How does Ontario Compare?

Download PowerPoint graphs for CSQI indicators

“Working together to create the best cancer system in the world”: that’s Cancer Care Ontario’s (CCO’s) vision. Is Ontario succeeding? To find out, we seek out national and international benchmarks against which to compare Ontario results. We highlight some of the main findings here to help us know where Ontario is doing well, and where the province can do better.

Finding Meaningful Comparisons

• Ensuring that we have comparable data and measures from multiple jurisdictions is a challenge, especially for those jurisdictions outside of Canada. Otherwise, our conclusions about performance won’t be meaningful or valid.
• This is the second year in which the CSQI has showcased international benchmarks for Ontario’s performance. We include more indicators for comparison this year.
• Here we compare Ontario with other jurisdictions selected, in most cases, because they have healthcare and data systems similar to those in Ontario.

New this Year

• We compare 5-year relative survival rates for breast, colorectal, lung and ovarian cancers
• We report on more modifiable risk factors and screening indicators:  
• vegetable and fruit consumption rates
• colorectal cancer screening (by FOBT – Fecal Occult Blood Test)
• cervical screening
• We added a section focused on patient experience

Survival and Mortality: important comparators

• Mortality and survival are both extremely important indicators that reflect a number of factors in the population and the quality of a country’s cancer care system:
• The effectiveness of prevention programs, in which incidence rates and modifiable risk factors play a role
• The effectiveness of diagnosis, captured through system-level screening programs that ensure cancers such as breast, prostate and colorectal are detected at early stages
• The success of innovations in treatment

Figure 1: Survival and mortality rates for female breast, prostate, colorectal, lung and ovarian cancers for selected jurisdictions

Notes

1. Mortality data are from WHO Mortality Database, 2005, accessed through http://www-dep.iarc.fr/.
2. See Technical Information 

Ontario among highest international cancer survival rates

• The International Cancer Benchmarking Partnership (ICBP), which looked at cancer survival across several international jurisdictions¹, is one important benchmarking effort accomplished through international collaboration, and requiring a high level of standardization of data, measures and analysis.
• The countries examined in the ICBP study include Canada, Australia, Denmark, Norway, Sweden and the United Kingdom.
• In this study, the 5-year relative survival for people in Canada diagnosed with a first primary invasive cancer was highest for lung and ovarian cancers, second highest for colorectal cancer, and third highest for female breast cancer.
• Canada has the highest survival rates for lung and ovarian cancers, Australia for colorectal cancer, and Sweden for female breast cancer.
• Out of the six jurisdictions used in the international comparison of survival rates, Canada ranks first for having the highest 5-year relative survival rates for lung and ovarian cancers, second for colorectal cancer, and third for female breast cancer. See Figure 2 for graphical representation of survival rates.
• For all types of cancers mentioned above, is the study reported that Ontario has higher survival rates than the Canadian average.
• Among the Canadian survival data, provincial data was available for Alberta, British Columbia, Manitoba and Ontario.
• Among the four provinces, Ontario has the best survival rates for colorectal cancer, ranks second highest for both lung and ovarian cancers, and third highest for female breast cancer.

Mortality rates in Ontario similar to other countries

• The World Health Organization (WHO) reports on more than 100 indicators for its 193 member states ² .  One of these indicators is the cancer mortality rate.
• In developed industrialized countries, mortality data have been collected within organized government systems for a very long time, and cause of death is assigned and coded in a similar way using an international classification system, the International Classification of Diseases ³ .
• This allows us to make meaningful international comparisons of the effectiveness of cancer control.
• Data for the comparison of mortality rates include the following jurisdictions: Canada, the United States, the United Kingdom, Japan, France, Sweden, Finland, Australia, Denmark, Netherlands, Norway and New Zealand.
• Mortality rates reflect the influence of incidence rates plus survival rates.  This means that decreasing cancer incidence through improved prevention, and increasing survival through improved screening and treatment, will both work to improve mortality rates.  
• Mortality data are available for many countries and are comparable between countries. The data presented on this page are from 2005, except Australian mortality data reported in 2006.
• However, the Index analyzes data from 2007 in the Cancer in Ontario section because these data are the most recent.
• Out of the 12 jurisdictions examined for mortality rates from the WHO Mortality Database, Canada ranks third lowest for prostate cancer, sixth lowest for female breast, and for both male and female colorectal cancer, ninth lowest for lung cancer in men, and eleventh lowest for lung cancer in women.
• Ontario has lower mortality rates than the Canadian average for prostate cancer, and for colorectal and lung cancers for both men and women.
• The Ontario mortality rate for female breast cancer is higher than the Canadian average.

A difference in reporting measures presents challenges in comparing risk and prevention among countries

• Among the factors that clearly affect mortality and survival rates are smoking, obesity, vegetable and fruit consumption, FOBT screening, cervical screening, and breast screening rates.
• Performance on these measures over the past two to three years gives us an in-depth look at how these population health and preventive behaviours contribute to lower mortality rates and higher survival rates.

Figure 3: Self-reported modifiable risk factors and screening rates for selected jurisdictions

Notes:

1. This table contains only self-reported data.
2. See Technical Information
   

Vegetable and fruit consumption in Ontario among highest in world

• Vegetable and fruit consumption in Ontario is among the highest rates internationally, but much lower than in Quebec. We can do better.
• Ontario has obesity rates similar to northern European countries, yet lower than the United States.
• Smoking rates in Ontario are similar to average Canadian smoking rates, but higher than British Columbia, the United States and Australia. These trends have persisted over several years, which means we in Ontario need to invigorate our smoking prevention and cessation work.
• Smoking has a significant effect on lung cancer incidence and mortality rates.
• Obesity contributes to a number of cancers.
• Fruits and non-starchy vegetables probably protect against cancers of the mouth, pharynx, larynx, esophagus and stomach. Fruits also probably protect against lung cancer. Vegetable and fruit consumption also serves as a marker of a healthy diet containing other constituents—carotene and lycopene, for instance—that probably protect against some cancers ⁴ .

Screening rates for colorectal, female breast, and cervical cancers

• FOBT participation in Ontario is higher than the Canadian average and the United States, yet significantly lower than in the best province, Manitoba.
• FOBT participation leads to the early detection and prevention of colorectal cancer.
• Increasing mammogram rates for women over the past two years may result in increased incidence rates, but also leads to earlier detection of cancer and higher survival rates.
• Cervical screening can lead to the prevention and early detection of cervical cancer.
• Cancer Care Ontario collects FOBT, mammogram, and cervical screening data provincially.
• However, for the Index, we are using self-reported responses from the Canadian Community Health Survey to compare Ontario with other jurisdictions.
• The way the data are compiled – not by an international source but by each individual jurisdiction – presents a challenge in comparing cancer modifiable risk factors and preventive behaviours among countries.
• These indicators were selected for comparison in the CSQI because they come from surveys that used similar methods of data collection (such as telephone interviews), similar definitions (of smoker categories, obesity, vegetable and fruit consumption, FOBT participation, and breast and cervical screening rates) and similar age groups.
• However, even these measures do not always use identical definitions.
• This means we must provide significant technical information to explain the details.

View more information about these comparisons

• Smoking is measured in Canada using the population 12 and older, while other jurisdictions use 15, 16 or 18 and older.
• All the jurisdictions use a Body Mass Index (BMI) of 30 and greater to define obesity, but in England and New Zealand the data is collected in a face-to-face interview, measuring the height and weight of the individual, eliminating bias that may occur in the other jurisdictions, where individuals self-report their weight in telephone surveys. Only jurisdictions with self-reported data for obesity rates are shown in the table.
• When monitoring FOBT participation across jurisdictions, the definition was consistent throughout countries; participants were in the same group of 50 years and over, who have had an FOBT within the past 2 years.
• When monitoring women who have had a mammogram within the past 2 years, the age groups included varies across jurisdictions. In Canada, participants ages 50 to 69 years are included in the reported rates. However, in the United States, participants included in the rates include all women over the age of 50 years.
• For the reporting of cervical screening rates, data include participants who have had a Pap smear within the past 3 years; however the age group of these participants varies. For example, Canadian rates include women ages 18 to 69 years. However, cervical screening rates from the United States include all women 18 years and older.

Ontario well below best international screening rates for breast cancer

• See Figure 4 for breast screening rates across Ontario and the best international comparator, Finland. Unlike the table above, this graph contains administrative data, or data that is collected within the health system.
• Of the jurisdictions with comparable data— including Ontario, Australia, Finland, the Netherlands, and the United Kingdom—Finland reports the highest breast screening rates at 84%.
• Breast screening rates in Finland are well above the Ontario average of 65%.
• Regular screening can detect cancer in its early stages, even before symptoms appear.
• Finding breast cancer early, before it has spread, increases the number of treatment options available, and can lead to better treatment outcomes and survival rates ⁵ .
• A recent meta-analysis of randomized controlled trials has shown that breast cancer death rates can be reduced by 14% for women aged 50–59 and by 32% for women aged 60–69 ⁶ . These reductions are considered statistically significant. About one woman in 10 will need more tests because her mammogram was not clearly normal. An abnormal mammogram does not necessarily mean that a woman has cancer, but it lets a healthcare provider know that further follow-up is needed.

Cervical screening rates in Ontario among the highest in the world

• See Figure 5 for admin-reported cervical screening rates across Ontario as well as for the best international comparators—Australia and the United Kingdom.
• Other international jurisdictions compared include Ontario, Finland and the Netherlands.
• Australia and the United Kingdom have the highest cervical screening rates at 74%, with Ontario not far behind at 73%.
• Cervical cancer screening is a test done to find unhealthy changes in the cells of the cervix that may indicate the presence of cervical cancer or precursor lesions, which can be treated so cancer does not develop.  
• Cervical cancer is caused by persistent infections with high-risk (oncogenic) human papillomavirus (HPV), and is transmitted through sexual contact^7,8,9.
• As HPV infections rarely cause symptoms, screening is the only way to detect precursors that might lead to cervical cancer.
• Regular screening with Pap tests has led to long-term declines in cervical cancer incidence and mortality rates¹⁰.

Patient experience an important aspect for monitoring cancer care

• In Ontario, the Canadian Ambulatory Oncology Patient Satisfaction Survey (AOPSS) reports on patient experience, but only in relation to the care received in outpatient cancer treatment settings.
• International jurisdictions such as Australia and New Zealand also have cancer patient experience surveys with content very similar to the AOPSS.
• The New South Wales Cancer Patient Satisfaction Survey 2008 is used as a representative survey for Australia and the 2009 Cancer Care Survey from New Zealand.
• Among the three surveys, patient experience is assessed by the way patients respond to items on a mailed survey asking them to rate their care across several dimensions:
• emotional support
• continuity and coordination of their care
• respect for their preferences
• their physical comfort
• how well they feel they have been informed, educated and communicated with
• how well they were able to access their care
• Cancer patients treated in ambulatory care settings continue to report a reasonably high degree of satisfaction with most aspects of care.
• These dimensions were found to reflect the experience of care, through studies conducted in the U.S. with several thousand patients.
• Provincial data examining the dimensions of care are provided courtesy of the Canadian Partnership Against Cancer¹¹, who’s 2010 System Performance Report included patient experience data comparing the following provinces: Ontario, Prince Edward Island, Nova Scotia, Alberta, British Columbia, Saskatchewan and Manitoba.
• See Figure 6 for an interprovincial comparison on the dimensions of care. Ontario does not rank as best for any of the dimensions of care. Prince Edward Island and Nova Scotia rank extremely well in patient experience.
• For each dimension of care, the best provincial rate is considerably higher than Ontario’s.

• Emotional support scores remain significantly lower than scores in other dimensions, therefore the sub-dimensions of emotional support are also examined.
• See Figure 7 for sub-dimensions of emotional support, and the best international comparator compared with Ontario.
• Out of the three jurisdictions examined–Ontario, Australia, and New Zealand–Ontario ranks as the best for the following survey questions:
• oncology provider went out of their way to help
• patient received enough information on sexual activity changes
• patients were told of their diagnosis in a sensitive manner
• However, emotional support rates are very similar between Ontario and the best international comparator. All of these jurisdictions have recognized the need to increase efforts at improving emotional support and better measuring the patient experience. We simply need to do better. This is a priority for cancer and health systems around the world.

• See Figure 8 for a closer examination of the emotional support dimension of care within the cancer outpatient care surveys.
• New Zealand has the highest rate for patients referred to provider for anxieties/fears at the time of diagnosis; however, several Ontario LHINs surpass this rate, with Windsor RCC performing best.
• Ontario has the highest rate for patients in touch with other providers for anxieties/fears during treatment, with Northwestern RCC performing best.

Moving Forward

• In future years, we hope to expand the number of jurisdictions we compare with Ontario and increase the number of measures we report on so we can provide a more meaningful analysis of CCO’s place on a world scale.
• We hope this will be possible through:
• CCO’s continued participation in international benchmarking studies
• investigating more research that offers meaningful comparisons
• looking at opportunities in the collection of data – for example, modifiable risk factors – where we might be able to modify our definitions slightly to align better with those used by other countries.

Notes

1. Coleman, M, D Foreman, H Bryant, C Maringe, U Nur, E Tracey, M Coory, J Hatcher, C  McGahan, D Turner, L Marrett, M Gjerstorff, T Johannesen, J Adolfsson, M Lambe, G Lawrence, D Meechan, E Morris, R Middleton, J Steward, M Richards, and the ICBP Module 1 Working Group. (2011). Cancer survival in Australia, Canada, Denmark, Norway, Sweden, and the UK, 1995-2007 (the International Cancer Benchmarking Partnership): an analysis of population-based cancer registry data. Lancet Oncology, 377: 127-138
2. See the World Health Organization website at: http://www.who.int/whosis/en/index.html, accessed April 18, 2011
3. See the World Health Organization website at: http://www.who.int/classifications/icd/en/, accessed April 18, 2011
4. World Cancer Research Fund/American Institute for Cancer Research. Food, nutrition, physical activity, and the prevention of cancer: a global perspective. AICR [Internet]. 2007 [cited 2011 March 14]. Available from: http://www.dietandcancerreport.org/.
5. Health Canada [Internet]. 2002. Report from the Evaluation Indicators Working Group: Guidelines for Monitoring Breast Screening Program Performance. [cited 2011 March 1]. Available from: http://www.phac-aspc.gc.ca/publicat/eiwg-gtie/.
6. Nelson H, Tyne K, Naik A, Bougatsos C, Chan B, Humphrey L. Screening for Breast Cancer:  An Update for the U.S. Preventive Services Task Force.  Annals of Internal Medicine. 2009; 151(10):727-737.
7. Ontario Agency for Health Protection and Promotion, Institute for Clinical Evaluative Sciences. Ontario burden of infectious disease study. Toronto, ON: OAHPP/ICES, 2010.
8. Walboomers JM, Jacobs MV, Manos MM, Bosch FX, Kummer JA, Shah KV, et al. Human Papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol. 1999; 189:12-9.
9. Franco EL, Schlecht NF, Saslow D. The epidemiology of cervical cancer. Cancer J. 2003; 9:348-59.
10. Cancer Care Ontario. Insight on cancer: News and information on cervical cancer. [Internet]. Toronto, ON: Canadian Cancer Society (Ontario Division), 2005. [cited 2011 Mar 1]. Available from: http://www.cancer.ca/vgn/images/portal/cit_86751114/39/52/536723336od_ioc_cervical_oct2005.pdf
11. See the Canadian Partnership Against Cancer website at: http://www.partnershipagainstcancer.ca/priorities/quality-standards/system-performance-indicators/, accessed April 18, 2011.