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Background The Edmonton Symptom Assessment System (ESAS) is a validated instrument whose use has been standardized in the Ontario cancer system to measure symptoms among ambulatory cancer patients. The objective was to examine the effect of ESAS exposure on overall survival. We hypothesized, a priori, that patients exposed to ESAS would have higher rates of overall survival than those who were not exposed. Methods This was a retrospective matched cohort study of adults diagnosed with cancer between 2007 and 2015. Patients were considered exposed if they were screened with ESAS at least once during the study period. Their first ESAS screening date defined the index date. Each exposed patient was matched randomly to a cancer patient without ESAS using a combination of hard matching (4 variables) and propensity score matching (14 variables). Kaplan‐Meier curves and multivariable Cox regression were used to evaluate the impact of ESAS exposure on survival. Results There were 128,893 pairs well matched on all baseline characteristics. The probability of survival within the first 5 years was higher among those exposed to ESAS compared to those who were not (81.9% vs. 76.4% at 1 year, 68.3% vs. 66.1% at 3 years, 61.9% vs. 61.4% at 5 years, P‐value < .0001). In the multivariable Cox regression model, ESAS was significantly associated with a decreased mortality risk (HR: 0.48, 95% CI: 0.47‐0.49). Conclusions Our results show that ESAS exposure is associated with improved survival in cancer patients. This provides real world evidence of the impact of routine symptom assessment in cancer care. We evaluated the impact of routine symptom screening, using the Edmonton Symptom Assessment System (ESAS), on overall survival in cancer patients. ESAS is used routinely in clinical practice in the cancer system in Ontario, Canada. In this retrospective matched cohort study of 128,893 pairs of cancer patients, those exposed to ESAS during their care had improved survival with an adjusted hazard ratio of 0.49 (95% CI: 0.48‐0.49) when compared to those not exposed. This study provides real world evidence of the impact of ESAS exposure on overall survival which is consistent with findings from randomized trials.

To evaluate whether the early identification of patients who may benefit from palliative care impacts on the use of palliative, community and acute-based care services. Between 2014 and 2017, physicians from eight sites were encouraged to systematically identify patients who were likely to die within one year and would were thought to benefit from early palliative care. Patients in the INTEGRATE Intervention Group were 1:1 matched to controls selected from provincial healthcare administrative data using propensity score-matching. The use of palliative care, community-based care services (home care, physician home visit, and outpatient opioid use) and acute care (emergency department, hospitalization) was each evaluated within one year after the date of identification. The hazard ratio (HR) in the Intervention Group was calculated for each outcome. Of the 1,185 patients in the Intervention Group, 951 (80.3%) used palliative care services during follow-up, compared to 739 (62.4%) among 1,185 patients in the Control Group [HR of 1.69 (95% CI 1.56 to 1.82)]. The Intervention Group also had higher proportions of patients who used home care [81.4% vs. 55.2%; HR 2.07 (95% CI 1.89 to 2.27)], had physician home visits [35.5% vs. 23.7%; HR 1.63 (95% CI 1.46 to 1.92)] or had increased outpatient opioid use [64.3% vs. 52.1%); HR 1.43 (95% CI 1.30 to 1.57]. The Intervention Group was also more likely to have a hospitalization that was not primarily focused on palliative care (1.42 (95% CI 1.28 to 1.58)) and an unplanned emergency department visit for non-palliative care purpose (1.47 (95% CI 1.32 to 1.64)). Physicians actively identifying patients who would benefit from palliative care resulted in increased use of palliative and community-based care services, but also increased use of acute care services.

Background Most Canadians die in hospital, and yet, many express a preference to die at home. Place of death is the result of the interaction among sociodemographic, illness- and healthcare-related factors. Although home death is sometimes considered a potential indicator of end-of-life/palliative care quality, some determinants of place of death are more modifiable than others. The objective of this systematic review was to evaluate the determinants of home and nursing home death in adult patients diagnosed with an advanced, life-limiting illness. Methods A systematic literature search was performed for studies in English published from January 1, 2004 to September 24, 2013 that evaluated the determinants of home or nursing home death compared to hospital death in adult patients with an advanced, life-limiting condition. The adjusted odds ratios, relative risks, and 95 % confidence intervals of each determinant were extracted from the studies. Meta-analyses were performed if appropriate. The quality of individual studies was assessed using the Newcastle-Ottawa scale and the body of evidence was assessed according to the GRADE Working Group criteria. Results Of the 5,900 citations identified, 26 retrospective cohort studies were eligible. The risk of bias in the studies identified was considered low. Factors associated with an increased likelihood of home versus hospital death included multidisciplinary home palliative care, preference for home death, cancer as opposed to other diagnoses, early referral to palliative care, not living alone, having a caregiver, and the caregiver’s coping skills. Conclusions Knowledge about the determinants of place of death can be used to inform care planning between healthcare providers, patients and family members regarding the feasibility of dying in the preferred location and may help explain the incongruence between preferred and actual place of death. Modifiable factors such as early referral to palliative care, presence of a multidisciplinary home palliative care team were identified, which may be amenable to interventions that improve the likelihood of a patient dying in the preferred location. Place of death may not be a very good indicator of the quality of end-of-life/palliative care since it is determined by multiple factors and is therefore dependent on individual circumstances.

The incidence of esophageal adenocarcinoma (EAC) is increasing worldwide and has overtaken squamous histology in occurrence. We studied the impact of socioeconomic status (SES) on EAC stage at diagnosis, receipt of treatment, and survival. A population-based retrospective cohort study was conducted using Ontario Cancer Registry-linked administrative health data. Multinomial logistic regression was used to examine the association between SES (income quintile) and stage at EAC diagnosis and EAC treatment. Survival times following EAC diagnosis were estimated using Kaplan-Meier method. Cox proportional-hazards regression analysis was used to examine the association between SES and EAC survival. Between 2003-2012, 2,125 EAC cases were diagnosed. Median survival for the lowest-SES group was 10.9 months compared to 11.6 months for the highest-SES group; the 5-year survival was 9.8% vs. 15.0%. Compared to individuals in the highest-SES group, individuals in the lowest-SES category experienced no significant difference in EAC treatment (91.6% vs. 93.3%, P = 0.314) and deaths (78.9% vs. 75.6%, P = 0.727). After controlling for covariates, no significant associations were found between SES and cancer stage at diagnosis and EAC treatment. Additionally, after controlling for age, gender, urban/rural residence, birth country, health region, aggregated diagnosis groups, cancer stage, treatment, and year of diagnosis, no significant association was found between SES and EAC survival. Moreover, increased mortality risk was observed among those with older age (P = 0.001), advanced-stage of EAC at diagnosis (P < 0.001), and those receiving chemotherapy alone, radiotherapy alone, or surgery plus chemotherapy (P < 0.001). Adjusted proportional-hazards model findings suggest that there is no association between SES and EAC survival. While the unadjusted model suggests reduced survival among individuals in lower income quintiles, this is no longer significant after adjusting for any covariate. Additionally, there is an apparent association between SES and survival when considering only those individuals diagnosed with stage 0-III EAC. These analyses suggest that the observed direct relationship between SES and survival is explained by patient-level factors including receipt of treatment, something that is potentially modifiable.

Background Performance of pancreaticoduodenectomy (PD) in high-volume centers has been posited to improve postoperative morbidity and mortality, consistent with the volume-outcomes hypothesis. We sought to evaluate the impact of hospital volume on 90-day PD outcomes at hepatopancreatobiliary (HPB) centers within a regionalized system. Methods A retrospective population-based observational cohort study was performed, using administrative records of patients undergoing PD between 2005 and 2013 in Ontario, Canada. Postoperative administrative codes were used to define complications. Patients’ 90-day postoperative outcomes were compared between center-volume categories using chi-square tests and multivariable regression. Volume cutoffs were defined using minimal regional standards (20PD/year), with assessment of the impact of further volume increases. Results Of 2660 patients, 2563 underwent PD at HPB centers. Of these, 38.9% underwent surgery at higher-volume centers ( > 40 PD/year), 36.9% at medium-volume centers (20–39 PD/year), and 24.1% at lower-volume centers (10–19 PD/year). Mortality (30- and 90-day) was lowest at higher-volume hospitals (1.5%, 2.7%, respectively) compared to medium-volume (3.9%, 6.3%) and lower-volume hospitals (2.9%, 5.2%) ( p  < 0.01). Patients treated at higher- and medium-volume centers had lower reoperation rates (10.3%, 10.7% vs. 16.7%, p  = 0.0002) and less prolonged length of stay (23.2%, 22.0% vs. 31.6%, p  < 0.0001) compared to lower-volume centers. Conclusion Progressive increases in hospital volume correspond to improved 90-day outcomes following PD.

Although advancements in systemic therapy have improved the outlook for pancreatic adenocarcinoma, it is not known if patients get access to these therapies. We aimed to examine the patterns and factors associated with access to specialized cancer consultations and subsequent receipt of cancer-directed therapy for patients with non-curative pancreatic adenocarcinoma. We conducted a population-based analysis of noncurative pancreatic adenocarcinoma diagnosed over 2005–2016 in Ontario by linking administrative health care data sets. Our primary outcomes were specialized cancer consultation and receipt of cancer-directed therapy (chemotherapy or a combination of chemo- and radiation therapy [chemoradiation therapy]). We examined specialized cancer consultation with hepato-pancreatico-biliary surgery, medical and radiation oncology. We used multivariable logistic regression to identify factors associated with medical oncology consultation and cancer-directed therapy. Of 10 881 patients, 64.9% had a consultation with specialists in medical oncology, 35.1% with hepatopancreatico-biliary surgery and 24.7% with radiation oncology. Sociodemographic characteristics were not associated with the likelihood of medical oncology consultation. Of these patients, 4144 received cancer-directed therapy, representing 38.1% of all patients and 58.6% of those who consulted with medical oncology. Of 6737 patients not receiving cancer-directed therapy, 2988 (44.4%) had a consultation with medical oncology. Older age and lowest income quintile were independently associated with lower likelihood of cancer-directed therapy. If the first specialized cancer consultation was with medical or radiation oncology, the likelihood of cancer-directed therapy was significantly higher compared with surgery. A considerable proportion of patients with noncurable pancreatic adenocarcinoma in Ontario did not have a specialized cancer consultation and most did not receive cancer-directed therapy. We identified disparities in specialized cancer consultation and receipt of systemic cancer-directed therapy that indicate potential gaps in assessment.

Hepatocellular carcinoma (HCC) presentation is heterogeneous necessitating a variety of therapeutic interventions with varying efficacies and associated prognoses. Poor prognostic patients often undergo non-curative palliative interventions including transarterial chemoembolization (TACE), sorafenib, chemotherapy, or purely supportive care. The decision to pursue one of many palliative interventions for HCC is complex and an economic evaluation comparing these interventions has not been done. This study evaluates the cost-effectiveness of non-curative palliative treatment strategies such as TACE alone or TACE+sorafenib, sorafenib alone, and non-sorafenib chemotherapy compared with no treatment or best supportive care (BSC) among patients diagnosed with HCC between 2007 and 2010 in a Canadian setting. Using person-level data, we estimated effectiveness in life years and quality-adjusted life years (QALYs) along with total health care costs (2013 US dollars) from the health care payer's perspective (3% annual discount). A net benefit regression approach accounting for baseline covariates with propensity score adjustment was used to calculate incremental net benefit to generate incremental cost-effectiveness ratio (ICER) and uncertainty measures. Among 1,172 identified patients diagnosed with HCC, 4.5%, 7.9%, and 5.6%, received TACE alone or TACE+sorafenib, sorafenib, and non-sorafenib chemotherapy clone, respectively. Compared with no treatment or BSC (81.9%), ICER estimates for TACE alone or TACE+sorafenib was $6,665/QALY (additional QALY: 0.47, additional cost: $3,120; 95% CI: -$18,800-$34,500/QALY). The cost-effectiveness acceptability curve demonstrated that if the relevant threshold was $50,000/QALY, TACE alone or TACE+sorafenib, non-sorafenib chemotherapy, and sorafenib alone, would have a cost-effectiveness probability of 99.7%, 46.6%, and 5.5%, respectively. Covariates associated with the incremental net benefit of treatments are age, sex, comorbidity, and cancer stage. Findings suggest that TACE with or without sorafenib is currently the most cost-effective active non-curative palliative treatment approach to HCC. Further research into new combination treatment strategies that afford the best tumor response is needed.

Background Overuse of anti-cancer therapy is an important quality-of-care issue. An aggressive approach to treatment can have negative effects on quality of life and cost, but its effect on survival is not well-defined. Methods Using the Surveillance, Epidemiology, and End Results-Medicare database, we identified 7,879 Medicare-enrolled patients aged 65 or older who died after having survived at least 3 months after diagnosis of advanced non-small cell lung cancer (NSCLC) between 1991 and 1999. We used Cox proportional hazards regression analysis, propensity scores, and instrumental variable analysis (IVA) to compare survival among patients who never received chemotherapy (n = 4,345), those who received standard chemotherapy but not within two weeks prior to death (n = 3,235), and those who were still receiving chemotherapy within 14 days of death (n = 299). Geographic variation in the application of chemotherapy was used as the instrument for IVA. Results Receipt of chemotherapy was associated with a 2-month improvement in overall survival. However, based on three different statistical approaches, no additional survival benefit was evident from continuing chemotherapy within 14 days of death. Moreover, patients receiving chemotherapy near the end of life were much less likely to enter hospice (81% versus 51% with no chemotherapy and 52% with standard chemotherapy, P < 0.001), or were more likely to be admitted within only 3 days of death. Conclusions Continuing chemotherapy for advanced NSCLC until very near death is associated with a decreased likelihood of receiving hospice care but not prolonged survival. Oncologists should strive to discontinue chemotherapy as death approaches and encourage patients to enroll in hospice for better end-of-life palliative care.

Cancer has not been an explicit priority of Canada's international health and development agenda, but it is key to realising the country's Sustainable Development Goal commitments. Multiple converging political, health, and social forces could now drive support for a more integrated Canadian approach to global cancer control. Success will depend on the extent to which Canadian leaders and institutions can build consensus as a community and agree to work together. Collaboration should include agreement on the framing and prioritisation of the core issues, building a broad coalition base, aligning with priorities of international partners, and on a governance structure that reflects the principles of equity, diversity, and inclusion. This Series paper will discuss global cancer control within Canada's global health agenda, how Canada can address its history of colonisation and present-day disparities in its global work, and the challenges and opportunities of creating a Canadian global cancer control network.

ObjectiveThe Canadian Real-world Evidence for Value in Cancer (CanREValue) Collaboration was established in response to growing interest in using real-world evidence (RWE) to support health technology assessment (HTA). CanREValue has developed a framework to generate and use RWE to inform cancer drug funding decisions.Design and participantsThe RWE framework was developed using a multistage, multistakeholder approach. First, an environmental scan and qualitative study were conducted to understand the current state and key stakeholder perspectives on RWE. Next, five formal working groups (WGs) were established consisting of stakeholders with cancer drug funding expertise including clinicians, patients, methodologists, payers, regulatory decision-makers and data analysts. Through stakeholder consultations, including modified Delphi exercises and workshops, each WG developed specific framework components and identified facilitators and barriers that may impact the uptake of RWE.SettingThe CanREValue Collaboration consisted of membership and participation from stakeholders and expertise from across Canada. Central research operations were managed from Toronto, Ontario, Canada.OutcomesDevelopment of an RWE framework reflective of the needs and perspectives of stakeholders directly involved and/or impacted by cancer drug funding decisions across Canada.ResultsThrough an iterative process, a comprehensive RWE framework was developed that outlined the end-to-end processes necessary for the generation and use of RWE for HTA reassessment in Canada. The framework consists of four phases that uses various tools, templates and processes, which can be applied as a whole or in part. A diverse range of stakeholders and expertise is involved in the decision-making of each phase of the process: Phase I: identification, selection and prioritisation of RWE questions; phase II: initiating and planning the RWE study; phase III: conducting the RWE study and phase IV: conducting reassessment.ConclusionsAs the cancer drug funding landscape continues to evolve, the need for RWE to support evidence-based policy reform, pricing and reallocation of funding from low to high value settings is crucial. We have developed a framework that is adaptable and responsive to the changing landscape. The tools, templates and processes within the framework can be applied by various stakeholder groups in whole or in part to support cancer drug funding decision-making in Canada and can be adapted for use in other jurisdictions.