management.

  • By increasing patient involvement in their own care—and identifying issues earlier—validated screening tools like ESAS can help improve the management of common cancer symptoms.
  • Patient self-reported outcomes are the gold standard for good symptom management, and patients have indicated that they find it valuable for their care.
  • Tracking a patient’s symptoms over time increases the clinician’s ability to identify changes with their patients and enter into a conversation about symptom management, while still responding directly to what patients have identified as their needs.

Improving communication and collaboration are important to patients.

  • The multidisciplinary approach to cancer care means patients often are asked the same questions about their symptoms by different healthcare providers. Some patients have reported finding this frustrating.
  • Electronic symptom screening has been shown to result in greater focus on issues that are most relevant to the patient’s experience and to significantly improve patient outcomes (including reduced symptom distress)4,5.
  • The use of standardized patient-reported assessments may increase discussion between patients and providers4.
  • A 2011 study investigating perceptions of healthcare professionals about the use of a symptom assessment system suggested that ESAS screening may improve interdisciplinary communication and patient care6.
  • Clinical decision support tools (such as the Symptom Management Guides) can help healthcare teams manage the patient’s cancer-related symptoms at the point-of-care.
  • The 2015 AOPSS patient-reported results identified that the following team members are responsible for addressing patient symptoms:
    • doctor (66.3%);
    • nurse (62.4%);
    • counsellor (social worker, psychologist, psychiatrist)(7.3%);
    • dietician (12.7%);
    • other healthcare professional (6.4%);
    • no one listened to my concerns (0.7%); and
    • I did not have a concern about any symptoms (22.8%).

Future directions of symptom screening and management include patient-reported outcome (PROs) tools.

  • New work in symptom management has begun that includes testing and implementing additional PROs tools beyond the current ESAS. These tools would allow patients the opportunity to provide information about symptoms they are experiencing specific to their disease, treatments or phases of the cancer journey.In 2013, the Symptom Management Program added a new PRO to the Interactive Symptom Assessment and Collection (ISAAC). This tool is called the Patient Reported Functional Status (PRFS), and it allows patients to rate their functional status using a standard 4-point scale. This rating helps clinicians better understand how patients are physically functioning, and this additional information can guide care planning and treatment decisions.
  • In 2014, the Symptom Management Program began testing disease-specific and symptom-specific PROs. The first disease-specific PRO is for prostate cancer patients, who have a unique symptom profile that includes sexual dysfunction and incontinence. The prostate cancer-specific PRO asks questions that are more relevant to this patient population. The symptom-specific PROs include measures for fatigue, pain, depression and anxiety. ESAS screens for these symptoms, but the symptom-specific PRO asks additional questions that could help with a clinical diagnosis related to these symptoms.
  • Moving forward, the mandate of the program is to support the implementation of patient-reported outcomes and symptom management to improve person-centred cancer care across Ontario.

Find out more

View Notes

  1. Barbera L, Seow H, Howell D, Sutradhar R, Earle C, Liu Y, et al. Symptom burden and performance status in a population-based cohort of ambulatory cancer patients. Cancer. 2010; 116:5767–76.
  2.  Barbera L, Atzema C, Sutradhar R, Seow H, Howell D, Husain A, et al. Do patient-reported symptoms predict emergency department visits in cancer patients? A population-based analysis. Ann Emerg Med. 2013; 61(4):427–437.
  3. Barbera L, Sutradhar R, Howell D, Atzema C, Sussman J, Seow H, et al. Does routine symptom screening with the Edmonton Symptom Assessment System (ESAS) decrease emergency department visits in breast cancer patients undergoing adjuvant chemotherapy? Support Care Cancer. 2015 [Epub ahead of print].
  4. Berry D, Blumenstein B, Halpenny B, Wolpin S, Fann J, Austin-Seymour M, et al. Enhancing patient-provider communication with the electronic self-report assessment for cancer: a randomized trial. J Clin Oncol. 2011; 29:1029–1035.
  5. Ruland C, Holte H, Roislien J, Heaven C, Hamilton G, Kristiansen J, et al. Effects of a computer-supported interactive tailored patient assessment tool on patient care, symptom distress, and patients’ need for symptom management support: a randomized clinical trial. J Am Med Inform Assn. 2010; 17:403–410.
  6. Bainbridge D, Seow H, Sussman J, Pond G, Martelli-Reid L, Herbert C, et al. Multidisciplinary health care professionals’ perceptions of the use and utility of a symptom assessment system for oncology patients. J Oncol Pract. 2011; 7:19–22.