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Reporting of Cancer Stage at Diagnosis

Key findings

Measure:  Reporting of cancer stage at diagnosis (Collaborative Staging) for stageable breast, cervix, colorectal, lung and prostate cancers

 

Desired Direction:

 

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As of this Report:

 

An image of an arrow pointing straight in a green box. This indicates that there has been no increase or decrease in performance over the previous periods identified and this action is exceeding or meeting target.

Stage capture rates using the Collaborative Staging (CS) data collection system exceed the provincial target of 90% completeness for breast, prostate, colorectal, lung and cervix cancers. When other types of cancer are considered, the overall stage capture rate for all stageable cancer cases in 2016 was 52%, a rate that is stable compared to the previous year. While both data from CS and clinician-staged data are collected by Cancer Care Ontario, the former is derived directly by Cancer Care Ontario staging staff using Tumour, Node and Metastasis Staging System (TNM) and prognostic data. The rates reported under this indicator do not reflect physician staging practice in the clinical setting but rather the completeness of stage data collection within the provincial cancer registry.

What is cancer staging?

  • Staging describes the extent or severity of a person’s cancer, based on the size and/or extension of the original (primary) tumour and how far it has spread in the body [1].
  • Almost all cancer patients begin their involvement with the cancer system through a series of diagnostic tests. These likely include imaging and, in many cases, removal of tissue or cells for examination (biopsy). These tests allow the nature and extent of the cancer to be determined.
  • Stage at diagnosis can be described as Stage 0 (in situ), Stage I and II (localized), Stage III (regional) or Stage IV (distant spread or metastasized). To date, in situ cases have not been staged by the provincial cancer registry.
  • A stageable case is one for which a staging schema exists (e.g., TNM and CS), a patient health record is available and the required data elements are documented in that record.
  • An unknown stage is the result of either limited stage workup and/or limited documentation within the patient record.

What is the Collaborative Staging data collection system and how is it different from Tumour, Node and Metastasis staging system data?

Measure:  Reporting of cancer stage at diagnosis (Collaborative Staging) for all stageable cancer

 

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 red box. This indicates that there has been no increase or decrease in performance over the previous periods identified and this action is well below targets.

  • The TNM staging system is promoted by the American Joint Committee on Cancer (AJCC) and the International Union against Cancer (UICC). It uses information about tumour growth (T), regional lymph node involvement (N) and the presence of distant metastases (M) to determine a patient’s stage of disease at diagnosis [2].
  • CS is a stage data collection system that uses an algorithm to combine elements of TNM to derive a stage group [2]. It has been the Canadian standard since 2004. Beginning with the 2018 diagnosis year, all Canadian provincial and territorial cancer registries will move to directly coded TNM, using the AJCC TNM 8th Edition.
  • In more recent years, prognostic factors that have a bearing on survival and treatment outcomes (such as biomarkers) have been incorporated into both TNM and CS.
  • “Unknown Stage” is assigned by the CS algorithm when there is insufficient information to assign a category.
  • “No Stage” is the term assigned to cases for which no hospital record is available for review. This can occur when (a) there is only a physician office record or a private lab report, (b) the hospital record is for a facility that is not part of the CS program or (c) the diagnosis year was closed off before the Ontario Cancer Registry (OCR) stage team could complete all cases.
  • The OCR captures stage at diagnosis for breast, lung, colorectal and prostate cancers using CS for cancers diagnosed from 2010 to the present. Cervical cancers have been captured by the OCR using CS since the 2011 diagnosis year.
  • Regional Cancer Centres (RCCs) submit TNM stage data to Cancer Care Ontario for those cancers not staged at Cancer Care Ontario using CS. However staging data from RCCs only captures cases referred to an RCC for diagnosis and first course of treatment.

Cancer diagnosis means accuracy of that diagnosis and knowing exactly what the next steps will be. There can be no doubt because as soon as those words are spoken a different journey in life begins.

Laurie P., Patient/Family Advisor

Figure 1. Number of total incident cases and stageable cancer cases diagnosed in Ontario, by year of diagnosis, 2010 to 2016

More information regarding the methodology is available.

Report date: February 2018

Data source: Ontario Cancer Registry

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. * Please refer to 'Data availability and limitations' in the technical information for additional details regarding the 2016 data.

 

Figure 2. Population stage capture using Collaborative Staging (CS) by Ontario Cancer Registry and Tumour, Node and Metastasis (TNM) by Regional Cancer Centres (RCC) for all stageable cases, 2010 to 2016

More information regarding the methodology is available.

Report date: February 2018

Data source: Ontario Cancer Registry

Prepared by: Analytics and Informatics, Cancer Care Ontario

Figure 3. Collaborative Staging (CS) capture rate by disease site for all CS sites, cases diagnosed 2010 to 2016

More information regarding the methodology is available.

Report date: February 2018

Data source: Ontario Cancer Registry

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. Breast, colorectal, lung, prostate and cervical cancer sites were mandated CS sites for 2016.
  2. Cervix is also included in gynecologic sites but has not been double counted in overall results.

 

Figure 4. Distribution of incident breast cancer cases by stage, cases diagnosed 2010 to 2016

More information regarding the methodology is available.

Report date: February 2018

Data source: Ontario Cancer Registry

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. Collaboratively Staged cases

 

Figure 5. Distribution of incident cervical cancer cases by stage, cases diagnosed 2010 to 2016

More information regarding the methodology is available.

Report date: February 2018

Data source: Ontario Cancer Registry

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. Collaboratively Staged cases
  2. † small cell counts

 

Figure 6. Distribution of incident colorectal cancer cases by stage, cases diagnosed 2010 to 2016

More information regarding the methodology is available.

Report date: February 2018

Data source: Ontario Cancer Registry

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. Collaboratively Staged cases

 

Figure 7. Distribution of incident lung cancer cases by stage, cases diagnosed 2010 to 2016

More information regarding the methodology is available.

Report date: February 2018

Data source: Ontario Cancer Registry

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. Collaboratively Staged cases

 

Figure 8. Distribution of incident prostate cancer cases by stage, cases diagnosed 2010 to 2016

More information regarding the methodology is available.

Report date: February 2018

Data source: Ontario Cancer Registry

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. Collaboratively Staged cases

 

Data Table 1. Number of total incident cases and stageable cancer cases diagnosed in Ontario, by year of diagnosis, 2010 to 2016

Ontario Cancer Registry cases 2010 2011 2012 2013 2014 2015 2016*
Incident cases 73,067 75,877 75,392 76,693 77,855 75,121 77,506
Stageable cases 63,198 65,670 64,642 65,086 65,953 64,481 66,430

Report date: February 2018

Data source: Ontario Cancer Registry

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. * Please refer to 'Data availability and limitations' in the technical information for additional details regarding the 2016 data.

 

Data Table 2. Population stage capture using Collaborative Staging (CS) by Ontario Cancer Registry and Tumour, Node and Metastasis (TNM) by Regional Cancer Centres (RCC) for all stageable cases, 2010 to 2016

Stage capture 2010 2011 2012 2013 2014 2015 2016
CS rate 57.0 59.2 62.9 63.7 50.5 52.2 51.7
TNM rate 15.6 13.5 12.1 10.0 15.2 16.1 15.4
No stage rate 27.5 27.3 25.0 26.3 34.3 31.7 32.9
CS counts 36,025 38,895 40,650 41,459 33,321 33,666 34,345
TNM counts 9,828 8,874 7,825 6,535 10,039 10,409 10,235
No stage 17,345 17,901 16,166 17,092 22,593 20,406 21,850
Total stageable cases 63,198 65,670 64,641 65,086 65,953 64,481 66,430

Report date: February 2018

Data source: Ontario Cancer Registry

Prepared by: Analytics and Informatics, Cancer Care Ontario

Data Table 3. Collaborative Staging (CS) capture rate by disease site for all CS sites, cases diagnosed 2010 to 2016

Disease site All stageable cases in 2011 CS staged cases in 2011 CS rate in 2011 All stageable cases in 2012 CS staged cases in 2012 CS rate in 2012 All stageable cases in 2013 CS staged cases in 2013 CS rate in 2013 All stageable cases in 2014 CS staged cases in 2014 CS rate in 2014 All stageable cases in 2015 CS staged cases in 2015 CS rate in 2015 All stageable cases in 2016 CS staged cases in 2016 CS rate in 2016
Breast 10,172.0 8,737.0 85.9 10,112.0 9,243.0 91.4 10,342.0 9,668.0 93.5 10,819.0 10,146.0 93.8 10,761.0 10,258.0 95.3 11,016.0 10,497.0 95.3
Colorectal 8,456.0 7,751.0 91.7 8,371.0 7,513.0 89.8 8,605.0 7,612.0 88.5 8,779.0 7,501.0 85.4 8,302.0 7,508.0 90.4 8,083.0 7,377.0 91.3
Lung 8,939.0 8,115.0 90.8 9,523.0 8,411.0 88.3 9,580.0 8,331.0 87.0 9,702.0 8,372.0 86.3 8,764.0 8,273.0 94.4 8,873.0 8,300.0 93.5
Prostate 9,874.0 8,892.0 90.1 8,419.0 7,192.0 85.4 7,620.0 6,796.0 89.2 7,529.0 6,830.0 90.7 7,692.0 7,123.0 92.6 8,271.0 7,639.0 92.4
Gynecologic 4,406.0 3,524.0 80.0 4,443.0 3,653.0 82.2 4,331.0 3,764.0 86.9 4,413.0 NA NA 4,576.0 NA NA 5,161.0 NA NA
Cervical 606.0 583.0 96.2 565.0 534.0 94.5 518.0 494.0 95.4 512.0 459.0 89.7 558.0 503.0 90.1 585.0 532.0 90.9
Melanoma skin 3,206.0 1,836.0 57.3 3,110.0 2,068.0 66.5 3,421.0 2,269.0 66.3 3,659.0 NA NA 3,691.0 NA NA 3,698.0 NA NA
Thyroid 3,194.0 NA NA 3,166.0 2,568.0 81.1 3,189.0 3,018.0 94.6 3,351.0 NA NA 3,170.0 NA NA 2,944.0 NA NA

Report date: February 2018

Data source: Ontario Cancer Registry

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. Breast, colorectal, lung, prostate and cervical cancer sites were mandated CS sites for 2016.
  2. Cervix is also included in gynecologic sites but has not been double counted in overall results.

 

Data Table 4. Distribution of incident breast cancer cases by stage, cases diagnosed 2010 to 2016

Collaborative stage Percentage in 2010 Number in 2010 Percentage in 2011 Number in 2011 Percentage in 2012 Number in 2012 Percentage in 2013 Number in 2013 Percentage in 2014 Number in 2014 Percentage in 2015 Number in 2015 Percentage in 2016 Number in 2016
I 42.9 3,667.0 43.3 3,778.0 43.4 3,999.0 42.5 4,097.0 43.9 4,440.0 44.4 4,543.0 44.3 4,638.0
II 37.0 3,157.0 36.7 3,200.0 37.0 3,412.0 38.0 3,664.0 38.2 3,863.0 37.2 3,814.0 37.6 3,943.0
III 14.2 1,214.0 14.2 1,240.0 13.8 1,270.0 13.5 1,297.0 12.7 1,285.0 12.9 1,316.0 12.6 1,318.0
IV 5.3 455.0 4.9 427.0 5.1 467.0 5.3 512.0 4.6 465.0 4.9 504.0 5.0 519.0
unkown 0.6 48.0 0.8 73.0 0.8 75.0 0.7 69.0 0.6 64.0 0.6 65.0 0.6 61.0

Report date: February 2018

Data source: Ontario Cancer Registry

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. Collaboratively Staged cases

 

Data Table 5. Distribution of incident cervical cancer cases by stage, cases diagnosed 2010 to 2016

Collaborative Stage Percentage in 2010 Number in 2010 Percentage in 2011 Number in 2011 Percentage in 2012 Number in 2012 Percentage in 2013 Number in 2013 Percentage in 2014 Number in 2014 Percentage in 2015 Number in 2015 Percentage in 2016 Number in 2016
I 59.6 124 55.2 322 56.1 299 55.4 273 50.1 230 56.3 283 54.7 291
II 10.1 21 15.4 90 15.2 81 15.6 77 14.4 66 15.3 77 21.1 112
III 15.9 33 15.4 90 15.0 80 16.0 79 19.4 89 15.5 78 13.7 73
IV 12.0 25 12.4 72 12.2 65 11.4 56 14.8 68 11.7 59 10.0 53
unknown 1.5 9 1.5 8 1.6 8 1.3 6 1.2 6

Report date: February 2018

Data source: Ontario Cancer Registry

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. Collaboratively Staged cases
  2. † small cell counts

 

Data Table 6. Distribution of incident colorectal cancer cases by stage, cases diagnosed 2010 to 2016

Collaborative Stage Percentage in 2010 Number in 2010 Percentage in 2011 Number in 2011 Percentage in 2012 Number in 2012 Percentage in 2013 Number in 2013 Percentage in 2014 Number in 2014 Percentage in 2015 Number in 2015 Percentage in 2016 Number in 2016
I 23.8 1,834 23.2 1,783 22.3 1,666 23.5 1,773 23.3 1,738 25.0 1,870 24.5 1,800
II 25.5 1,964 26.3 2,026 24.8 1,847 25.7 1,939 27.3 2,036 25.8 1,925 25.2 1,854
III 28.5 2,199 27.5 2,113 29.6 2,206 29.2 2,204 29.8 2,225 29.3 2,192 30.0 2,208
IV 19.6 1,510 19.6 1,507 20.0 1,489 18.8 1,423 17.3 1,294 17.8 1,332 18.0 1,320
unkown 2.7 210 3.5 266 3.4 252 2.9 215 2.3 169 2.1 153 2.3 168

Report date: February 2018

Data source: Ontario Cancer Registry

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. Collaboratively Staged cases

 

Data Table 7. Distribution of incident lung cancer cases by stage, cases diagnosed 2010 to 2016

Collaborative Stage Percentage in 2010 Number in 2010 Percentage in 2011 Number in 2011 Percentage in 2012 Number in 2012 Percentage in 2013 Number in 2013 Percentage in 2014 Number in 2014 Percentage in 2015 Number in 2015 Percentage in 2016 Number in 2016
I 17.4 1,398 18.0 1,452 19.3 1,621 20.4 1,697 23.4 1,954 24.5 2,026 26.4 2,188
II 7.8 629 8.2 663 8.4 708 8.5 703 8.4 699 9.0 741 8.2 678
III 17.7 1,429 19.1 1,548 20.2 1,694 19.4 1,611 19.3 1,616 19.4 1,604 19.2 1,593
IV 56.0 4,511 53.5 4,327 50.8 4,262 50.6 4,209 48.2 4,033 46.7 3,859 45.9 3,799
unknown 1.0 84 1.2 97 1.3 105 1.1 95 0.7 60 0.4 32 0.3 27

Report date: February 2018

Data source: Ontario Cancer Registry

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. Collaboratively Staged cases

 

Data Table 8. Distribution of incident prostate cancer cases by stage, cases diagnosed 2010 to 2016

Collaborative Stage Percentage in 2010 Number in 2010 Percentage in 2011 Number in 2011 Percentage in 2012 Number in 2012 Percentage in 2013 Number in 2013 Percentage in 2014 Number in 2014 Percentage in 2015 Number in 2015 Percentage in 2016 Number in 2016
I 27.2 2,400 26.5 2,360 23.7 1,701 23.1 1,570 21.5 1,471 21.6 1,541 22.4 1,713
II 52.5 4,639 52.1 4,633 53.3 3,835 51.5 3,500 53.4 3,646 52.2 3,717 51.1 3,906
III 12.1 1,073 12.5 1,115 13.8 992 14.1 959 13.6 926 12.9 921 13.7 1,044
IV 7.7 677 7.9 703 8.7 627 10.8 731 11.2 762 12.9 915 12.5 954
unknown 0.6 51 0.9 81 0.5 37 0.5 36 0.4 25 0.4 29 0.3 22

Report date: February 2018

Data source: Ontario Cancer Registry

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. Collaboratively Staged cases

 

What do the results show?

Collaborative Staging rates have improved for breast, colorectal, lung and prostate cancers, but the overall cases with Collaborative Staging have decreased (Figures 1, 2 and 3).

  • The number of stageable cases in Ontario increased 6%, from 63,198 in 2010 to 66,430 in 2016. The ratio of stageable cancers to incident cases, however, has remained relatively stable (Figure 1).
  • Beginning in 2014, Cancer Care Ontario ceased capturing CS stage data for non-cervix gynecologic cancers, melanoma and thyroid cancer. Primarily as a result of this change, the overall CS stage capture rate decreased in 2014 (Figure 2).
  • With the OCR’s new focus on staging breast, colorectal, lung and prostate cancers in 2014, an increase was observed in the stage capture rates for those 4 sites, which now exceed the provincial aim of 90% completeness. The highest rate in 2016 was for breast and lung cancers (95%) (Figure 3).

Breast, cervical, colorectal and prostate cancers had consistent stage distribution from 2010 to 2016. The exception is lung cancer, for which Stage I cases have increased over time (Figures 4 to 8).

  • The stage distribution of breast cancer varied little over the 7 years examined, with approximately 80% of cases diagnosed at early Stage I and II (Figure 4).
  • Similarly, from 74% to 80% of cases for prostate cancer were in the first 2 stages (Figure 8). This is in contrast to colorectal cancer, for which approximately 50% of cases were Stage I and II (Figure 6). The stage distribution for prostate and colorectal cancers has been relatively consistent from 2010 to 2016.
  • Cervical cancer stage distribution was fairly consistent across years. However, due the smaller cohort, even minor shifts in the number of cases diagnosed can result in greater change in stage distribution (Figure 5).
  • The Stage IV distribution of all lung cancer cases decreased from 56% in 2010 to 46% in 2016. However, Stage IV still remained the most common stage at diagnosis for lung cancer (Figure 7). The greater distribution in late stage cancers is indicative of the issues preventing early detection, specifically asymptomatic disease and the lack of screening programs [3].
  • Stage distribution rates in Ontario for breast, colorectal, prostate and lung cancers are generally consistent with other jurisdictions across Canada [4].

Why is this important to Ontarians?

  • Clinical stage at diagnosis helps physicians to plan appropriate treatment and to determine the likely outcome or course of the disease [2, 5].
  • From a system performance perspective, population-level stage at diagnosis facilitates cancer surveillance and healthcare planning. Knowing the distribution of cancer stage allows cancer agencies to better evaluate the effectiveness of screening programs and the prioritization of resources for those disease sites that have a higher incidence of advanced disease [3].
  • Linking the stage of cancer with outcome and treatment data provides valuable information, allowing the cancer system to assess the quality of cancer care and identify new ways to improve the delivery of that care. For example, this Cancer Screening Quality Index (CSQI) provides performance information on the following indicators (which depend on accurate stage information):

Find out more

For more information on stage capture, please see Cancer Care Ontario’s website.

Notes

  1. What is Cancer Staging? [Internet]. Chicago: American Joint Committee on Cancer; c2018 [cited 2017 Jan 24]. Available from here.
  2. Fritz, A. Cancer registry CASEbook. Volume I. Second ed. Reno (NV): A. Fritz and Associates; 2012.
  3. Canadian Partnership against Cancer. The 2015 cancer system performance report [Internet]. Toronto: Canadian Partnership against Cancer; 2015 [cited 2017 Jan 24]. Available from here.
  4. Canadian Partnership against Cancer. The 2017 cancer system performance report [Internet]. Toronto: Canadian Partnership against Cancer; 2017 [cited 2018 Feb 13]. Available from here.
  5. Purpose of Staging [Internet]. Bethesda (MD): National Institute of Health; n.d. [cited 2017 Jan 24]. Available from here.