Access to Radiation Treatment

Key findings

Radiation treatment utilization has remained consistent over the past several years. While large regional variations in the use of radiation treatment to treat prostate and lung cancer persist at the county level, that variability has decreased for rectal cancer. Additionally, a number of counties have increased their radiation treatment utilization for prostate and lung cancer. Radiation continues to be well accepted as treatment for breast cancer.

Measure: Percentage of patients treated with radiation at some point during their illness

Desired Direction:

An image of an arrow pointing upwards. This indicates that desired direction for this action is upwards.

As of this Report:

An image of an arrow pointing straight in a yellow box. This indicates that there has been no increase or decrease in performance over the previous periods identified and this action is below but approaching target or has notable regional variation.

What is radiation treatment?

Radiation treatment uses energy (radiation) from X-rays, gamma rays and electrons to destroy cancer cells.
In high doses, radiation destroys cells in the area being treated. It does this by damaging the DNA in cancer cell genes, making it impossible for them to grow and divide.
During radiation treatment, both cancer cells (which are growing in an uncontrolled way) and healthy cells are affected, but most healthy cells can repair themselves.
Radiation can be used with curative intent before or after surgery, or for palliative purposes (to relieve symptoms such as pain). This report measures radiation use for both scenarios.
Approximately half of cancer patients require radiation treatment at some point during their illness.

What are utilization targets and benchmarks?

Several different methods are used to calculate expected radiation treatment utilization rates.
Cancer Care Ontario’s provincial target for radiation utilization (48%) is set by the provincial Radiation Treatment Program. The aim is a longer-term goal.
Benchmarks for each type of cancer are created from the best possible disease-specific rates achieved in Ontario by counties with few access barriers to radiation treatment ^[1].

Figure 1. Percentage of cancer cases treated with radiotherapy at any time during the course of their illness, 2011 to 2017, by Local Health Integration Network (LHIN)

More information regarding the methodology is available.

Report date: February 7, 2018

Data source: Ontario Cancer Registry, Activity Level Reporting

Prepared by: Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute

Notes: Rates were estimated using the MCUT Method based on the radiotherapy given between November 1, 2012, and October 31, 2017

Figure 2. Percentage of breast cancer cases that would have benefited from, but did not receive, radiotherapy (actual compared to benchmark), 2011 to 2017, by County

More information regarding the methodology is available.

Figure 3. Percentage of lung cancer cases that would have benefited from, but did not receive, radiotherapy (actual compared to benchmark), 2011 to 2017, by County

More information regarding the methodology is available.

Figure 4. Percentage of prostate cancer cases that would have benefited from, but did not receive, radiotherapy (actual compared to benchmark), 2011 to 2017, by County

More information regarding the methodology is available.

Figure 5. Percentage of rectal cancer cases that would have benefited from, but did not receive, radiotherapy (actual compared to benchmark), 2011 to 2017, by County

More information regarding the methodology is available.

Data Table 1. Percentage of cancer cases treated with radiotherapy at any time during the course of their illness, 2011 to 2017, by Local Health Integration Network (LHIN)

LHIN	Percentage (%) in 2012-2013	Lower confidence interval in 2012-2013	Upper confidence interval in 2012-2013	Percentage (%) in 2013-2014	Lower confidence interval in 2013-2014	Upper confidence interval in 2013-2014	Percentage (%) in 2014-2015	Lower confidence interval in 2014-2015	Upper confidence interval in 2014-2015	Percentage (%) in 2015-2016	Lower confidence interval in 2015-2016	Upper confidence interval in 2015-2016	Percentage (%) in 2016-2017	Lower confidence interval in 2016-2017	Upper confidence interval in 2016-2017
Ontario	37.8	37.4	38.2	37.3	36.9	37.7	37.5	37.2	37.9	39.0	38.6	39.3	38.7	38.3	39.0
Erie St. Clair	38.8	37.2	40.4	35.9	34.4	37.4	37.2	35.7	38.8	39.9	38.3	41.5	38.7	37.1	40.2
South West	37.2	36.0	38.5	35.2	33.9	36.4	35.5	34.2	36.8	37.3	36.1	38.6	37.7	36.5	39.0
Waterloo Wellington	38.2	36.6	39.8	39.3	37.7	40.9	38.0	36.4	39.6	41.7	40.1	43.4	41.7	40.1	43.3
Hmltn-Ngr-Hldmnd-Brnt	36.2	35.2	37.3	36.1	35.1	37.2	38.1	37.1	39.2	38.3	37.2	39.4	38.8	37.7	39.8
Central West	37.3	35.6	39.1	37.3	35.6	39.1	36.9	35.2	38.5	38.1	36.4	39.7	37.5	35.8	39.1
Mississauga Halton	38.9	37.5	40.2	37.9	36.6	39.3	38.1	36.8	39.5	39.2	37.8	40.6	36.8	35.5	38.1
Toronto Central	36.9	35.6	38.3	37.2	35.9	38.6	37.4	36.0	38.8	37.7	36.4	39.0	36.9	35.7	38.2
Central	38.5	37.4	39.6	36.3	35.2	37.3	38.1	37.0	39.2	38.1	37.0	39.2	38.7	37.7	39.7
Central East	36.8	35.7	37.9	36.6	35.5	37.6	37.0	36.0	38.1	38.5	37.4	39.6	37.8	36.8	38.9
South East	40.4	38.8	42.1	40.8	39.1	42.6	40.3	38.6	42.0	43.9	42.2	45.6	43.0	41.3	44.6
Champlain	41.8	40.6	43.1	42.1	40.8	43.3	40.7	39.5	41.9	42.7	41.5	43.9	42.9	41.7	44.1
North Simcoe Muskoka	36.5	34.7	38.3	37.4	35.6	39.2	35.8	34.0	37.6	37.8	36.0	39.6	39.3	37.5	41.1
North East	40.0	38.4	41.6	40.8	39.2	42.3	38.3	36.7	39.9	43.2	41.6	44.8	42.8	41.2	44.5
North West	34.8	31.9	37.8	36.0	33.1	39.0	38.6	35.6	41.5	38.1	35.1	41.0	42.4	39.4	45.3

Report date: February 7, 2018

Data source: Ontario Cancer Registry, Activity Level Reporting

Prepared by: Division of Cancer Care and Epidemioloty, Queen's Cancer Research Institute

Note:

Rates were estimated using the MCUT Method based on the radiotherapy given between November 1, 2012 and October 31, 2017.

Data Table 2. Percentage of breast cancer cases that would have benefited from, but did not receive, radiotherapy (actual compared to benchmark), 2011 to 2017, by County

Map specifications	2012-2013	2013-2014	2014-2015	2015-2016	2016-2017
Ontario	37.78	37.29	37.54	38.98	38.65
Erie_St__Clair	38.8	35.91	37.2	39.88	38.66
South_West	37.24	35.15	35.48	37.33	37.74
Waterloo_Wellington	38.2	39.29	37.95	41.7	41.68
Hmltn_Ngr_Hldmnd_Brnt	36.23	36.12	38.12	38.29	38.77
Central_West	37.34	37.34	36.88	38.05	37.47
Mississauga_Halton	38.85	37.92	38.14	39.2	36.78
Toronto_Central	36.92	37.24	37.4	37.7	36.93
Central	38.5	36.27	38.08	38.09	38.7
Central_East	36.8	36.55	37	38.48	37.84
South_East	40.43	40.83	40.32	43.9	42.96
Champlain	41.84	42.07	40.72	42.72	42.86
North_Simcoe_Muskoka	36.51	37.43	35.76	37.8	39.33
North_East	39.97	40.75	38.27	43.2	42.84
North_West	34.83	36.02	38.57	38.05	42.37

Data Table 3. Percentage of lung cancer cases that would have benefited from, but did not receive, radiotherapy (actual compared to benchmark), 2011 to 2017, by County

County Name	Stormont, Dundas & Glengarry	Prescott & Russell	Ottawa-Carleton RM	Leeds & Grenville	Lanark	Frontenac	Lennox & Addington	Hastings	Prince Edward	Northumberland	Peterborough	Victoria	Durham RM	York RM	Metropolitan Toronto RM	Peel RM	Dufferin	Wellington	Halton RM	Hamilton-Wentworth RM	Niagara RM	Haldimand-Norfolk RM	Brant	Waterloo RM	Perth	Oxford	Elgin	Kent	Essex	Lambton	Middlesex	Huron	Bruce	Grey	Simcoe	Muskoka DM	Haliburton	Renfrew	Nipissing Dist.	Parry Sound Dist.	Manitoulin Dist.	Sudbury RM	Timiskaming Dist.	Cochrane Dist.	Algoma Dist.	Thunder Bay Dist.	Rainy River Dist.	Kenora
LUNG	5.8	2	0.6	0	5.7	0	0	4.6	9.6	9.9	6.3	10	7.4	19.2	18.1	16.1	34	12.1	20.3	22.1	20.9	27.1	32.4	13.6	16.7	5.8	13.1	9.2	0	24.1	3.8	16.9	28.3	28.4	13.7	13.6	22.5	1.8	0	11.4	0	0	7.6	1.6	0	16.2	51.7	data unavailable

Data Table 4. Percentage of prostate cancer cases that would have benefited from, but did not receive, radiotherapy (actual compared to benchmark), 2011 to 2017, by County

County Name	Stormont, Dundas & Glengarry	Prescott & Russell	Ottawa-Carleton RM	Leeds & Grenville	Lanark	Frontenac	Lennox & Addington	Hastings	Prince Edward	Northumberland	Peterborough	Victoria	Durham RM	York RM	Metropolitan Toronto RM	Peel RM	Dufferin	Wellington	Halton RM	Hamilton-Wentworth RM	Niagara RM	Haldimand-Norfolk RM	Brant	Waterloo RM	Perth	Oxford	Elgin	Kent	Essex	Lambton	Middlesex	Huron	Bruce	Grey	Simcoe	Muskoka DM	Haliburton	Renfrew	Nipissing Dist.	Parry Sound Dist.	Manitoulin Dist.	Sudbury RM	Timiskaming Dist.	Cochrane Dist.	Algoma Dist.	Thunder Bay Dist.	Rainy River Dist.	Kenora
PROSTATE	0	16	0	14.5	11.5	0	0	28	30.6	26.9	55.8	41.4	19.2	15.3	20.4	3.3	14.7	3.3	16.8	24.7	15.8	21.1	17.1	17.1	24.5	26.8	4.6	30.2	0	35.2	19.1	25.6	24.6	13.9	34.4	0	9.5	10.5	0	0	0	9.6	0	0	34.8	5.1	0	data unavailable

Data Table 5. Percentage of rectal cancer cases that would have benefited from, but did not receive, radiotherapy (actual compared to benchmark), 2011 to 2017, by County

County Name	Stormont, Dundas & Glengarry	Prescott & Russell	Ottawa-Carleton RM	Leeds & Grenville	Lanark	Frontenac	Lennox & Addington	Hastings	Prince Edward	Northumberland	Peterborough	Victoria	Durham RM	York RM	Metropolitan Toronto RM	Peel RM	Dufferin	Wellington	Halton RM	Hamilton-Wentworth RM	Niagara RM	Haldimand-Norfolk RM	Brant	Waterloo RM	Perth	Oxford	Elgin	Kent	Essex	Lambton	Middlesex	Huron	Bruce	Grey	Simcoe	Muskoka DM	Haliburton	Renfrew	Nipissing Dist.	Parry Sound Dist.	Manitoulin Dist.	Sudbury RM	Timiskaming Dist.	Cochrane Dist.	Algoma Dist.	Thunder Bay Dist.	Rainy River Dist.	Kenora
RECTAL	11.5	24.2	9.2	16.5	21.4	0	0	18.4	0	21.2	11.3	11	21.1	20.7	14.5	26.4	25.9	5.2	31.5	17.1	15.7	0	37.7	0	18	18	8.9	20.4	7.3	28.9	11.4	12.8	0	19.1	9.7	15.7	19.7	7.3	12.8	0	0	0	53.7	16.6	0	0	1.9	data unavailable

Data Table 1. Percentage of cancer cases treated with radiotherapy at any time during the course of their illness, 2011 to 2017, by Local Health Integration Network (LHIN)

What do the results show?

Use of radiation treatment remains stable despite increasing complexity of treatment (Figure 1).

Overall, 39% of cancer patients in the province received radiation treatment at some point in 2016/2017. The Ontario average continues to remain consistent, year over year.
As the incidence of cancer increases, the additional need for radiation affects utilization rates. For example, a 3% increase in the number of cases treated is necessary to maintain the same utilization rate from one year to the next, while improving the overall utilization rate by 1% over a 1-year period requires an additional 3% increase in the number of cases treated (a 6% total increase from the previous year).
The use of radiation treatment has remained consistent despite the introduction of high-precision Intensity Modulated Radiation Therapy (IMRT). This form of radiotherapy could have resulted in slight decreases in utilization rates because of the higher complexity and workload associated with this new type of treatment.

Utilization rates are rising for most regions, but regional variation persists (Figure 1).

Utilization rates across the province have steadily increased over the past several years. Most Local Health Integration Networks (LHINs) have shown improvements.
These improvements can be attributed to the introduction of new radiation treatment facilities and additional radiation treatment units in existing centres from 2005 to 2012 through the Radiation Treatment Capital Investment Strategy. Another factor has been investment in additional radiation oncology positions by the Ministry of Health and Long-Term Care.
Regional variation exists in the use of radiation treatment. The South East and Champlain LHINs had the highest radiation treatment utilization in 2016/2017 with 43%. Mississauga Halton and Toronto Central had the lowest utilization rates with 37%.

The use of radiation treatment varies across types of cancer and counties (Figures 2 to 5).

The use of radiation treatment varies across both LHINs and the counties within each LHIN.
The percentage shortfall from the benchmarks for breast, lung, prostate and rectal cancers is shown in Figures 2 through 5.
Radiation seems fairly well accepted as a treatment for breast cancer, as shown by most counties falling within 5% of the benchmark rate.
Regional variability exists for utilization of radiation for lung cancer, but numerous counties have experienced a significant increase of use in recent years.
Variability in radiation treatment for prostate cancer is high and varies by county, but many counties have had their rate of radiation utilization increase significantly (data not shown).
This variability in treatment patterns at the county level likely reflects differences in (a) physician referral patterns, (b) access to radiation treatment facilities and (c) the distance of treatment facilities from the homes of patients.
Patients in North West LHIN may have received treatment in Manitoba, and these patients are not included in the maps.

Why is this important to patient care?

Radiation treatment is used to destroy cancer cells or provide relief from cancer symptoms.
In some cases, radiation is the only option for treatment. In other cases, it is combined with surgery and chemotherapy to destroy any remaining cancer cells and prevent the cancer from returning.
Medical evidence has shown that not using radiation treatment when it is indicated can lead to serious adverse outcomes, such as a higher chance that the cancer will return (recurrence) and decreased survival ^[2].
Radiation treatment is not appropriate for every patient with cancer, and each type of cancer has its own benchmark rate.
By measuring county-level radiation utilization rates, we can identify areas where physicians are less likely to refer patients for radiation treatment.
Cancer incidence is increasing, and it is projected to continue to increase (see the section on incidence in Cancer in Ontario).
Radiation utilization rates need to increase just to keep up with the resulting demand for care.
In past years, the expansion of radiation treatment centres has allowed Ontario to keep up with this increasing demand and improve utilization. If the province is to meet aggressive utilization targets while matching growing demand, however, radiation capacity also must increase.

Find out more

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

Notes

Radiotherapy: quality and access issues. In: Sullivan T, Evans W, Angus H, Hudson A, editors. Strengthening the quality of cancer services in Ontario. Ottawa: CHA Press; 2003.
Zhang-Salomons J, Mackillop WJ. Estimating the lifetime utilization rate of radiotherapy in cancer patients: the Multicohort Current Utilization Table (MCUT) method. Comput Method Prog Biomed. 2008;92(1):99–108.