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Radiation Treatment Program
Implementation Plan 2019–2023

Cancer Care Ontario logo.

A companion report to the Ontario Cancer Plan

 

This first Radiation Treatment Program implementation plan is based on the Ontario Cancer Plan 2019 to 2023. This plan identifies program areas of focus for the next 4 years to support safe, accessible, high-quality radiation treatment for all Ontarians.

The goals of the implementation plan are to ensure that:

  • all people who need radiation treatment get safe, appropriate high-quality care based on the best available evidence
  • barriers to access care are actively addressed so patients who would benefit from radiation treatment can receive it as close as possible to home
  • innovative radiation treatment approaches are evaluated and adopted in a timely way

This plan was developed in consultation with clinicians, administrators, regional partners, and with input from patient and family advisors across the province. Through continued collaboration with these groups, and, in time, Ontario Health, we can work through the initiatives in this plan to achieve the goals of the Ontario Cancer Plan and improve the performance of our health systems.

Picture of Padraig Warde

Padraig Warde

Provincial Head of Radiation Treatment

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The Radiation Treatment Program Implementation Plan describes our plan to work across 5 strategic areas of focus to continue to improve and support delivery of the highest quality of care for patients every step of the way through their treatment journey, while putting patients at the centre of every decision we make and everything we do.”

Padraig Warde
Provincial Head of Radiation Treatment

picture of Robin-McLeod

Robin McLeod

Vice-President, Clinical Programs & Quality Initiatives

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Radiation is a common and effective treatment modality for cancer patients. In Ontario, patients can be assured that they receive safe and effective cancer treatment, as well as patient-oriented care. This implementation plan will guide care for patients who require radiation for the next 4 years. It will ensure that patients continue to receive the best treatment, and that new treatments and innovations are adopted as they are developed.

Ontario has been a leader in the introduction of peer review – a process where a second radiation oncologist reviews the plan to ensure that patients receive the correct treatment – and this will be implemented in other aspects of radiation. We will continue to ensure that patients receive new and innovative care, and that care is provided in a timely way. We will also adopt a new funding model tied to best practice care. All of these initiatives will lead to improved patient care.

The implementation plan was developed by the Radiation Treatment Program team at Cancer Care Ontario, led by Dr. Padraig Warde. In addition, multiple stakeholders, and patients and family members provided input. I thank all of them for contributing to this important work.”

Robin McLeod
Vice-President, Clinical Programs & Quality Initiatives

Program Areas of Focus

This implementation plan deals with issues beyond capital planning, which was the Radiation Treatment Program’s main focus in the past. All of these areas of focus support the “Person-Centred” goal from the Ontario Cancer Plan 2019 to 2023, and align with a corresponding strategic objective.

To learn more about the program’s work to improve the quality of radiation treatment in Ontario over the past 10 years, view the Radiation Treatment Program Timeline

These are our 5 areas of focus for the next 4 years:

Radiation Treatment Integrated Wait Time

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Timely

This focus area aligns with the following strategic objective of the “Timely” goal in the Ontario Cancer Plan 2019 to 2023:

Improve timeliness of diagnostic and treatment services by advancing wait time monitoring and performance management strategies

Reduce patients’ wait times from referral to radiation oncology to first day of treatment.

WHY THIS IS IMPORTANT

People continue to wait too long to start treatment after they are diagnosed with cancer. These delays lead to additional stress and anxiety for patients and families, and can compromise treatment outcomes in some situations. Delays continue to happen despite significant improvements in some wait time intervals over the past decade, including the time from when a cancer centre receives a patient referral to when the patient is seen in consultation. As well, certain population groups, such as First Nations, can face even longer delays while waiting for medical travel approvals from the federally administered Non-Insured Health Benefits. Cancer Care Ontario’s target wait time for this “referral to consult” interval is 2 weeks.

The percentage of patients seen for consultation within 2 weeks of referral has improved from approximately 40% in 2009/2010 to over 80% in 2017/2018.



WHAT WILL BE DONE

The wait time from diagnosis to start of radiation treatment includes a number of intervals associated with these dates:

  • date of diagnosis
  • date referral is received by the regional radiation medicine program
  • date of consult with a radiation oncologist
  • date of first treatment

The Radiation Treatment Program is developing a new wait time measurement to help analyze the delays patients experience from diagnosis to the start of their treatment. This measurement will focus on the time from when a referral reaches a regional radiation oncology program to the first day of treatment. This interval is called the radiation integrated wait time.

Radiation Integrated Wait Time Intervals

Radiation Integrated Wait Time Intervals diagram

The program will tackle this complex issue by disease site, and prioritize those cancers that receive radiation as primary treatment and are highly curable.

INITIATIVES

Our work in this area will be divided into 4 phases:

  • Analyze, understand and describe integrated wait times locally and provincially starting with 2 fast growing tumours (head and neck, and cervical cancers)
  • Explore how other jurisdictions have approached this issue to gain insights for developing clinically relevant, data-driven benchmark targets
  • Engage in multi-program and specialty collaboration (including diagnostic imaging services, laboratory services, systemic treatment and surgical oncology programs, and the Indigenous Cancer Care Unit), to identify possible areas for improvement
  • Support regional cancer centres in developing action plans to ensure patients receive treatment as soon as possible after diagnosis

Development of a New Funding Model

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Efficient

This focus area aligns with the following strategic objective of the “Efficient” goal in the Ontario Cancer Plan 2019 to 2023:

Increase value of services through funding models, evaluation, policy development and new models of care.

Develop and implement a new funding model that provides efficient care for all patients.

WHY THIS IS IMPORTANT

The existing radiation treatment funding model was implemented in the late 1990s. It was based on a one-time block funding approach. That means a cancer centre receives operating funds to run the radiation medicine program based on the number of new patient consultations done by radiation oncologists. This model does not consider:

  • whether a patient actually receives radiation treatment after consultation
  • the complexity of treatment delivered (i.e., advancements in treatment techniques and technologies)
  • the quality of the care received by patients
  • follow-up care (and re-treatment where appropriate)

WHAT WILL BE DONE

Funding for radiation treatment in Ontario is changing to a quality-based procedures model. This model ties funding to specific patient care activities to improve the use of resources in the province.

The development of the model supports the sharing of best practices between regional cancer centres, the identification of key quality metrics, and ultimately supports the adoption of a more standardized approach to care for patients.

This funding model aligns with the Ministry of Health’s Health System Funding Reform initiative, as well as existing funding models for systemic treatment and cancer surgery.

New Funding Model Development - Radiation Treatment Quality-Based Procedures

New Funding Model Development chart

INITIATIVES

Our work in this area will be divided into 2 phases:

  • Establish radiation treatment protocols and define quality metrics based on evidence-based best practices in the delivery of care for patients requiring radiation treatment
  • Implement and support the operations and ongoing maintenance of the new radiation treatment funding model, including monitoring how well radiation programs align with delivery of best practices

I was really impressed by how quickly things moved along with my radiation treatment: I waited less than a week to consult with the radiation oncologist, then the process started the week after that. The doctor and the radiation technician were very detailed in explaining what they were doing and why. That was so reassuring. Still, having radiation treatment is scary and overwhelming. There needs to be more focus on understanding the psychological and emotional impacts and helping patients find support. ”

Joanne M. has had breast cancer 3 times. She finished 7 weeks of radiation treatment in February 2019.

Promoting Equitable Access to Radiation Treatment

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Equitable

This focus area aligns with the following strategic objective of the “Equitable” goal in the Ontario Cancer Plan 2019 to 2023:

Develop health policy advice and implement strategies for supporting identified underserved and vulnerable populations

Achieve sustained improvement in access to radiation treatment across the province in all regions and in all patient sub-groups.

Radiation treatment utilization measures access to treatment by examining the proportion of newly diagnosed patients who receive radiation treatment within 1 year of diagnosis. Benchmark rates exist for all adult cancers and major cancer types (e.g., breast, lung, prostate and rectal) to determine and monitor appropriate access by Ontario health region.

WHY THIS IS IMPORTANT

Utilization rates in Ontario have increased since 2009, but still fall short of provincial benchmark targets, which are based on validated international standards. The most recent data, from 2016, shows that the rate of use of radiation treatment within 1 year of diagnosis for all adult cancer patients diagnosed in Ontario was 34.1%, lower than the provincial benchmark target of 35.5%. This means that approximately 1,000 Ontarians diagnosed with cancer that year who would have benefited from radiation therapy did not receive it.

The addition of new treatment machines and diffusion of treatment techniques (i.e., stereotactic for lung and brachytherapy for cervix and prostate) across provincial cancer centres has supported improved utilization rates and overall patient experience. This has considerably shortened the distance patients travel for all forms of treatment. Find more details on provincial capacity planning in the Radiation Treatment Capital Investment Strategy.

Undergoing radiation treatment was probably the best organized part of my cancer care journey. I had 25 concurrent radiation-chemotherapy treatments over 5 weeks, and the whole process went very well. All patients throughout this province should have access to the same excellent quality care that I received, but I know that’s not the case. Radiation treatment services are currently underused. Access to care must be improved through appropriate referrals, the expansion of current centres and better utilization of current capacity, including patients being given the option to travel to the best, most appropriate care.”

Derek Finnerty was treated for metastatic ampullary cancer in Mississauga in 2012.

WHAT WILL BE DONE

The program will improve equitable access to best practice radiation treatment over the next 4 years.

Our work in this area will be divided into 3 areas:

  • Sustain and improve radiation treatment utilization with the goal of achieving the benchmark targets across all regions and in all patient sub-groups
  • Understand and improve access to care among the Indigenous populations in Ontario, in collaboration with the Indigenous Cancer Care Unit
  • Explore the equity of patient access to new treatment approaches, such as curative stereotactic radiation treatment in various cancers

Safety and Quality – Peer Review

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Safe

This focus area aligns with the following strategic objective of the “Safe” goal in the Ontario Cancer Plan 2019 to 2023:

Develop and implement clinical standards and practices to improve treatment quality and safety

Improve the safety and quality of radiation treatment for Ontario patients.

Over the next 4 years we will work with Regional Cancer Centres to strengthen all aspects of the safe delivery of radiation treatment. We will focus on advancing safety through further development of the Peer Review Quality Assurance Program (introduced in 2013).

The World Health Organization defines quality assurance in radiation treatment as: …all procedures that ensure consistency of the medical prescription, and safe fulfillment of that prescription, as regards to the dose to the target volume, together with minimal dose to normal tissue, minimal exposure of personnel and adequate patient monitoring aimed at determining the end result of treatment.”

The Radiation Treatment Program endorses and supports the Canadian Partnership for Quality Radiotherapy Quality Assurance Guidelines for Canadian Radiation Treatment Programs. These guidelines recommend that a quality assurance program address all aspects of radiation treatment planning and delivery, including:

  • the organization of radiation treatment programs
  • the qualifications of the personnel involved in radiation treatment
  • the performance of the planning and treatment equipment
  • policies and procedures
  • monitoring and reporting of incidents

WHY THIS IS IMPORTANT

Radiation oncology peer review is a step in the patient treatment pathway that supports the delivery of high-quality and safe radiation therapy.

It involves having the radiation treatment patient plan reviewed by a second radiation oncologist or, ideally, by a multidisciplinary team (including radiation therapists and medical physicists). Peer reviewers suggest improvements to the plan, and the review process promotes learning within the profession. This quality assurance activity takes place after treatment planning but before treatment delivery.

Even with the implementation and full adoption of peer review in Ontario, literature supports that less than 5% of treatment plans will require substantial changes for established peer review programs.

WHAT WILL BE DONE

The Radiation Treatment Program will focus on 4 specific initiatives in peer review with an emphasis on advancing and sustaining this area of focus.

INITIATIVES

Our work in this area will be divided into 4 areas:

  1. Define and document elements for best practice peer review in the curative and palliative domains and develop a process to measure adherence to these recommendations
  2. Develop and implement novel peer review strategies in other aspects of radiation treatment (e.g., medical physics and radiation therapy plan checks)
  3. Investigate the possible role of artificial intelligence approaches in peer review.
  4. Establish and facilitate peer review between regional cancer centres to support reduced variation in radiation treatment delivery across the province and facilitate the delivery of advanced treatment approaches closer to home.

Supporting Innovative Treatment Approaches

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Effective

This focus area aligns with the following strategic objective of the “Effective” goal in the Ontario Cancer Plan 2019 to 2023:

Develop strategies to support evaluation and implementation of innovative technologies and interventions

Support dissemination of innovative treatment approaches, in a timely way, to Ontario patients.

The Radiation Treatment Program supports innovation through the assessment and implementation of new treatment technologies as high-quality treatment approaches become available. For example, the program rolled out Intensity Modulated Radiation Therapy across the province from 2008 to 2011 and evaluated the Cyberknife system in 2017.

WHY THIS IS IMPORTANT

Radiation treatment is rooted in technological innovation that has evolved over time and continues to advance at a fast pace. As new treatment technologies or approaches become best practice standard of care, the Radiation Treatment Program helps inform and educate healthcare providers across the province. This helps make sure that all patients who would benefit from new treatment approaches have access.

The program works with the cancer centres to create and implement cost-effective strategies, and efficient and effective models of care. In addition, the program works to increase and improve access for new treatment approaches in a time of cost-containment and rapid technology advancement. This work will support excellence in care to Ontario patients.

WHAT WILL BE DONE

The Radiation Treatment Program will work with healthcare experts to build evidence for new treatment approaches. This work will include cost effectiveness assessment and budget impact analyses to determine the appropriateness and feasibility of these new approaches. We also will work together to put a process in place to roll out new treatment approaches across the province when they are approved.

INITIATIVES

Our work in this area will be focused on the following areas:

  • Linacs with integrated MR Systems – These new treatment units combine a magnetic resonance imaging scanner and a linear accelerator, enabling more precise delivery of the treatment to the tumour, the ability to tailor the shape of X-ray beams in real time, and delivery of accurate radiation to both stable and moving tumours.
  • Adaptive radiotherapy strategies –The systematic monitoring of variations in target and neighbouring structures in the body to modify treatment plans as needed during radiation therapy, thereby reducing toxicity and improving local control.
  • Artificial Intelligence - The role of advanced information technology approaches, such as automation of treatment planning to improve both consistency and efficiency
  • Proton beam therapy –Uses protons instead of X-rays to radiate the tumour, providing better treatment control while reducing side effects by minimizing radiation of normal tissues (especially important for pediatric patients).

Radiation Treatment in Ontario

Current state

The Radiation Treatment Program works closely with the Surgical Oncology, Systemic Treatment, Psychosocial Oncology and Palliative Care Programs to provide an integrated cancer treatment approach for people with cancer in Ontario.

After a person is diagnosed with cancer, their treatment options are determined by the type and extent of the disease, and their individual needs and preferences. For many people with localized cancers that can be cured, radiation therapy is an essential element of their treatment plan. It also can lessen symptoms for many people with cancer that is locally advanced or has spread to other parts of the body.

In Ontario, radiation services are offered only in the 14 regional cancer centers and 3 satellite radiation treatment facilities. Since the patient management, radiotherapy treatments, and the capital infrastructure required to support a radiation medicine program are highly specialized, some degree of treatment centralization is required to ensure high quality of radiotherapy services.

In 2018, over 50,000 newly diagnosed patients were assessed for radiation treatment; over 42,000 of those patients received treatment (see figure). More than 25% of patients who had radiation treatment intended to cure their cancer also had chemotherapy at the same time to make the tumour more sensitive to the effects of radiation treatment.

Number of patient consults and treated cases

Total Radiation Treated Cases Chart

Looking to the future

Cancer is one of the leading causes of death worldwide, with an estimated 18.1 million cases and 9.6 million deaths in 2018. One in every 2 Ontarians is expected to be diagnosed with cancer during their lifetime. The number of new cancer cases diagnosed each year in Ontario continues to increase. Approximately 90,500 new cases of cancer were diagnosed in Ontario in 2018. That is about 571 cases of cancer for every 100,000 people (after adjusting for age).

NEW CANCER CASES ARE RISING


DEMAND FOR RADIATION TREATMENT IS GROWING

As the number of new cases of cancer and access (utilization rates) to treatment improves, the demand for radiation treatment continues to grow. The number of people treated with radiation has grown from 37,136 in 2012 to 42,060 in 2018, about 2% each year. As the population grows and ages, the number of newly diagnosed cancers is expected to rise by approximately 4% annually over the next 10 years.

This increased demand will place pressure on the system, including on radiation medicine programs across Ontario as the need for health human resources increases. In addition, with improved systemic treatments and technologies for cancer, many patients are living longer and receiving an increased number of palliative radiation therapy courses than in the past.

The Radiation Treatment Capital Investment Strategy 2018 identifies the need for an additional 26 treatment units by 2028 to assure appropriate access to care.

When I was diagnosed with breast cancer, I received my radiation treatments at The Ottawa Hospital, 20 minutes away from my home. But a friend of mine in North Bay who also had breast cancer had to travel to Sudbury for her radiation. That meant she had to stay in Sudbury, away from her husband and children, for a week at a time. Having cancer is the biggest stress in your life. You shouldn’t have to travel long distances or be away from your supports.”

Ann R. had 25 radiation treatments after a lumpectomy in 2012.

Evaluating our Progress

The Radiation Treatment Program Implementation Plan will be evaluated using the Realist Evaluation Framework (Pawson & Tilley, 1997). This framework accommodates changes and unknown variables that may develop during implementation. It provides a practice iterative and tailored approach to guide the evaluation of the plan.

The program will test the identified areas of focus over the next 4 years by evaluating the outcomes and adapting the initiatives as needed.

Realist Evaluation Framework

Realist Evaluation Framework Diagram

How this plan uses the framework

The implementation and evaluation of the initiatives will depend on the following questions:

  • What mechanisms will generate the desired outcomes?
  • What features of the context will affect if or how the mechanism operates?

 

The following table describes how the program will measure the successful implementation of the areas of focus and respective initiatives.

Outcome Measures, by Program Area of Focus
Program Area of Focus Outcome Measure Description
Radiation Integrated Wait Time Reduction in wait times from referral to radiation oncology to start of treatment Improve the patient’s wait time experience from referral to radiation oncology to the date of first treatment
New Funding Model Ongoing monitoring of quality metrics through regular reporting, surveys and chart audits Develop and implement a new funding model that provides best practice and equitable care for all patients
Access/Utilization Improved access to state of-the-art care for all Ontarians Achieve sustained improvement in access to radiation treatment for patients in all healthcare regions across the province
Peer Review Improved quality and safety of radiation treatment Provide safer and higher quality radiation treatment for patients and across cancer centres
Supporting Innovative Treatment Approaches Enable rapid clinical, operational and financial assessment of innovative techniques Support dissemination of innovative treatment approaches, where appropriate, in a timely way to Ontario patients

About This Plan

Methodology

The Radiation Treatment Program Implementation Plan was developed during 2018 and 2019. This iterative process included:

  • initial planning, data gathering and analysis in consultation with clinicians and administrators
  • review of related strategic plans on a regional, national and international level
  • ongoing consultation with stakeholders throughout the province as the plan was refined, including patient and family advisors, regional cancer centres and other CCO business areas
  • review of and reflection on the Radiation Treatment Program’s successes (and failures) over the past decade

The Radiation Treatment Program Implementation Plan aligns with the capital investment strategy, which supports:

  • maintenance and improvements in radiation therapy wait times
  • radiation therapy replacement grants
  • utilization rates
  • capacity planning

Partners

Thank you to the partners at the regional cancer centres for their invaluable support. Their commitment and support is critical to this program’s success in improving care for people with cancer in Ontario.

  • Regional radiation clinical leads
  • Professional advisory committees: radiation oncology, medical physics, radiation therapy
  • Community of practice members, working group leads, and leads

Acknowledgements

The following CCO staff, advisors and volunteers contributed to this plan.

EXECUTIVE SPONSORS

Garth Matheson, Vice-President, Planning and Regional Programs, and Analytics and Informatics

Robin McLeod, Vice-President, Clinical Programs and Quality Initiatives

CLINICAL PROGRAMS & QUALITY INITIATIVES

Padraig Warde, Provincial Head, Radiation Treatment Program

Elaine Meertens, Director, Diagnosis and Treatment Programs

Eric Gutierrez, Group Manager, Radiation Treatment Program

Farzana McCallum, Team Lead, Radiation Treatment Program

Carina Simniceanu, Senior Specialist, Radiation Treatment Program

Julie Himmelman, Senior Specialist, Radiation Treatment Program

RADIATION TREATMENT PROGRAM CLINICAL QUALITY LEADS

Michael Brundage, Radiation Oncologist

Margaret Hart, Radiation Therapist

Jean-Pierre Bissonnette, Medical Physicist

OTHER CONTRIBUTORS AND PARTNERS

Sophie Foxcroft, Systems and Infrastructure Planning

Jon Irish, Provincial Head of Surgical Oncology Program

Leta Forbes, Provincial Head of Systemic Therapy Program

Claire Holloway, Provincial Clinical Lead, Disease Pathway Management

Julian Debranowski, Program Head, Imaging

Alethea Kewayosh, Director, Indigenous Cancer Care Unit

Joanne MacPhail, Patient and Family Advisor

Derek Finnerty, Patient and Family Advisor

Ann Rawson, Patient and Family Advisor