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Working Together to Improve Ontario’s Cancer System Working together to improve Ontario’s cancer system

Onset of the COVID-19 Pandemic and its Impact on the Ontario Cancer System

Onset of the COVID-19 Pandemic and its Impact on the Ontario Cancer System

In March 2020, cases of COVID-19 were on the rise across Ontario with the emergence of the pandemic’s first wave. The increasing numbers raised concern that patients with COVID-19 would overwhelm the province’s hospital system as had occurred in New York and other areas around the world.

In response, the Ministry of Health issued Directive #2 for Health Care Providers on March 19, 2020 aimed at preserving health system capacity to more effectively manage COVID-19 by reducing or stopping all non-essential and elective services. Within the cancer system, there was an immediate impact on screening, diagnostic, surgical, and other cancer services.

Data source: Ontario COVID-19 Data Tool (Public Health Ontario)

Date Table 1: COVID-19 daily case counts in Ontario, 2020 to 2021
Date Cases Cases - 7 day rolling average
1-Mar-20 2 2
2-Mar-20 0 2
3-Mar-20 2 2
4-Mar-20 1 3
5-Mar-20 4 3
6-Mar-20 3 3
7-Mar-20 3 3
8-Mar-20 5 2
9-Mar-20 6 3
10-Mar-20 9 4
11-Mar-20 23 5
12-Mar-20 37 9
13-Mar-20 36 14
14-Mar-20 32 20
15-Mar-20 36 25
16-Mar-20 53 30
17-Mar-20 59 38
18-Mar-20 59 46
19-Mar-20 69 52
20-Mar-20 99 57
21-Mar-20 72 68
22-Mar-20 87 74
23-Mar-20 145 83
24-Mar-20 174 98
25-Mar-20 138 117
26-Mar-20 250 131
27-Mar-20 297 161
28-Mar-20 235 194
29-Mar-20 227 221
30-Mar-20 439 244
31-Mar-20 412 293
1-Apr-20 454 333
2-Apr-20 450 386
3-Apr-20 465 419
4-Apr-20 350 447
5-Apr-20 371 466
6-Apr-20 479 490
7-Apr-20 459 497
8-Apr-20 494 505
9-Apr-20 489 511
10-Apr-20 399 518
11-Apr-20 477 507
12-Apr-20 549 528
13-Apr-20 603 558
14-Apr-20 558 578
15-Apr-20 618 595
16-Apr-20 582 615
17-Apr-20 754 631
18-Apr-20 601 690
19-Apr-20 595 711
20-Apr-20 614 718
21-Apr-20 522 720
22-Apr-20 548 714
23-Apr-20 511 703
24-Apr-20 435 691
25-Apr-20 428 638
26-Apr-20 368 609
27-Apr-20 480 571
28-Apr-20 417 549
29-Apr-20 408 531
30-Apr-20 409 508
1-May-20 488 491
2-May-20 333 500
3-May-20 341 484
4-May-20 333 479
5-May-20 409 455
6-May-20 356 453
7-May-20 306 445
8-May-20 298 428
9-May-20 310 396
10-May-20 294 392
11-May-20 216 384
12-May-20 258 365
13-May-20 362 340
14-May-20 342 341
15-May-20 379 347
16-May-20 371 360
17-May-20 421 370
18-May-20 376 391
19-May-20 327 418
20-May-20 388 430
21-May-20 338 434
22-May-20 400 433
23-May-20 367 437
24-May-20 340 436
25-May-20 399 423
26-May-20 273 426
27-May-20 323 417
28-May-20 325 407
29-May-20 606 404
30-May-20 346 439
31-May-20 412 435
1-Jun-20 397 447
2-Jun-20 366 447
3-Jun-20 348 462
4-Jun-20 279 467
5-Jun-20 279 459
6-Jun-20 222 404
7-Jun-20 207 384
8-Jun-20 214 350
9-Jun-20 216 319
10-Jun-20 237 294
11-Jun-20 187 276
12-Jun-20 240 260
13-Jun-20 171 254
14-Jun-20 143 245
15-Jun-20 177 235
16-Jun-20 175 228
17-Jun-20 191 222
18-Jun-20 198 214
19-Jun-20 189 216
20-Jun-20 154 207
21-Jun-20 174 204
22-Jun-20 201 210
23-Jun-20 152 214
24-Jun-20 164 210
25-Jun-20 146 205
26-Jun-20 182 197
27-Jun-20 231 195
28-Jun-20 205 208
29-Jun-20 131 213
30-Jun-20 176 202
1-Jul-20 150 206
2-Jul-20 142 203
3-Jul-20 152 203
4-Jul-20 129 198
5-Jul-20 92 181
6-Jul-20 105 162
7-Jul-20 139 158
8-Jul-20 142 151
9-Jul-20 137 150
10-Jul-20 124 149
11-Jul-20 128 145
12-Jul-20 113 144
13-Jul-20 98 148
14-Jul-20 105 147
15-Jul-20 133 141
16-Jul-20 142 140
17-Jul-20 165 140
18-Jul-20 175 147
19-Jul-20 122 155
20-Jul-20 178 157
21-Jul-20 118 170
22-Jul-20 123 172
23-Jul-20 195 170
24-Jul-20 139 179
25-Jul-20 118 175
26-Jul-20 125 165
27-Jul-20 122 166
28-Jul-20 122 157
29-Jul-20 99 157
30-Jul-20 109 153
31-Jul-20 127 139
1-Aug-20 103 137
2-Aug-20 57 134
3-Aug-20 97 123
4-Aug-20 87 119
5-Aug-20 81 113
6-Aug-20 97 110
7-Aug-20 81 108
8-Aug-20 92 100
9-Aug-20 90 99
10-Aug-20 69 104
11-Aug-20 88 99
12-Aug-20 96 100
13-Aug-20 90 102
14-Aug-20 91 101
15-Aug-20 86 103
16-Aug-20 100 102
17-Aug-20 99 103
18-Aug-20 104 108
19-Aug-20 104 111
20-Aug-20 108 112
21-Aug-20 133 115
22-Aug-20 82 122
23-Aug-20 101 122
24-Aug-20 118 122
25-Aug-20 120 125
26-Aug-20 131 128
27-Aug-20 150 132
28-Aug-20 120 139
29-Aug-20 111 137
30-Aug-20 121 142
31-Aug-20 135 145
1-Sep-20 123 148
2-Sep-20 126 148
3-Sep-20 169 148
4-Sep-20 155 151
5-Sep-20 147 157
6-Sep-20 193 163
7-Sep-20 173 175
8-Sep-20 181 181
9-Sep-20 194 191
10-Sep-20 202 202
11-Sep-20 265 207
12-Sep-20 295 226
13-Sep-20 215 250
14-Sep-20 279 254
15-Sep-20 318 272
16-Sep-20 335 295
17-Sep-20 429 318
18-Sep-20 398 356
19-Sep-20 401 378
20-Sep-20 401 396
21-Sep-20 387 427
22-Sep-20 373 445
23-Sep-20 396 454
24-Sep-20 427 464
25-Sep-20 514 464
26-Sep-20 624 483
27-Sep-20 560 520
28-Sep-20 531 547
29-Sep-20 609 571
30-Sep-20 681 610
1-Oct-20 623 658
2-Oct-20 674 690
3-Oct-20 544 717
4-Oct-20 587 704
5-Oct-20 577 708
6-Oct-20 758 716
7-Oct-20 879 741
8-Oct-20 743 774
9-Oct-20 803 794
10-Oct-20 688 815
11-Oct-20 797 839
12-Oct-20 591 874
13-Oct-20 833 876
14-Oct-20 880 889
15-Oct-20 764 889
16-Oct-20 707 893
17-Oct-20 705 877
18-Oct-20 801 879
19-Oct-20 755 880
20-Oct-20 758 907
21-Oct-20 841 895
22-Oct-20 992 888
23-Oct-20 954 926
24-Oct-20 936 968
25-Oct-20 881 1,006
26-Oct-20 778 1,019
27-Oct-20 875 1,023
28-Oct-20 925 1,043
29-Oct-20 892 1,057
30-Oct-20 1,090 1,040
31-Oct-20 946 1,063
1-Nov-20 1,102 1,064
2-Nov-20 969 1,101
3-Nov-20 876 1,133
4-Nov-20 942 1,133
5-Nov-20 1,261 1,136
6-Nov-20 1,298 1,198
7-Nov-20 1,157 1,232
8-Nov-20 1,325 1,267
9-Nov-20 1,427 1,305
10-Nov-20 1,574 1,381
11-Nov-20 1,532 1,497
12-Nov-20 1,597 1,596
13-Nov-20 1,484 1,652
14-Nov-20 1,492 1,683
15-Nov-20 1,293 1,738
16-Nov-20 1,345 1,733
17-Nov-20 1,251 1,719
18-Nov-20 1,465 1,666
19-Nov-20 1,497 1,654
20-Nov-20 1,635 1,638
21-Nov-20 1,503 1,663
22-Nov-20 1,320 1,665
23-Nov-20 1,364 1,669
24-Nov-20 1,410 1,672
25-Nov-20 1,696 1,699
26-Nov-20 1,856 1,737
27-Nov-20 1,763 1,797
28-Nov-20 1,725 1,819
29-Nov-20 1,678 1,856
30-Nov-20 1,627 1,915
1-Dec-20 1,815 1,959
2-Dec-20 1,761 2,027
3-Dec-20 1,825 2,037
4-Dec-20 1,890 2,032
5-Dec-20 2,086 2,053
6-Dec-20 1,733 2,114
7-Dec-20 1,780 2,123
8-Dec-20 1,867 2,148
9-Dec-20 1,910 2,157
10-Dec-20 1,888 2,182
11-Dec-20 1,913 2,192
12-Dec-20 1,967 2,196
13-Dec-20 1,974 2,176
14-Dec-20 2,058 2,216
15-Dec-20 2,247 2,263
16-Dec-20 2,311 2,326
17-Dec-20 2,373 2,393
18-Dec-20 2,414 2,474
19-Dec-20 2,275 2,557
20-Dec-20 2,338 2,609
21-Dec-20 2,164 2,669
22-Dec-20 2,553 2,687
23-Dec-20 2,221 2,738
24-Dec-20 1,929 2,723
25-Dec-20 2,188 2,649
26-Dec-20 2,238 2,611
27-Dec-20 2,137 2,605
28-Dec-20 2,740 2,572
29-Dec-20 3,192 2,668
30-Dec-20 2,805 2,774
31-Dec-20 3,407 2,871
1-Jan-21 3,276 3,118
2-Jan-21 2,887 3,299
3-Jan-21 3,304 3,407
4-Jan-21 3,137 3,602
5-Jan-21 3,326 3,668
6-Jan-21 3,741 3,690
7-Jan-21 4,168 3,846
8-Jan-21 3,819 3,973
9-Jan-21 3,376 4,063
10-Jan-21 3,106 4,145
11-Jan-21 2,836 4,112
12-Jan-21 3,175 4,062
13-Jan-21 3,334 4,037
14-Jan-21 2,992 3,969
15-Jan-21 3,211 3,773
16-Jan-21 2,727 3,671
17-Jan-21 2,085 3,563
18-Jan-21 2,400 3,393
19-Jan-21 2,417 3,320
20-Jan-21 2,756 3,194
21-Jan-21 2,345 3,098
22-Jan-21 2,470 2,990
23-Jan-21 1,922 2,866
24-Jan-21 1,788 2,732
25-Jan-21 1,624 2,683
26-Jan-21 1,898 2,554
27-Jan-21 1,962 2,467
28-Jan-21 1,959 2,335
29-Jan-21 1,878 2,270
30-Jan-21 1,657 2,172
31-Jan-21 1,453 2,128
1-Feb-21 1,259 2,072
2-Feb-21 1,446 2,011
3-Feb-21 1,495 1,936
4-Feb-21 1,381 1,858
5-Feb-21 1,501 1,761
6-Feb-21 1,247 1,699
7-Feb-21 1,105 1,630
8-Feb-21 963 1,572
9-Feb-21 1,131 1,523
10-Feb-21 1,300 1,470
11-Feb-21 1,219 1,438
12-Feb-21 1,182 1,411
13-Feb-21 998 1,358
14-Feb-21 932 1,316
15-Feb-21 858 1,287
16-Feb-21 1,000 1,270
17-Feb-21 1,100 1,248
18-Feb-21 1,197 1,215
19-Feb-21 1,222 1,211
20-Feb-21 1,147 1,218
21-Feb-21 989 1,243
22-Feb-21 904 1,252
23-Feb-21 1,127 1,260
24-Feb-21 1,189 1,281
25-Feb-21 1,242 1,296
26-Feb-21 1,113 1,303
27-Feb-21 1,117 1,285
28-Feb-21 1,002 1,280
1-Mar-21 915 1,282
2-Mar-21 1,116 1,284
3-Mar-21 1,131 1,282
4-Mar-21 1,236 1,273
5-Mar-21 1,249 1,272
6-Mar-21 1,284 1,294
7-Mar-21 1,255 1,322
8-Mar-21 1,179 1,364
9-Mar-21 1,236 1,408
10-Mar-21 1,351 1,428
11-Mar-21 1,462 1,465
12-Mar-21 1,596 1,503
13-Mar-21 1,399 1,560
14-Mar-21 1,236 1,580
15-Mar-21 1,203 1,576
16-Mar-21 1,541 1,580
17-Mar-21 1,705 1,631
18-Mar-21 1,769 1,690
19-Mar-21 1,815 1,741
20-Mar-21 1,755 1,778
21-Mar-21 1,593 1,837
22-Mar-21 1,753 1,897
23-Mar-21 1,834 1,988
24-Mar-21 2,183 2,037
25-Mar-21 2,238 2,117
26-Mar-21 2,566 2,195
27-Mar-21 2,219 2,320
28-Mar-21 2,241 2,398
29-Mar-21 2,212 2,506
30-Mar-21 2,500 2,582
31-Mar-21 2,868 2,693
1-Apr-21 2,982 2,807
2-Apr-21 3,088 2,931
3-Apr-21 3,051 3,018
4-Apr-21 2,921 3,157
5-Apr-21 2,925 3,270
6-Apr-21 3,402 3,389
7-Apr-21 3,763 3,539
8-Apr-21 3,906 3,688
9-Apr-21 3,939 3,842
10-Apr-21 4,718 3,984
11-Apr-21 3,983 4,262
12-Apr-21 4,025 4,439
13-Apr-21 4,280 4,622
14-Apr-21 5,069 4,769
15-Apr-21 4,831 4,986
16-Apr-21 3,901 5,141
17-Apr-21 4,805 5,134
18-Apr-21 4,281 5,149
19-Apr-21 3,672 5,198
20-Apr-21 3,986 5,140
21-Apr-21 4,007 5,091
22-Apr-21 4,508 4,914
23-Apr-21 4,059 4,860
24-Apr-21 3,822 4,886
25-Apr-21 3,646 4,722
26-Apr-21 3,138 4,616
27-Apr-21 3,512 4,527
28-Apr-21 4,014 4,448
29-Apr-21 3,826 4,450
30-Apr-21 3,380 4,336
1-May-21 3,696 4,223
2-May-21 2,951 4,202
3-May-21 2,602 4,086
4-May-21 2,894 3,997
5-May-21 3,280 3,894
6-May-21 3,366 3,771
7-May-21 2,957 3,695
8-May-21 2,703 3,624
9-May-21 2,282 3,459
10-May-21 2,076 3,347
11-May-21 2,563 3,259
12-May-21 2,591 3,204
13-May-21 2,349 3,089
14-May-21 2,450 2,920
15-May-21 2,208 2,835
16-May-21 1,692 2,753
17-May-21 1,614 2,655
18-May-21 1,927 2,578
19-May-21 2,136 2,472
20-May-21 1,816 2,396
21-May-21 1,870 2,307
22-May-21 1,600 2,210
23-May-21 1,211 2,109
24-May-21 1,016 2,029
25-May-21 986 1,929
26-May-21 1,209 1,772
27-May-21 1,224 1,618
28-May-21 1,057 1,519
29-May-21 1,056 1,384
30-May-21 705 1,293
31-May-21 662 1,209
1-Jun-21 811 1,150
2-Jun-21 862 1,121
3-Jun-21 855 1,063
4-Jun-21 709 1,001
5-Jun-21 606 943
6-Jun-21 489 868
7-Jun-21 418 832
8-Jun-21 514 792
9-Jun-21 593 742
10-Jun-21 511 697
11-Jun-21 523 640
12-Jun-21 434 609
13-Jun-21 351 580
14-Jun-21 354 557
15-Jun-21 374 547
16-Jun-21 369 523
17-Jun-21 349 486
18-Jun-21 330 459
19-Jun-21 292 427
20-Jun-21 261 403
21-Jun-21 200 388
22-Jun-21 276 362
23-Jun-21 295 346
24-Jun-21 300 334
25-Jun-21 304 326
26-Jun-21 248 321
27-Jun-21 208 314
28-Jun-21 183 305
29-Jun-21 242 302
30-Jun-21 235 297
1-Jul-21 190 287
2-Jul-21 197 268
3-Jul-21 216 250
4-Jul-21 158 245
5-Jul-21 129 237
6-Jul-21 229 228
7-Jul-21 224 226
8-Jul-21 162 224
9-Jul-21 171 219
10-Jul-21 153 215
11-Jul-21 125 204
12-Jul-21 112 199
13-Jul-21 157 196
14-Jul-21 140 184
15-Jul-21 178 170
16-Jul-21 179 173
17-Jul-21 155 174
18-Jul-21 122 174
19-Jul-21 130 174
20-Jul-21 168 177
21-Jul-21 179 179
22-Jul-21 192 185
23-Jul-21 169 187
24-Jul-21 146 186
25-Jul-21 136 184
26-Jul-21 127 187
27-Jul-21 171 186
28-Jul-21 235 187
29-Jul-21 250 196
30-Jul-21 234 206
31-Jul-21 192 216
1-Aug-21 150 224
2-Aug-21 139 226
3-Aug-21 208 228

Data source: Ontario COVID-19 Data Tool (Public Health Ontario)

Notes:

  1. Date refers to the report date when the COVID-19 case was reported to public health (not the specimen collection/test date or the date associated with a variant of concern).
  2. Number of cases are confirmed COVID-19 cases as reported by public health units and recorded in public health information systems.
  3. Cases - 7 day rolling average is the daily average number of confirmed COVID-19 cases in the previous seven days, using a rolling 7-day window.

Though services began to resume at the end of May 2020, the combined impact of COVID-19 and the directive continued to test the cancer system throughout the first year of the pandemic and beyond. This CSQI Special Focus Story spotlights the effect of the pandemic on Ontario’s cancer system, how the system responded and adapted in the immediate term, and the plans that are underway for longer term recovery.

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Cancer services were disrupted

As a world leader in cancer care, Ontario was well-positioned to manage system pressures, but COVID-19 presented a unique challenge with the unprecedented shutdown of key cancer services.

The impact of these disruptions rippled across the care continuum, with reductions in:

  • visits and assessments with primary care providers to detect early signs and symptoms of cancer
  • cancer screening to detect early cancer
  • biopsies for the diagnosis of cancer
  • imaging for early detection and/or staging of cancer
  • surgical services to treat diagnosed cancer

This was further compounded by the general feeling of “health care hesitancy” brought on by COVID-19 safety concerns which deterred people from visiting their health care providers.

From pre-diagnosis to beyond initial treatment, my fate has been closely tied to COVID-19’s trajectory during this unpredictable storm. Changes in appointments, disruptions in travel plans, delays for tests and treatments, I experienced them all.

Real Lassonde,  Patient

I was fortunate that my diagnosis and surgery were just prior to COVID-19, but there was a lot of anxiety about whether my follow-up treatment would be delayed due to pandemic restrictions or hospital outbreaks.

Farah Tayabali,  Patient and CQCO member

The impact of the directive was both immediate and enduring. During the first wave, cancer screening tests and related diagnostic assessment procedures decreased substantially. The incidence of malignant cancer cases decreased by 32% in May 2020 compared with 2019, consistent with the shutdown of key cancer services and the hesitancy to visit primary care providers due to the pandemic. Fecal tests to screen for colorectal cancer also decreased by 91% during the same time period, screening mammograms by 99%, and non-emergency cancer surgeries by 33%.

Data source: Lab Reporting Tool (LRT), Fecal Immunochemical Test (FIT) GI Endo Data Submission Portal (DSP), Integrated Client Management System (ICMS)

Data source: Ontario Cancer Registry (OCR), Activity Level Reporting (ALR)

Data Table 2: Screening fecal test and screening mammogram volumes, 2019 to 2021
Month Screening fecal test Screening mammogram
Apr-19 60,194 61,655
May-19 57,732 64,616
Jun-19 43,890 58,166
Jul-19 40,508 61,219
Aug-19 59,339 57,463
Sep-19 57,235 58,720
Oct-19 64,368 67,796
Nov-19 59,491 64,359
Dec-19 54,370 49,834
Jan-20 61,629 61,332
Feb-20 60,312 55,167
Mar-20 53,338 31,651
Apr-20 12,871 149
May-20 5,389 609
Jun-20 3,748 5,005
Jul-20 7,024 28,904
Aug-20 16,538 37,393
Sep-20 25,179 45,556
Oct-20 38,762 47,391
Nov-20 39,970 48,124
Dec-20 43,257 39,099
Jan-21 42,200 39,021
Feb-21 47,740 43,023
Mar-21 64,202 62,858

Data source: Lab Reporting Tool (LRT), Fecal Immunochemical Test (FIT) GI Endo Data Submission Portal (DSP), Integrated Client Management System (ICMS)

Prepared by: Cancer Screening, Prevention and Cancer Control, Ontario Health (Cancer Care Ontario)

Notes:

  1. Directive #2 issued on March 19, 2020
  2. Number of fecal tests completed by residents ages 49 to 85 years old.
  3. Number of mammograms completed by residents ages 50 to 74 years old.
Data Table 3: Cancer surgeries and incident malignant cancer cases, 2019 to 2021
Month Incident malignant cancer cases Cancer surgeries
Apr-19 6,855 5,012
May-19 7,222 5,222
Jun-19 6,453 4,733
Jul-19 6,852 4,576
Aug-19 6,289 4,285
Sep-19 6,593 4,841
Oct-19 7,252 5,260
Nov-19 6,974 4,906
Dec-19 6,170 4,161
Jan-20 7,442 5,114
Feb-20 6,588 4,462
Mar-20 6,247 4,162
Apr-20 4,506 3,158
May-20 4,945 3,411
Jun-20 6,189 4,085
Jul-20 6,585 4,100
Aug-20 6,223 3,641
Sep-20 6,921 4,229
Oct-20 7,050 4,448
Nov-20 7,297 4,314
Dec-20 7,090 4,066
Jan-21 7,087 4,283
Feb-21 6,251 4,199
Mar-21 7,401 4,766

Data source: Ontario Cancer Registry (OCR), Activity Level Reporting (ALR)

Prepared by: Access to Care, Ontario Health (Cancer Care Ontario)

Notes:

  1. Directive #2 issued on March 19, 2020.
  2. Incident malignant cancer cases include cases flagged as incident and malignant (behaviour code from OCR = 3).
  3. Cancer surgeries exclude patients < 18 years old and include both lymphoma and skin (melanoma and carcinoma) procedures.
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Urgent and time-sensitive cancer care continued

Despite these service interruptions, many people continued to receive cancer diagnostic services, surgery and other treatment. Ontario Health (Cancer Care Ontario) released clinical guidance documents and tip sheets for hospitals and cancer centres, which included recommendations to help manage the increasing backlogs and prioritize cancer services during the pandemic. In close coordination with Ontario Health (Cancer Care Ontario), the 14 Regional Cancer Programs implemented the necessary changes to mitigate the impact on patients.

Women at high risk for breast cancer whose screening tests were deferred in the first wave were prioritized once cancer screening services resumed. As a result, high risk breast cancer screening comprised nearly 12% of all screening mammogram volumes in May 2020, a marked increase from about 2% in February 2020.

Data source: Integrated Client Management System (ICMS)

Data Table 4: Screening mammogram volume by risk group, 2020
Month High risk (initial screens and rescreens) Average risk (initial screens) Average risk (annual rescreens) Average risk (biennial rescreens)
Jan-20 1.8 17.5 20 61
Feb-20 1.9 17.8 19.2 61.2
Mar-20 1.9 17 19.7 61
Apr-20 0.7 11.4 28.9 59.1
May-20 11.8 17.7 20.9 49.6

Data source: Integrated Client Management System (ICMS)

Prepared by: Cancer Screening, Prevention and Cancer Control, Ontario Health (Cancer Care Ontario)

  1. Eligible high risk Ontario Breast Screening Program (OBSP) participants are screened every year, while eligible average risk OBSP participants can return for screening every two years (biennial screens), every year (annual screens) or in one year for a single year (initial screen), depending on their recall. 
  2. Participants include 50 to 74 years old (OBSP) and 30-69 years old (High Risk OBSP). 

In June 2020, cancer staging and diagnostic magnetic resonance imaging (MRI) volumes returned to 2019 levels after a slight dip from March to May 2020. The existing backlogs of imaging referrals also increased despite the relatively brief disruption to imaging services during the first wave. Though additional imaging capacity was introduced with the resumption of services, this was insufficient to address the expanded backlog.

While some cancer surgeries were paused during the first wave, higher-priority surgeries mostly continued without disruption. Overall, cancer surgeries declined by 35% in May 2020 compared with 2019. During this same time period, cancer surgery volumes rose for Priority 2 patients but fell for Priority 3 and Priority 4 patients.

Data source: Activity Level Reporting (ALR)

Note: Patient Priority Levels

  • Priority 1: Immediate – emergency surgery required
  • Priority 2: Patients diagnosed with highly aggressive malignancies
  • Priority 3: Patients with known or suspected invasive cancer that do not meet the criteria of Priority 2 or Priority 4
  • Priority 4: Patients diagnosed with indolent malignancies
Data Table 5: Cancer surgery volume by patient priority level, 2019 to 2021
Month Priority 2 Priority 3 Priority 4
Apr-19 180 2,749 2,083
May-19 196 2,861 2,165
Jun-19 165 2,642 1,926
Jul-19 170 2,561 1,845
Aug-19 117 2,304 1,864
Sep-19 157 2,597 2,087
Oct-19 180 2,844 2,236
Nov-19 154 2,689 2,063
Dec-19 168 2,385 1,608
Jan-20 196 2,668 2,250
Feb-20 199 2,424 1,839
Mar-20 195 2,451 1,516
Apr-20 288 2,129 741
May-20 322 2,100 989
Jun-20 419 2,404 1,262
Jul-20 346 2,462 1,292
Aug-20 257 2,259 1,125
Sep-20 278 2,706 1,245
Oct-20 273 2,854 1,321
Nov-20 226 2,830 1,258
Dec-20 245 2,705 1,116
Jan-21 252 2,855 1,176
Feb-21 263 2,698 1,238
Mar-21 266 3,174 1,326

Data source: Activity Level Reporting (ALR)

Prepared by: Access to Care, Ontario Health (Cancer Care Ontario)

Notes:

  1. Cancer surgeries exclude patients < 18 years old and include both lymphoma and skin (melanoma and carcinoma) procedures.
  2. Directive #2 issued on March 19, 2020.

The reduction in cancer screening, diagnostic care, and surgeries corresponded to a decrease in radiation consultations and treatment volumes. Systemic and radiation treatment services continued during the pandemic, but in some cases the delivery, timing, and frequency of these treatments were affected. Examples of modifications include:

  • shifting some systemic treatments from adjuvant to neo-adjuvant care for patients needing surgery that may have been delayed (neo-adjuvant care refers to systemic treatment delivered before surgery rather than after)
  • diverting some patients from surgery to radiation alone or chemo-radiation alternative treatments
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Existing backlogs grew

The pandemic resulted in new unique challenges and complicated some existing ones. Screening, diagnostic care, and surgical wait lists grew steadily for patients in the province’s cancer system during the first year of the pandemic, adding to pre-existing backlogs.

Screening mammogram backlogs, particularly for biennial rescreens, surged during the first wave, as are outpatient hospital colonoscopy backlogs for surveillance and other screening.

Data source: Integrated Client Management System (ICMS)

Data source: Laboratory Reporting Tool (LRT), FIT Data Submission Portal (DSP), GI Endo Data Submission Portal (DSP), Ontario Health Insurance Plan (OHIP)

Data Table 6: Mammogram backlog volume by screen type, 2020 to 2021
Month Biennial rescreens High risk screens Initial screens Annual or one-year re-screens
Mar-20 17,897 597 5,071 6,264
Apr-20 54,801 1,827 15,527 19,180
May-20 93,205 3,107 26,408 32,622
Jun-20 125,102 4,170 35,446 43,786
Jul-20 144,491 4,816 40,939 50,572
Aug-20 156,533 5,218 44,351 54,786
Sep-20 164,431 5,481 46,589 57,551
Oct-20 176,674 5,889 50,058 61,836
Nov-20 186,415 6,214 52,818 65,245
Dec-20 192,856 6,429 54,643 67,500
Jan-21 201,782 6,726 57,172 70,624
Feb-21 204,263 6,809 57,874 71,492
Mar-21 203,436 6,781 57,640 71,203
Apr-21 210,913 7,030 59,759 73,820
May-21 220,867 7,362 62,579 77,303

Data source: Integrated Client Management System (ICMS)

Prepared by: Cancer Screening, Prevention and Cancer Control, Ontario Health (Cancer Care Ontario)

Notes:

  1. Screening mammogram backlog volume refers to the cumulative number of screening mammograms estimated to be not performed due to the pandemic. This is calculated by subtracting the number of screening mammograms completed (observed volumes) from the expected number of mammograms (non-pandemic). Backlog volume by screen type is determined using the screen type distributions based on the 2019 data.
  2. Eligible high risk Ontario Breast Screening Program (OBSP) participants are screened every year, while eligible average risk OBSP participants can return for screening every two years (biennial screens), every year (annual screens) or in one year for a single year (initial screen), depending on their recall. 
  3. Participants include 50 to 74 years old (OBSP) and 30-69 years old (High Risk OBSP). 
Data Table 7: Projected hospital outpatient colonoscopy backlog by indication, June to December 2021
Month Fecal test Symptomatic Family history Surveillance Other screening
Mar-20 4,539 3,592 1,200 2,718 2,315
Apr-20 4,035 13,457 3,824 9,668 7,124
May-20 2,893 22,328 6,772 17,119 12,164
Jun-20 1,619 25,134 8,812 22,281 15,865
Jul-20 1,241 25,733 10,059 24,659 18,331
Aug-20 1,435 25,363 10,633 25,872 19,808
Sep-20 1,768 24,408 11,091 26,477 21,104
Oct-20 2,188 24,407 11,581 27,390 22,610
Nov-20 2,320 23,413 11,830 27,854 23,593
Dec-20 2,374 22,101 12,291 27,857 24,304
Jan-21 2,280 23,399 13,115 29,176 26,869
Feb-21 2,636 23,443 13,704 29,886 28,838
Mar-21 3,019 21,099 13,738 29,468 30,156
Apr-21 2,926 23,554 14,977 32,449 33,403
May-21 3,062 28,160 17,252 37,928 37,599
Jun-21 0 29,315 18,300 39,196 39,236
Jul-21 0 30,543 19,122 39,820 40,533
Aug-21 0 31,125 19,687 40,296 41,510
Sep-21 0 30,348 20,339 40,704 42,545
Oct-21 0 28,489 20,935 40,573 43,472
Nov-21 0 26,037 21,374 40,159 44,149
Dec-21 0 24,044 21,708 39,330 44,502

Data source: Laboratory Reporting Tool (LRT), FIT Data Submission Portal (DSP), GI Endo Data Submission Portal (DSP), Ontario Health Insurance Plan (OHIP)

Prepared by: Cancer Screening, Prevention and Cancer Control, Ontario Health (Cancer Care Ontario)

Notes:

  1. Number of outpatient colonoscopies performed in the selected setting, region and/or hospital, by indication.
  2. The "backlog" of fecal test colonoscopies in observed months is calculated as the number of individuals who had an abnormal fecal test result and did not have a follow-up colonoscopy, excluding individuals who may never complete a follow-up colonoscopy (expected to be 10% of all individuals with an abnormal result within the past 9 months, estimated to be between 2,000 and 2,500 individuals in Ontario during normal, non-pandemic circumstances).

The pandemic also intensified existing pressures and backlogs for diagnostic imaging with computed tomography (CT) and MRI. While this mostly affected non-cancer imaging services, cancer imaging services may also be impacted in the future with the expected surge of patients whose care was delayed.

Cancer surgeries deferred during the first wave also led to a substantial backlog, particularly for Priority 4 patients.

In the absence of expanded capacity and other management strategies, it may take several years to address the added backlog.

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Cancer services were adapted to enable patient care

Ontario’s cancer system responded to the challenges of COVID-19 with parallel goals: to keep patients safe and to continue to provide key services.

Virtual care played a pivotal role in enabling care during the pandemic. Initial and follow-up consultations quickly switched to virtual visits at the start of the pandemic for some services. New case consultations conducted virtually for systemic treatment rose to 46.5% by May 2020 compared with 0.3% in May 2019. And, the percentage of virtual systemic treatment follow-up visits increased to 51.8% in May 2020 from 2.1% in May 2019.

Data source: Activity Level Reporting (ALR)

Data Table 8: Virtual systemic treatment new and follow-up visits, 2019 to 2021
Month New systemic visits Follow-up systemic visits
Jan-19 21 1,258
Feb-19 18 1,034
Mar-19 19 1,063
Apr-19 14 1,253
May-19 21 1,204
Jun-19 31 1,065
Jul-19 31 1,172
Aug-19 24 1,104
Sep-19 29 1,124
Oct-19 31 1,393
Nov-19 33 1,304
Dec-19 25 1,185
Jan-20 30 1,510
Feb-20 30 1,247
Mar-20 605 8,884
Apr-20 2,862 28,907
May-20 2,215 28,517
Jun-20 1,936 28,964
Jul-20 1,675 25,435
Aug-20 1,432 20,773
Sep-20 1,547 22,717
Oct-20 1,712 23,822
Nov-20 1,829 23,895
Dec-20 1,683 23,809
Jan-21 2,054 27,670
Feb-21 1,899 24,991
Mar-21 2,033 28,267
Apr-21 1,955 25,897

Data source: Activity Level Reporting (ALR)

Prepared by: Quality Measurement and Evaluation, Ontario Health (Cancer Care Ontario)

Notes:

  1. Directive #2 issued on March 19, 2020

For radiation treatment, new case consultations conducted virtually increased to 58.1% in May 2020 compared with 1.4% in May 2019. The percentage of virtual radiation treatment follow-up visits also increased to 64.7% in May 2020 from 3.5% in May 2019.

Data source: Activity Level Reporting (ALR)

Data Table 9: Virtual radiation treatment new and follow-up visits, 2019 to 2021
Month New radiation visits Follow-up radiation visits
Jan-19 61 553
Feb-19 51 482
Mar-19 75 601
Apr-19 58 608
May-19 63 608
Jun-19 61 521
Jul-19 67 547
Aug-19 60 492
Sep-19 71 629
Oct-19 77 660
Nov-19 56 592
Dec-19 73 606
Jan-20 66 759
Feb-20 58 515
Mar-20 539 3331
Apr-20 2523 10871
May-20 1966 10507
Jun-20 1679 10889
Jul-20 1529 9668
Aug-20 1273 8332
Sep-20 1466 9408
Oct-20 1492 9621
Nov-20 1595 9834
Dec-20 1746 9658
Jan-21 1954 10800
Feb-21 1814 9691
Mar-21 2062 11182
Apr-21 1860 10602

Data source: Activity Level Reporting (ALR)

Prepared by: Quality Measurement and Evaluation, Ontario Health (Cancer Care Ontario)

Notes:

  1. Directive #2 issued on March 19, 2020

Multidisciplinary Cancer Conferences (MCCs) shifted to a virtual setting and continued to play a pivotal role in reviewing individual cancer patients to make recommendations on their diagnosis and treatment options. MCCs were especially important as many patients were offered drug therapies as an alternative to up-front surgery.

While many outpatient programs were ramping down or pausing during the pandemic, the same could not be said for cancer care, cancer does not wait or pause. Our teams had to pivot to a virtual care model in which patients were afforded the same level of high-quality care they need and deserve.

Cynthia Heron,  Regional Oncology Nurse Lead, Central Regional Cancer Program, Ontario Health

Although benefits such as patient convenience, transportation related cost savings, and limiting exposure to COVID-19 were realized through the provision of virtual care, there remain issues that need to be addressed, including:

  • inequitable access to technology, for both patients and providers
  • questions on how best to incorporate the interprofessional team in care (e.g. nursing, psychosocial oncology)
  • lack of consistent access to translation services

Furthermore, this rapid shift to virtual care occurred in the absence of the requisite guidance and frameworks that would have accompanied such a significant shift prior to the pandemic. In response to the needs of this urgent implementation of virtual care, Ontario Health published clinical guidance for the appropriate use of virtual cancer care, based on the principles of person-centred care. These principles were endorsed provincially and will help guide the ongoing implementation of virtual cancer care.

Where possible, cancer treatment delivery was modified to limit patients’ exposure to COVID-19 from in-person hospital and other visits. These include:

  • switching to oral cancer medications
  • offering flexible start dates or extending treatment breaks
  • extending the dosing interval between systemic treatment cycles (where this change did not impact outcomes)
  • increasing the use of hypofractionation for people undergoing radiation treatments, where appropriate (hypofractionation consists of higher doses per visit and fewer treatment visits)
  • introducing home screening for treatment-related symptoms that can be accessed via patients’ personal devices, like mobile phones, tablets and laptops

Data source: Provincial Drug Reimbursement Program (PDRP)

Data Table 10: COVID-19-related systemic treatment modification requests, 2020 to 2021
Month Extended Dosing Intervals Extended Treatment Breaks/Flexible Starts Modifications due to Capacity Constraints Neoadjuvant Use Temporarily Holding One Drug Switches to Alternative Treatment Options
Mar-20 0 1 12 0 1 0
Apr-20 133 17 29 12 1 4
May-20 107 16 19 8 3 0
Jun-20 74 61 17 5 2 1
Jul-20 64 34 10 5 2 1
Aug-20 50 17 11 5 0 1
Sep-20 31 17 10 8 4 0
Oct-20 31 7 8 12 2 0
Nov-20 33 9 2 5 2 0
Dec-20 40 3 3 6 4 0
Jan-21 34 8 5 6 4 1
Feb-21 26 3 4 11 0 2
Mar-21 40 14 2 8 2 1
Apr-21 39 13 6 9 1 0
May-21 25 20 7 10 1 0

Data source: Provincial Drug Reimbursement Program (PDRP)

 

Prepared by: Provincial Drug Reimbursement Program, Ontario Health (Cancer Care Ontario)

 

Notes:

  1. Extended dosing intervals for specific funding policies (details outlined in memorandums to hospitals).
  2. Extended treatment breaks/Flexible starts for patients that take a treatment break during the pandemic, PDRP will fund restarts, even if disease progression occurs while on the break.
  3. Modifications due to capacity constraints refer to selected treatment algorithms modified due to limitations in surgery, radiation, or systemic therapy delivery, or to avoid use of chemotherapy (details outlined in memorandums to hospitals).
  4. Neoadjuvant use refers to systemic treatments that are typically funded in the adjuvant setting that will also be funded in the neoadjuvant setting.
  5. Temporarily holding one drug to minimize patients’ exposure to hospitals or to reduce their risk of immunosuppression. The addition of the drug will be funded, even if disease progression occurs during the use of the modified regimen.
  6. Switches to alternative treatment options where a patient on one funded treatment option needs to be switched to an alternative funded option (details outlined in memorandums to hospitals).
  7. Directive #2 issued on March 19, 2020.
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After the pandemic, the cancer system will face new challenges and continue to adapt

By mid-2021, the cancer system in Ontario had adapted to respond to the pandemic and began to address some of the resulting system pressures. However, system recovery and stabilization will require more time and bring additional challenges.

As the health system recovers and patients return, they may do so with cancers diagnosed at a later stage. The mental health and social implications for patients arising from the pandemic will also add to their burden. After the first wave, follow-up visits for psychosocial oncology increased, rising to 6,500 in June 2020 compared with 5,456 in June 2019.

Data source: Activity Level Reporting (ALR)

Data Table 11: Psychosocial oncology follow-up visits, 2019 to 2021
Month 2019 2020 2021
Jan 6224 6601 6498
Feb 5316 5883 6623
Mar 5894 5940 8202
Apr 6007 5948 n/a
May 6336 5918 n/a
Jun 5456 6516 n/a
Jul 5909 6371 n/a
Aug 5079 5818 n/a
Sep 5792 6621 n/a
Oct 6644 6836 n/a
Nov 6005 6663 n/a
Dec 5580 6168  

Data source: Activity Level Reporting (ALR)

Prepared by: Quality Measurement and Evaluation, Ontario Health (Cancer Care Ontario)

While backlogs continue, a variety of solutions have been introduced to help reduce the impact on patients. The Ministry of Health has provided new funding for hospitals to address deferred surgical care and other medical procedures due to the pandemic. This will increase local capacity, reduce backlogs and respond to other care needs. Additional funding for innovations at the hospital, regional, and provincial level may also improve wait times for patients. Potential strategies and process changes to improve the efficiency of surgical services include centralized wait lists for surgery and imaging referrals, maximized use of operating capacity, and partnerships between independent health facilities and hospitals to provide surgeries and other procedures.

Cancer care is a team-based approach – patients, families, and providers working together. Optimizing the provider experience leads to a better patient experience and ultimately outcomes. Burnout among cancer care providers in Ontario was a significant issue before the pandemic and it has only accelerated to the forefront of the issues we need to deal with in the COVID-19 recovery period.

Dr. Simron Singh, Provincial Head, Person Centred Care, Ontario Health (Cancer Care Ontario)

Some approaches that have been adopted during the pandemic could also become permanent. These include virtual care, increased use of hypofractionation for radiation treatment, and home deliveries of oral systemic treatments for patients.

The COVID-19 pandemic had a profound and lasting impact on the province’s cancer system. Ongoing management and monitoring, including lessons learned from the pandemic, will be essential to support long term recovery.