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Northern Cancer Control Strategy Final Report

Northern Cancer Control Strategy


A Joint Initiative of the
British Columbia Cancer Agency
and Northern Health

Final Report
March 2005
Northern Cancer Control Strategy Final Report

Table of Contents
1. Executive Summary ........................................................................................................ 2
1.1. Approach to Planning ............................................................................................ 2
1.2. Data and Inventory Assessment ............................................................................ 2
1.3. Building a Northern Cancer Program --Recommendations................................... 5
1.4. Summary and Next Steps ...................................................................................... 8
2. The Northern Cancer Control Project ............................................................................. 9
2.1. Overview ............................................................................................................... 9
2.2. Project Participants and Roles ............................................................................... 9
2.3. Project Timelines................................................................................................. 10
3. Principles underlying cancer control in B.C. ................................................................ 11
3.1. The Organization of Cancer Control in B.C........................................................ 11
3.2. Delivering this Population Based Cancer Control Program ................................ 11
3.3. BCCA Strategic Plan 2004-2010......................................................................... 11
4. The Findings…Health and Cancer in the North ........................................................... 12
4.1. The Data .............................................................................................................. 12
4.2. Prevention and Promotion Findings .................................................................... 19
4.3. Screening Findings .............................................................................................. 21
4.4. Detection, Treatment, and Care Findings ............................................................ 24
5. Analysis & Recommendations for Enhanced Cancer Control in the North.................. 31
5.1. Decision Criteria.................................................................................................. 31
5.2. Develop a Northern Cancer Program .................................................................. 31
5.3. Prevention, Promotion and Screening Priorities.................................................. 32
5.4. Detection and Diagnosis Priorities ...................................................................... 33
5.5. Treatment and Care Priorities.............................................................................. 33
5.6. Additional Considerations and Enablers of the Strategy ..................................... 36
6. Appendices.................................................................................................................... 39
6.1. Data...................................................................................................................... 39
6.2. Prevention and Promotion ................................................................................... 53
6.3. Screening ............................................................................................................. 55
6.4. Detection, Treatment and Care ............................................................................ 56
6.5. Implementing the Priorities ................................................................................. 63

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Northern Cancer Control Strategy Final Report

1. EXECUTIVE SUMMARY
1.1. Approach to Planning
The Northern Cancer Strategy Project is a joint initiative between the British
Columbia Cancer Agency (BCCA) and Northern Health (NH). The mandate is to
create a plan to address the cancer control needs of Northerners into the
foreseeable future in a way that responds to the epidemiology of cancer in the North
and the demographic and service delivery challenges that are unique to Northern
BC.
The mandate of the Project is to plan for a continuum of cancer related services
from Prevention and Health Promotion, to Screening, Detection, Treatment,
Rehabilitation, and Research. A framework is used to match the issues surfaced in
the Preliminary Findings Document with priorities for action around three main
categories of outcome:
Incidence of cancer,
Survival from cancer, and
Quality of life and Access to services for Northerners.
The information and ideas contained in this report rely primarily on the knowledge
and experience of Northern physicians, nurses, pharmacists and program staff from
the Northeast, Northern Interior and Northwest Health Service Delivery Areas
(HSDA’s) and the clinical leaders and medical specialists from the BC Cancer
Agency. Through the invitation of the Northern Medical Advisory Committee, 15
medical staff members from communities across the North contributed to the
identification of weaknesses in current services and offered many ideas for
improvements. Similarly, nurses, pharmacists, palliative care workers, diagnostic
technologists and public health professionals contributed their knowledge of
limitations in current clinic activities and prevention programs, including access and
communication issues as identified by patients. Together, they made many
suggestions to strengthen and better link cancer services. Northern Health’s recent
public consultation process also contributed perspectives from many communities
that more needs to be done to prevent illness and foster better health as well as to
improve access to services. Representatives from the Canadian Cancer Society
contributed insights into areas where patients and the public had voiced a desire for
improved services. Through contributions of staff of the BC Cancer Agency, all of
this information was considered within the context of a province wide program of
cancer control.
The primary focus of this strategy is to improve outcomes. Actions and projects
proposed will be monitored and measured to ensure the changes are improving
cancer control in the North.

1.2. Data and Inventory Assessment


Northern Health covers the northern two-thirds of the Province of British Columbia.
The Northern population has significantly poorer health than other regions of BC.
Over 300,000 people live within NH boundaries (7% of the population of BC), and
this is expected to increase to 348,000 by 2010.
The unique geography and demographics of the North create challenges (and
opportunities) for every aspect of planning for cancer-related services.

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The key characteristics of the Region include:


A small widely dispersed population with a higher proportion of young
people than the provincial average;
An expectation for rapid growth in the number of seniors;
An increase in the number of new cancer cases reported annually from
1000 in 2005 to 1400 in 2015;
A high level of behavioral risk for cancer including high smoking rates, high
levels of alcohol consumption and high rates of obesity; and
The highest proportion of Aboriginal people in BC with numerous levels of
organization and differing models of health service provision. Data
suggests that the participation in mammography and cervical cancer
screening programs is less among aboriginal people and that smoking rates
are higher still than in the surrounding population.
The inventory of current services and programs shows that Northern Health
provides a number of cancer control activities across the continuum of care in each
of the three HSDA’s. Some of these programs are delivered in partnerships with
other agencies such as the Canadian Cancer Society or are funded by the BC
Cancer Agency. For example, under the heading of Prevention and Promotion,
Northern Health runs or supports a number of programs such as Hepatitis B
Immunization, Viral Hepatitis C Clinic, Tobacco Control Program, Canadian Cancer
Society Prevention Strategy, Sun Safety, Environmental Health, Nutrition Programs,
Sexually Transmitted Disease Clinics, and the Primary Health Care Initiative.

Currently, the BC Cancer Agency partners with NH to provide cancer services in


communities across the region, including:

A Community Cancer Centre in Prince George providing a range of


systemic therapy for cancer patients;
Five Community Cancer Services located in Fort St. John, Dawson Creek,
Smithers, Terrace and Prince Rupert -- each has oncology-certified nurses
providing service to cancer patients such as chemotherapy administration,
navigation (two sites), education and support; and
Traveling consultation services by Agency oncologists.
BCCA works with NH to deliver the screening mammography program and the
cervical screening program. Screening for colorectal and prostate cancer through
primary care physicians is available; however no formal population-based programs
exist.
Northern Health citizens have access to clinical laboratory services and a variety of
diagnostic imaging modalities including x-ray, CT, MRI, and Nuclear Medicine
scans.
General and sub-specialty surgery is offered in many Northern communities. A
general surgeon from Prince George is an executive member of the BCCA Surgical
Oncology Network.
BCCA provides training to several Northern family practitioners in oncology. These
practitioners are linked through the Family Practice Oncology Network and are
trained to assess and support chemotherapy patients.
Supportive services are offered but there is no formal program to serve cancer
patients, resources are limited and not all communities can provide support across

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Northern Cancer Control Strategy Final Report

the continuum of care e.g. psychosocial support, nutrition counseling for cancer
patients etc. Palliative and hospice care is offered across NH but it is fragmented.
The use of telehealth for cancer control is also limited in NH.
Some of the issues that have emerged from the data and inventory review include:
Significantly higher Standardized Mortality ratios for all cancers combined
and specifically Lung Cancer.
Poorer 5 year survival rates for breast, prostate, colorectal, and lung cancer
as compared to residents of other Health Authorities in B.C.
Surgical and chemotherapy treatment services and a range of prevention
and screening services have been developed over time in the North, but
are not well linked to ensure the best coordination of service to the
client/patient or to ensure optimal results.
While systemic therapy (chemotherapy) is offered in a number of
communities, resources are limited, demand is increasing and no
supporting structure exists to assist the communities with implementing
quality improvements or guidelines, or provide relief nurse staffing and
training, etc.
Diagnostic testing is offered across the three HSDA’s, however consistent
organization is limited and quality assurance occurs outside of an overall
regional Health Authority framework. Reference group clinicians identified a
need to establish clear clinical guidelines and decrease the time required of
patients for investigation in circumstances where multiple studies were
required to reach a diagnosis.
More family practitioners in oncology are needed to improve patient access
to care within the Northeast, Northern Interior and Northwest Health Service
Delivery Areas.
Patients referred for radiation therapy must travel outside of the region to
BC Cancer Agency sites or Alberta, which presents social and financial
challenges.
Variability exists across the 3 HSDA’s in the use of radiation therapy for
both the initial treatment of cancer and palliative treatment for late stage
cancer. Overall, Northerners have similar rates of curative treatment to
other British Columbians, but rates of radiotherapy for palliative treatment
are lower for Northerners than for residents of the southern mainland.
Supportive care and palliative care services tend to be fragmented and
differ by community.
Some important unanswered questions remain relating to gaps in the data:
What specific cancer services are being provided in Alberta to people in the
Northeast… Do Northerners present with more advanced cancer than their
provincial counterparts?

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1.3. Building a Northern Cancer Program --


Recommendations
1.3.1. Develop a Regional Cancer Program for NH
The North is the only region of BC without a Regional Cancer Program. The issues
clearly demonstrate the need for leadership and ongoing monitoring; therefore it is
recommended that Northern Health and the BCCA jointly establish a Regional
Cancer Program. Program leadership will respond to patient service issues and
assist with the coordination of services, programs, standards and guidelines across
the North.
In developing a strong Northern Cancer Program, a key challenge will be to find the
best balance between making services more accessible to Northerners in their
communities, while also recognizing that treatment success for patients who need
specialized services such as cancer surgery, chemotherapy and radiotherapy
generally improves with the volume of care provided in any one sub specialty.
The following diagram outlines the mandate of the proposed Northern Cancer
Program as well as the current services and short term priorities for implementation
across the continuum of cancer control. The strategies are listed on the following
pages and discussed in greater detail in section 5. High level action plans for the
priorities are located in Section 6.5 of the Appendices.
The green boxes represent initiatives that NH would lead; initiatives in yellow boxes
would be lead by BCCA, while those in pink boxes would be joint initiatives of NH
and BCCA.

Program Leadership, Outcomes Measurement, and Quality Improvement

Prevention Screening Detection Treatment Supportive Palliative &


Continuum of & & Care & End of Life
Cancer Control Promotion Diagnosis Rehab Care

Hepatitis B & C Breast Lab Surgical Oncology: FPON


Palliative &
Urology, General
Heart Health Cervical Diagnostic Nutrition Hospice
Imaging services
Current Northern Tobacco Control Colorectal* Radiation Therapy: Pharmacy
available in
Service & Programs Pathology Must be referred to
STD Prostate* Home Care all HSDA’s
other Centres
Environmental Health Women's Rehab
Health Systemic Therapy:
Chronic Disease Mgmt. Psychosocial
Program Available in all
Primary Health Care HSDA’s in several
Initiative communities

Retrospective Enhanced Palliative


Tobacco
Staging Study Consultation Care
Control

Chemo Review
Short Term Priorities Women’s Health Program
Telehealth
Research & Best
Practices to Improve Navigation, Primary Care/Diagnostic Coordination and Transportation
NH Health Status

Surgical
Oncology

*Not currently available as ‘organized’ screening programs in BC.

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1.3.2. Short Term Priorities


Prevention, Promotion and Screening
The data demonstrated the need to support programs that would reduce the
incidence of cancer. The three priorities are:
Develop a Comprehensive Tobacco Control Strategy.
Support the Women’s Health Program to increase cancer screening rates.
Investigate known programs and best practices that reduce the incidence of
cancers amenable to preventive action.
Detection and Diagnosis
Complete a Retrospective Staging Study to better understand where
resources and effort should be focused to improve survival.
Link diagnostic testing processes with primary care practitioners to develop
a coordinated system from first encounter to screening, detection, treatment
and follow up. This priority will see the establishment of clear clinical
guidelines and will decrease the time required of patients for investigation in
circumstances where multiple studies are required.
Treatment and Care
Develop travel assistance strategies to reduce the burden of travel for
cancer patients.
Ensure that surgeons in the North have access to timely outcomes
information and an opportunity to participate in a surgical oncology best
practices program.
Increase capacity in systemic/chemotherapy services in the immediate
future. An external assessment will be completed to provide guidance with
respect to clinic services and the integration of these services into a region
wide program.
The burden of travel for care planning, treatment and follow-up is very
significant for patients requiring treatments such as radiotherapy. In
addition to improvements in transportation, the following short term actions
will reduce the very significant burden of travel for patients:
o Enhance navigation services across NH to support patients in the
planning and organization of their treatment to minimize travel
requirements.
o Increase the accessibility of consultation for specialist care through
the application of telehealth.
Explore how consultative services to Northern family practitioners from
BCCA tumor site specific specialists in radiation, medical, and surgical
oncology could be enhanced.
Develop and implement a comprehensive Palliative Care Program that has
linkages with Home Care, Hospice Services and the BCCA Palliative Care
Network.

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1.3.3. Additional Considerations and Enablers


Research and Education
Work in this area will be ongoing and will be an essential enabler of the Northern
Cancer Program by improving recruitment and retention as well as through
evidenced based improvements to care. The BCCA is engaged in all aspects of
research at the provincial, national and international levels. Northern Health has an
opportunity to build relationships with BCCA, UNBC, UBC and the Northern Medical
Program to work collaboratively to expand research and teaching in the area of
cancer control.
Information Technology
Having the appropriate technical infrastructure will enable the Northern Cancer
Program to improve patient care as well as monitor and share clinical information.
There are several initiatives underway that will be essential enablers of the
priorities. For example:
The Clinical Information System (CIS) will interface with PHSA-BCCA,
Cancer Information System (CAIS).
Telehealth is well established in the North and opportunities exist to link
through PHSA for the provision of diagnostic reports and interpretations.
The Physician Connectivity Project will connect all doctors across the
North.
The BC Bycast Diagnostic Imaging Network will allow for effective, fast and
efficient access to electronic diagnostic images to and from PHSA, other
Health Authorities, and Northern Health.
The Private Network Gateway (PNG) initiative will provide a fully integrated
and secure network for Health Authorities to access electronic clinical data.
Linkages with Yukon and Alberta
Areas with rural and remote populations often share similar characteristics in that
they have low population density, greater unemployment, income inequality and a
higher proportion of Aboriginal persons. It will be important for the leadership of the
Program to engage jurisdictions with similar populations such as the Yukon to
determine areas for collaboration and shared learning.
It will also be important to develop ties with the Alberta Cancer Board to explore
border issues around referral patterns.

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1.4. Summary and Next Steps


Northerners clearly face a burden of access to cancer care. The agreed upon
treatment and care priorities reflect a short term approach to reducing this burden
by reviewing the systems, processes and supportive programs for cancer patients.
Many of the quality of life and access issues reflect a real service problem
associated with sub optimal patient education, communications, and coordination of
appointments, travel planning and navigation. These issues, in addition to a
significant number of anecdotal problems around specialist services, require
interventions and improvements that ensure care planning, treatment and follow up
activities are done efficiently for patients and their care providers. This will require
reducing the uncertainty, unnecessary delays and travel hardships for patients and
families. NH and BCCA are committed to working together to improve the cancer
services and programs for Northerners.
The short term priorities for the Northern Cancer Program are designed to allow
work to begin immediately to improve outcomes with respect to the incidence of
cancer, survival, as well as access and quality of life. They will also build the
essential foundation required to enable further development of cancer care in the
North, including some additional elements of surgical, medical and radiation
oncology services. As these short term priorities are accomplished, Northern
Health and the BC Cancer Agency will seek out service models that can improve
access to care in smaller centers without compromising service reliability and
patient outcomes.
The process for developing a Northern Cancer Program will be an ongoing and
iterative one that will require strong, effective partnerships of medical staff and
program leaders between NH and BCCA. It also needs to be an inclusive process
involving internal and external stakeholders in the planning and implementation of
the strategic priorities. It will necessitate fresh looks at existing data and
information and the development of new data to answer emerging questions. Next
steps include:
Due diligence/project planning and budgeting for each of the short term
priorities;
Quarterly meetings between BCCA and NH, to monitor progress and
continue planning for the longer term initiatives; and
Yearly planning sessions with broad stakeholder input to review progress
on the plans, determine outcome improvements, data requirements and
begin detailed planning on next priorities.

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2. THE NORTHERN CANCER CONTROL PROJECT


2.1. Overview
The British Columbia Cancer Agency, an agency of the Provincial Health Services
Authority (PHSA), and Northern Health are partnering to produce a joint cancer
control strategy for Northern patients.

Project Vision: To strengthen the capacity to prevent, detect, and treat cancer and
support patients in the North.
Project Goal: Develop a shared vision of short and long-term priorities for cancer
control in the North that are patient focused, evidence and data driven.
This phase of the strategy is focused on opportunity definition. The team
investigated existing programs and services, analyzed data and made
recommendations for change. Subsequent initiatives will focus on detailed
implementation planning for needed changes.

2.2. Project Participants and Roles


The Executive Sponsors are Simon Sutcliffe, President of BCCA and Malcolm
Maxwell, CEO of Northern Health.
The Steering Committee consisted of Cathy Ulrich, VP Clinical Services/CNO,
Northern Health; David Butcher, VP Medicine, Northern Health; Barry Sheehan,
Radiation Oncologist, Vancouver Centre, BCCA; and Sandra Broughton, Regional
Administrator, Southern Interior, BCCA.
A Reference Group, based on the current Regional Cancer Committee, with
additional stakeholders included:
NHA: Dr. Winston Bishop (Internist), Dr. Phil Staniland (Physician, Palliative
Care), Dr. Gilbert Wankling (surgeon, NI), Dr. Zhou (Pathologist, NI), Judy
Firth (Palliative Care, Community Services, PG), Gayle Magrath (RN,
Cancer Care Unit, PGRH), Ladonna Fehr (RN, Cancer Care Unit, PGRH),
Cindy Mueller (RN, Cancer Care Unit, PGRH), Corinna Werbecky (RN,
Cancer Care Unit, PGRH), Dr. Dana Cole (Pharmacist, PGRH), Andrea
Lindsay (Director, Acute and Community Services, Quesnel), Elizabeth
Zook (Pastoral Care, PGRH), Kerri McCaig (Tobacco Reduction
Coordinator), Lynda Anderson (Public Health Nurse, Northern Interior
Health Unit), Edna McLellan (Public Health Nurse Northwest), Kathy
MacDonald, Regional Director, Preventive Public Health, Lucy Beck,
Regional Director, Public Health Protection, Dr. David Bowering (Chief
Medical Health Officer), Heather Tant (Dietitian), Val Stewart (Patient Care
Manager Pediatrics, PGRH), Mark Coulter (Regional Director, Diagnostic
Services), Marshal Moleschi (Health Services Administrator), Judy Rea
(RN, Prince Rupert Regional Hospital, Prince Rupert), Lynn Shervill (RN,
Bulkley Valley District Hospital, Smithers), Jennifer Kennedy, (Manager,
Special Projects, H&CC – Palliative Care), Joanne Cozac, (Patient Care
Manager, PGRH – Chair of Cancer Strategy Reference Group), Michael
McMillan (COO-NI), Dr. Dan Horvat, (Medical Director, NI), Dr. John Mah
(NI), Dr. Meredith Hunter (NI), Dr. Shannon Douglas (NI), Dr. Biz Bastian
(NW), Dr. Warwick Evans (NW), Dr. Lorna Sandler (NE), Natalie Manhard
(NE), Lynn Smiley (NE), Dr. Becky Temple (NE), Dr. Robert Newman (NE),

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Northern Cancer Control Strategy Final Report

Dr. Steven Ashwell (NE).BCCA: Marilyn Porter: Regional Systemic Therapy


Leader, Dr. Joanne Stephen: Research Consultant for Cancer Rehab,
Richard Doll: BC Cancer Agency, Jaya Venkatesh (Administrator of the
Provincial Systemic Therapy Program) who will forward to Dr Susan
O’Reilly (Professor and Head of Medical Oncology and leader for the
Vancouver Region (BCCA), Dr. Tom Keane, Provincial RT Program Leader
(BCCA).
Other Agencies: Donalda Carson (Prince George Hospice Society, PG),
Steve Horton (Cancer Society), Joanne Snetsinger (Cancer Society),
Stephanie Powell (Cancer Society), Judith Quinlan (Alliance for Breast
Cancer Information and Support), Joanne Fairlie, (Assist. Deputy Minister,
Yukon Health & Social Services).
The establishment of a Reference Group enabled the sharing and vetting of
ongoing learning and findings with a wide range of stakeholders.
The Project Manager was Maureen Knox, an independent health care consultant
with a background in cancer treatment.

2.3. Project Timelines


The project began in mid-October of 2004. A project charter was developed in early
November and data gathering and inventory collection was completed in late
December. The issues were analyzed and priorities determined by the Sponsors
and Steering Committee in January. The findings and priorities were validated with
the Reference Group in January and the final report will be submitted to Malcolm
Maxwell and Simon Sutcliffe in March of 2005.

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3. PRINCIPLES UNDERLYING CANCER CONTROL IN


B.C.
3.1. The Organization of Cancer Control in B.C.
The BC Cancer Agency is responsible for delivering a program of cancer control to
the population of British Columbia. The vision of the BCCA is a cancer free society,
which is reflected in the mission – to reduce the incidence of cancer, to reduce the
mortality from cancer and to improve the quality of life of those living with cancer.
The BC Cancer Agency is a population-based cancer control organization with a
well developed, stable platform for its service, education and research mandate.
This population based program is used to deliver cancer control. The population of
BC is those who are healthy, healthy at higher risk population, asymptomatic with
cancer, acutely ill with cancer, chronically ill with cancer, cured and dying of cancer.

3.2. Delivering this Population Based Cancer Control


Program
Sites, programs, networks and services are the components required to delivering
this population based program. There are four regional centres in Vancouver,
Victoria, Surrey, Kelowna and one planned centre in Abbotsford (2008) that provide
assessment, treatment, supportive care, pain and symptom management and
palliative care services. Chemotherapy and supportive care is provided through 26
community cancer centres/clinics and chemotherapy by community cancer centre
nurse in another six communities. Provincial programs include, prevention, early
detection (Screening Mammography Program of BC (SMPBC) and Cervical
Screening Program), diagnostics (imaging, pathology and laboratory), treatment
(surgical, radiation therapy and systemic therapy), supportive, rehabilitation and
palliation, and end of life care. These programs include interventional services,
research, education, information, communication and linkages. The goal of the
Provincial Networks is to assist the BC Cancer Agency (BCCA) in its mandate to
improve cancer control in the province by providing support and connections in the
community. The Network includes Tumour Groups, SMPBC, Hereditary Cancer,
Surgical Oncology Council/Network, Paediatric Oncology Council/Network, Family
Practice Oncology Network, Palliative Care, Consultative Clinics and Psychosocial.
Common services provide support across the sites, programs and networks and
they include the website (www.bccancer.bc.ca), Clinical Practice Guidelines,
Priorities and Evaluation Committee, Professional Practice Standards, Registry,
Surveillance and Outcomes and Professional Education.

3.3. BCCA Strategic Plan 2004-2010


Despite two decades of continuing improvement in age-standardized mortality rates
(ASMR), the impact of interventions on death from cancer – the population burden
of cancer continues to rise as a result of aging of a growing population. The BCCA
Strategic Plan will sustain the provincial cancer control platform whilst transforming
the Agency into a "transactional research organization" directed to enhancing
cancer control outcomes. In partnerships with the Health Authority in each region,
BCCA works within the longer term framework set out in this document. The plan is
available on the website noted above.

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4. THE FINDINGS…HEALTH AND CANCER IN THE


NORTH
A process was undertaken in November and December of 2004 to collect relevant
data and inventory programs and services in order to provide an overview of cancer
control in the North. The collection was completed using a framework that looks at
the continuum of cancer as described by the Canadian Cancer Control Strategy
framework:
Prevention and Promotion
Screening
Detection, Treatment and Care (includes palliative care)
Data were collected from various sources including NH, BCCA, and the Ministry of
Health etc. The inventory was developed from information submitted by program
personnel.
(Additional data can be found in Section 6.1 of the Appendices.)

4.1. The Data


4.1.1. The Population of the North
The vast area served by Northern Health covers approximately 588,000 square
kilometers or two-thirds of BC and, with a population of approximately 299,446
(2005) persons, it has the lowest population density per square kilometer of any BC
Health Area.
Administratively, Northern Health is divided into three Health Service Delivery
Areas: Northwest, Northern Interior and the Northeast. The vast geography, the
small widely distributed population and the differing needs of each community
present enormous challenges when it comes to promoting good health, preventing
disease and providing sustainable and integrated health services.
On average the population in the North is considerably younger than the rest of BC
although, like the rest of BC, the northern population is growing older.
The average age of people in the North is 34 years of age whereas the average age
of the BC population is 38 years. The following chart demonstrates that the
population is aging and the percentage of those over 65 is expected to increase
significantly over the next 10 years.

Total
HA Name Year Gender 0 -19 20-54 55+ 65+ 75+ Pop-
ulation
Northern 2005 All 86631 156660 56155 25957 10092 299446
% 28.9 52.3 18.8 8.7 3.4 100.0
Northern 2015 All 77203 163582 82856 40331 14345 323641
% 23.9 50.5 25.6 12.5 4.4 100.

Source: BC Stats, Population Projections, PEOPLE 29, acquired through the Health Data Warehouse-
Dec 22, 2004.

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Aboriginal, First Nations and Métis peoples comprise a very significant and
important part of the Northern population. According to the most recent Census,
there are between 35,000 and 45,000 Aboriginal First Nations and Métis persons
residing in the area served by Northern Health.

4.1.2. The Burden of Cancer in the North


At present it is estimated that there are about 1000 new cancer diagnoses in
Northerners each year and it is estimated that about 8,000 Northerners are living
with some form of cancer. By the year 2015, we can expect the number of new
cancers to climb to approximately 1400 per year and there will be about 11,000
persons living with a diagnosis of cancer in Northern BC.
The impact will be significant on all care providers including physicians, nurses,
palliative care resources etc. It will be important to develop services such as the
Family Practice Oncology Network to ensure consistent follow up services.

12000

10000
People Living with Cancer

8000

6000

4000

2000

0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Custom Data Analysis provided to NH by BCCA November 2004.

4.1.3. Morbidity and Mortality


Life expectancies for Northerners are from three to four years shorter than those for
BC residents overall.
Cancers are a significant cause of death amongst Northerners second only to
deaths from Circulatory and Heart Disease. Between 1991 and 2001, cancer
accounted for 3977 deaths in the North.
The Standardized Mortality Ratio (SMR) is an internationally recognized Health
Status indicator. The SMR is a good measure for comparing mortality data that are
based on a small number of cases or for comparing mortality data by geographical
area. The SMR is the ratio of the actual number of deaths to the expected number
of deaths. The area served by Northern Health is distinguished by having the
highest SMR’s in British Columbia for many causes of death including all Cancers
and Lung Cancer. If these ratios are adjusted for age and population structure (Age
Standardized Mortality Ratios demonstrated on the following graph) the North still
has a death rate for cancer that is above the BC average.

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The graph below shows that the age standardized rate of death for all cancers
combined in Northern Health is 18.11 per 10,000 vs. the provincial rate of 16.05
BC

Northern

Van. Island

Van.Coastal

Fraser

Interior

10 12 14 16 18 20
Age Standardized Mortality Rate per 10,000

Source: Data to support graphic obtained from BC Vital Stats, acquired through the Health
Data Warehouse.

The data that describes the Incidence of cancer in the North appears to show a
great deal of variability between the 3 HSDA’s for example, an age standardized
rate of 58/100,000 in the Northwest for colorectal cancer compared to rates of
44/100,000 in the Northern Interior and a BC rate of 46.6/100,000. (See the
following 3 tables)

Age Standardized Female Cancer


Incidence Rates per 100,000 by
Selected Cancer Types 1999-2003

400
350
300 Breast
250 Colorectal
200
150 Lung
100 Other
50 Prostate
0
All Cancers
Northwest Northern Northeast BC Total
Interior

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Northern Cancer Control Strategy Final Report

Females Breast Colorectal Lung Other Prostate All Cancers


Northwest 121.3 57.7 49.4 133.6 0 362.1
Northern Interior 97.9 42.2 56 157.3 0 353.4
Northeast 86.8 47.1 43.6 115.4 0 292.9
BC Total 105.1 44.4 46.9 153.2 0 349.6

p value vs. rest of BC


Northwest 0.015 0.02 0.52 0.11 0 0.16
Northern Interior 0.1 0.51 0.035 0.6 0 0.98
Northeast 0.055 0.48 0.83 0.00044 0 0.0013

Age Standardized Male Cancer


Incidence Rates per 100,000 by
Selected Cancer Types 1999-2003

400
350
300 Breast
250 Colorectal
200
150 Lung
100 Other
50 Prostate
0
All Cancers
Northwest Northern Northeast BC Total
Interior

All
Males Breast Colorectal Lung Other Prostate Cancers
Northwest 0 58.3 48.6 167.5 105.2 379.5
Northern Interior 0 46 60.9 146.2 120.2 373.4
Northeast 0 52.6 64.1 132.8 121 370.5
BC Total 0 48.8 52.5 154.5 115 370.8

p value vs. rest of BC


Northwest 0 0.1 0.49 0.12 0.089 0.64
Northern Interior 0 0.23 0.067 0.28 0.79 0.78
Northeast 0 0.59 0.11 0.016 0.77 0.55

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Northern Cancer Control Strategy Final Report

Age Standardized All Cancer Incidence


Rates per 100,000 by Selected Cancer
Types 1999-1003

400
350
300 Breast
250 Colorectal
200
Lung
150
100 Other
50 Prostate
0
All Cancers
Northwest Northern Northeast BC Total
Interior

All
All Breast Colorectal Lung Other Prostate Cancers
Northwest 0 58 49 150.4 0 370.7
Northern Interior 0 44.1 58.4 151.8 0 363.3
Northeast 0 49.8 53.7 124 0 331.4
BC Total 0 46.6 49.7 153.9 0 360.1

p value vs. rest of BC


Northwest 0 0.0056 0.88 0.9 0 0.21
Northern Interior 0 0.18 0.006 0.7 0 0.89
Northeast 0 0.38 0.28 3.50E-05 0 0.0092

Source: BCCA February 2005

While the statistical tests do not generally indicate that the variability between the
3HSDA’s and the BC incidence rates are statistically significant, the incidence data
should be interpreted with caution given that the numbers of cases in the North are
relatively small. The rates are highly dependent on the population denominators
that are used, which are based on projections from Census counts which may be
higher than the “truth” due to the slowing of the economy in most of the North.

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Northern Cancer Control Strategy Final Report

The data that describes the 5-year survival rates also show a great deal of
variability between HSDA’s in the North. For example, the 5 year survival for lung
cancer ranges from 16.4% in the Northwest to 11.7% in the Northern Interior to
8.3% in the Northeast.

5-Year Survival Rates per 1,000 Incident


Cases for Selected Cancer Types 1999-
2003

1
0.9
0.8 Breast
0.7 Colorectal
0.6
0.5 Lung
0.4 Other
0.3
0.2 Prostate
0.1 All Cancers
0
Northwest Northern Northeast BC Total Weighted
Interior

All
Breast Colorectal Lung Other Prostate Cancers Weighted
Northwest 0.841 0.537 0.164 0.561 0.929 0.608 0.603
Northern Interior 0.794 0.592 0.117 0.493 0.803 0.543 0.548
Northeast 0.811 0.604 0.083 0.527 0.875 0.58 0.573
BC Total 0.846 0.569 0.148 0.497 0.871 0.574 0.569

p values vs. rest of BC


Northwest 0.21 0.12 0.9 0.041 0.13 0.19
Northern Interior 0.098 0.86 0.023 0.87 0.0062 0.0065
Northeast 0.28 0.98 0.33 0.77 0.78 0.71

Source: BCCA Feb. 2005.

We can be confident in the “tombstone” data that indicate that the mortality rates of
lung cancers and all cancers combined are significantly elevated in Northern
Health. More work will need to be done to ensure the reliability of our cancer
incidence rates.
While 5-year survival rates are slightly lower than the BC rate when considered
across all of Northern Health, there is a great deal of apparent variability between
HSDA’s. Defining how cancer incidence and survival interact to produce the
observed mortality rates will be an important task for ongoing consideration as the
proposed cancer strategy goes forward.

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Northern Cancer Control Strategy Final Report

Data Themes
• The unique geography and demographics create challenges (and opportunities).
The key challenges include:
• Small widely dispersed population with a higher proportion of young people.
• Rapid growth in the number of seniors predicted.
• The highest proportion of Aboriginal people of any BC Health Authority.
• High Standardized Mortality Ratios for All Cancers and Lung Cancer.
• Variable and somewhat poorer overall 5 year survival rates for breast, prostate,
colorectal, and lung cancer.
• Gaps still exist in the data
• What type of cancer service does the Alberta Cancer Board provide to the
residents of the Northeast?
• Do Northerners present with more advanced cancer than their provincial
counterparts, and if they do, what factors contribute to this?

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Northern Cancer Control Strategy Final Report

4.2. Prevention and Promotion Findings


Cancer prevention and healthy lifestyle promotion should be a key element in all
cancer control strategies. Key elements of any cancer control plan generally include
programs that focus on tobacco reduction, nutrition, sun safety, environmental, and
healthy lifestyles.
The North has many characteristics that require coordinated, comprehensive
approaches to reduce the incidence of cancers:
Nearly 32 % of all Northerners are current smokers.
37% of Northerners permit smoking inside their homes.
In 2005, NH can expect 136 new lung cancers. By 2015, this number will
have climbed to 164 new cases per year.
Northerners have an average BMI that is higher than the average for the
rest of BC.
The rates of alcohol consumption are higher in the North.
The rates of STD’s are higher in the North.
Northern residents are exposed to a number of environmental risk factors
including:
o Radon gas has been identified particularly in the Northern Interior;
o Arsenic levels in some water sources exceeds incoming national
guidelines; and
o Sun exposure.
Efforts to reduce lifestyle related cancers require a comprehensive approach.
Northern Health runs or supports a number of Programs such as Hepatitis B
Immunization, Viral Hepatitis C Clinic, Heart Health, Tobacco Control Programs,
Canadian Cancer Society Prevention Strategy, Sun Safety, Environmental Health
Programs, Nutrition Programs, Sexually Transmitted Disease Clinics, Chronic
Disease Management Programs and the Primary Health Care Initiative.
While many programs and services are offered across the North, they are
fragmented and rely on Public Health to partner with numerous other organizations
to assist with funding, initiation and implementation.
(See Section 6.2 in the Appendices for further program information by HSDA.)

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Northern Cancer Control Strategy Final Report

Prevention and Promotions Themes


• NH has a population with a high level of behavioural risk.
• Programs are offered across Northern Health, however given the importance of
the modifiable risk factors in reducing cancer incidence, opportunities exist to
enhance or expand services.
• Public Health program resources and funding are limited.
• Programs are often fragmented and differ by community or HSDA.
• Prevention and Promotion programs and services are often the result of NH
partnering with other agencies and or responding to regulations, standards and
guidelines e.g. BCCDC, School Districts, Ministry of Health Services, Healthy
Heart Society, Canadian Cancer Society, and Health Canada etc.

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Northern Cancer Control Strategy Final Report

4.3. Screening Findings


The purpose of screening is to detect cancer at an early stage of development; prior
to the development of symptoms. Screening can also identify precursors of cancer,
the treatment for which can reduce the risk of cancer developing.
Although a number of cancer screening tests have been developed, only a few
have been proven effective and therefore recommended for defined populations.
BCCA operates two screening programs:
1. Screening Mammography Program of BC
2. Cervical Cancer Screening Program

Screening Mammography Participation Rates 2001-2002

BC
Northeast Screening mammography is an
Northern Interior important strategy for the early
Northwest detection of breast cancer.
N. Vancouver Is.
Central Vancouver Is. Provincially, the screening program
S. Vancouver Is. participation rate is 47.15 %.
North Shore/Cst Garibaldi Participation rates in the North are
Vancouver as follows. Northwest 33.5 %,
Richmond Northern Interior 46.9 % and the
Fraser South Northeast 38.5%.
Fraser North
Fraser East
Though participation is lower than
Thomp Cariboo Shus
the provincial rate, approximately
Okanagan
20,000 women every 2 years
Kootenay Boundary
undergo Breast Cancer screening in
East Kootenay
Northern BC
0 25 47.1
50 75 100
Participation Rate (percent)

Screening Mammography Program of BC,

BC Cancer Agency published through the Health data Warehouse.

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Northern Cancer Control Strategy Final Report

Cervical Screening Participation Rates 2000 - 2002

BC
Northeast Cervical cancer is the most commonly
Northern Interior diagnosed form of reproductive cancer.
Northwest
This is due to the development and
N.Vancouver Is.
Central Vancouver Is.
widespread use of the Pap (smear) test.
S.Vancouver Is.
North Shore/Cst Garibaldi
Each year approximately 21,000 Northern
Vancouver
women undergo cervical screening in the
Richmond area served by Northern Health. This
Fraser South translates to a regional program
Fraser North participation rate of 190.3 / 1000 women
Fraser East
ages 20 – 69, which is lower than the
Thomp Cariboo Shus
Okanagan
Provincial average of 205/1000 women.
Kootenay Boundary One cancer is prevented for every 1500
East Kootenay Pap smears.
0 50 100 150 205
200 250 300
Rate per 1000 women

Source: Cervical Cancer Screening Program – acquired through the


Health Data Warehouse.

In addition to the BCCA Programs, a Women's Health Care Program is operated


by NH. This Program uses Primary Health Care Transition Funding to enhance
reproductive health services and screening for cancers of the cervix and breast as
well as Sexually Transmitted Infections (HPV) in six rural communities. A key
feature of this Program has been the training of Aboriginal service providers to
increase the use of services by this underserved population.

Prostate and Colon Cancer Detection:


Early detection is also important for prostate and colon cancer and consists of
specific symptom review, risk determination based on family and personal medical
history and physical examination, such as digital rectal examination. Follow-up
studies such as the Prostate Specific Antigen test (PSA), colonoscopy, or special
radiology should be done when history, physical examination, or the age and sex of
the patient indicate they are needed. The value of these studies applied to the
general population rather than on an individual basis has not been validated.
There are currently no statistics available to compare the standards of practice with
respect to office-based screening for prostate and colon cancer in the North with the
rest of BC, but issues such as a relative shortage of primary care and specialist
physicians in some Northern communities would clearly affect the ability of Northern
citizens to access these important screening services.
(See Section 6.3 in the Appendices for further screening information by HSDA.)

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Northern Cancer Control Strategy Final Report

Screening Themes
• Participation rates for breast and cervical screening fall slightly below provincial
averages.
• Geography and road quality prevent mobile mammography units from visiting
some remote communities.
• The First Nations population is known to have a higher incidence of cervical
cancer than the general population; however they have lower rates of
participation in screening programs.
• The lack of coordinated primary care standards and scheduling for screening and
detection in some Northern communities negatively impacts citizen’s access to
screening and detection programs and services.

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Northern Cancer Control Strategy Final Report

4.4. Detection, Treatment, and Care Findings


Detection
Early detection means detecting cancer prior to the development of symptoms or as
soon as is practicable after the development of symptoms. Detecting a cancer early
means the likelihood of cure goes up as the cancer will be localized to the body
organ of origin. Early detection of cancer can involve education about signs and
symptoms and improved access to primary care.
Northern Health citizens have access to a variety of laboratory services and
diagnostic imaging modalities including x-ray, CT, MRI, and Nuclear Medicine
scans. While diagnostic testing is offered across the three HSDA’s, consistent
organization is limited and quality assurance occurs outside the Health Authority
framework.
Laboratory Services include in-patient and out-patient Clinical Pathology services:
Hematology, Chemistry, Microbiology, Transfusion services and Anatomic
Pathology. Transfusion services include both blood and specific blood components
such as platelets. Also included is a fast track outpatient laboratory service for
cancer patients.
Hematology services are closely tied to the cancer program as are blood
transfusion services. Services performed range from complete blood counts (CBC),
through peripheral smears for analysis of certain blood cell types, to bone marrow
analysis.
Limited cytology services are provided. Fluid screening and Fine Needle
aspirates/biopsies are provided in some communities. The majority of cytology is
sent out to the BC Cancer Agency.
(See Section 6.4 in the Appendices for further diagnostic facility information.)

Treatment and Care


Treatment of cancer is complex, involving a range of therapies including surgery,
radiation, chemotherapy, hormonal therapy, supportive services and palliative care.
The aim of treatment is to cure or to prolong and improve the quality of the life of
those with cancer.
A summary of NH treatment programs and services follows:

Surgery
Surgery is available in the North from a variety of general and sub-specialist
surgeons e.g. general, orthopedic, urology, oral maxillofacial, plastic, gynecology,
ENT and pediatric ENT, ophthalmology, dental, and endocrine. General and sub-
specialty cancer surgery is offered in many Northern communities but involvement
with the BCCA Surgical Oncology Network is limited and based on the individual
surgeon. This is likely a reflection of the creation of a regional medical staff
structure only within the last year. A general surgeon from Prince George is an
executive member of the BCCA Surgical Oncology Network.

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Northern Cancer Control Strategy Final Report

Breast Conserving Surgery: The relative rate of breast conserving surgery is


illustrative of the ability of patients to obtain current modes of treatment. Breast
conserving surgery, or lumpectomy, is a less disfiguring option for the surgical
treatment of breast cancer than mastectomy. However, a percentage of women
undergoing lumpectomy will require further surgery, which may include mastectomy
if surgical staging of their disease indicates spread of the cancer. Women may be
offered a choice of surgeries and their ability to choose may be contingent on
access to adjuvant therapies or to rapid laboratory confirmation of the presence or
absence of tumor spread. The relative number of breast cancer patients being
offered and choosing breast conserving surgery is used here as an indicator of
Northerner’s access to current standards of surgical oncology.

Lumpectomies as a Percent
of all Breast Surgery
Breast-conserving surgery (lumpectomy),
followed by radiation treatment, is the
recommended procedure for most women
with early stage breast cancer.
BC Guidelines produced by the Canadian
Northeast
Northern Interior Medical Association and Health Canada
Northwest suggest that four out of five women with
N. Vancouver Is. early breast cancer may be treated
Central Vancouver Is. successfully with breast conserving
S. Vancouver Is. surgery rather than a radical mastectomy.
N. Shore/Cst Garibaldi Lumpectomy is commonly combined with
Vancouver the excision of lymph nodes from the axilla
Richmond (armpit) to determine the potential for
Fraser South spread of the cancer
Fraser North

Fraser East
The graph to the left shows that the rates
Thomp Cariboo Shus
of Breast Conserving Surgery at slightly
Okanagan
above the Provincial average in Northern
Kootenay Boundary
Interior (NI) and Northwest (NW). The
East Kootenay
rates for Northeast (NE) are lower but
0 10 20 30 40 50 60 63.4 70 80 90 further investigation will be necessary to
100
Percent of all Breast Surgeries
determine if it is due to referral patterns to
Source: Morbidity Database, BC Ministry of Health – acquired Alberta.
through the Health Data Warehouse. Breast Conserving
Surgery reflects hospitalization data for fiscal 2000/2001.

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Northern Cancer Control Strategy Final Report

Radiation Therapy
Radiation therapy or radiotherapy is one of the most important types of non-surgical
treatment prescribed for patients with common cancers. Radiotherapy is given
through repetitive treatments, usually on a daily basis, provided over an extended
time period. The proportion of cancer patients treated by radiotherapy at some time
during their illness has risen steadily to about 50%.

There are no radiation therapy facilities in NH. Therefore, patients referred for
radiation treatment must travel to one of the BCCA sites in Vancouver, Victoria,
Kelowna or Fraser Valley for an extended period of time, which typically ranges
from three to six weeks. This presents travel and social challenges for patients and
their families. In 2003, 357 people from NH were referred to BCCA radiation
facilities. Most of those patients went to the Vancouver Centre (309) while a
substantial minority went to the Southern Interior Cancer Centre in Kelowna (44). A
handful of patients went to the Fraser or Island facilities.
The table following indicates the number of Northeast residents accessing services
of the Alberta Cancer Board. At this time data is not available on the type of
services accessed, but some portion of these numbers would include radiotherapy.

Region Township Count


North Eastern BC Chetwynd 21
Dawson Creek 78
Fort Nelson 23
Fort St. John 66
Tete Jaune Cache 4
Tumbler Ridge 14

Source: BCCA February 2005

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Northern Cancer Control Strategy Final Report

The table following indicates that people living in NH are referred for radiation
therapy less often than those living near radiation facilities e.g. Okanagan, Fraser
Valley, Vancouver or Vancouver Island.
Data from at least one year indicates that initial radiation treatment rates in the
North (i.e., cases referred within 12 months of diagnosis) are comparable to the rest
of the province with relatively high rates in the NW, slightly lower rates in the NI,
and low rates in the NE….again, probably due to referrals to Alberta. Overall,
Northerners have similar rates of curative treatment to other British Columbians, but
rates of radiotherapy for palliative treatment are lower for Northerners than for
residents of the southern mainland.

Referral Patterns: BC Cancer Agency New Cases, Referred Cases and


Radiation Cases by Health Authority and Health Service Delivery Area
Years 2000-2002 Years 1995-1997
Health Health Service New Referral Radiation New Referral Radiation
Authority Delivery Area Cases Cases Cases Cases Cases Cases
# # % # % # # % # %
East Kootenay 901 423 46.9 141 15.6 899 259 28.8 65 7.2
Kootenay/Boundary 1184 608 51.4 255 21.5 1238 456 36.8 180 14.5
Interior
Okanagan 5195 3545 68.2 1408 27.1 4856 1755 36.1 717 14.8
Thompson/Cariboo 2955 1456 49.3 788 26.7 2480 938 37.8 378 15.2
Fraser East 3174 2042 64.3 860 27.1 2986 1830 61.3 848 28.4
Fraser Fraser North 6179 3705 60.0 1702 27.5 5350 2882 53.9 1547 28.9
Fraser South 6848 4471 65.3 2049 29.9 5905 3677 62.3 1824 30.9
Richmond 1819 1003 55.1 468 25.7 1596 843 52.8 459 28.8
Vancouver
Coastal Vancouver 6518 4381 67.2 1827 28.0 6330 3844 60.7 2033 32.1
Nrth Shore/Garibaldi 3642 2019 55.4 935 25.7 3343 1620 48.5 870 26.0
South Vanc. Island 6646 4700 70.7 1838 27.7 5917 3947 66.7 1800 30.4
Vancouver
Island Central Vanc. Island 4076 2730 67.0 1162 28.5 3476 2095 60.3 947 27.2
North Vanc. Island 687 456 66.4 215 31.3 632 412 65.2 178 28.2
Northwest 777 487 62.7 180 23.2 650 368 56.6 146 22.5
Northern Northern Interior 1393 638 45.8 276 19.8 1255 511 40.7 230 18.3
Northeast 467 157 33.6 69 14.8 501 124 24.8 53 10.6
Blank Blank 528 292 55.3 128 24.2 296 103 34.8 45 15.2
Grand Total 52989 33113 62.5 14301 27.0 47710 25664 53.8 12320 25.8

Key: All Cases: Cancer cases in this table include all invasive cancer diagnosis in BC residents
and exclude non-melanoma skin cancers. Health Authority / Health Service Delivery Area:
Includes Health Authority / Health Service Delivery Areas at time of diagnosis. Non-Referred
Cases: Diagnosis Date = 1995-1997 and 2000-2002 Referred Cases: Site Admit Date =
1995-1997 and 2000-2002. Percentage is of total new cases. Radiation Cases: Radiation
Start Date within 6 months of the Site Admit Date (Referred Cases). Percentage is of total
new cases. SOURCE: CAIS (Patient Information) DATE RETRIEVED: 02 November 2004

Travelling to access radiation therapy services is clearly a burden for cancer


patients in the North. This strategy will reduce some of this burden through the
recommendation of several short term priorities namely transportation, navigation,
telehealth and enhanced consultation.

Systemic Therapy/Chemotherapy

Chemotherapy is one of the most common treatments for cancer. It is the main
treatment for some types of cancer, such as leukemia, Hodgkin's Disease and Non-
Hodgkin's Lymphomas. Cancers of the lung, breast, testes, colon, ovary, and
stomach are also treated with chemotherapy. For some patients, chemotherapy
may be the only treatment they receive.

BCCA operates one Community Cancer Centre in Prince George and five
Community Cancer Services in Dawson Creek, Ft. St. John, Prince Rupert, Terrace
and Smithers. The Community Cancer Centre provides a full range of systemic

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Northern Cancer Control Strategy Final Report

therapy for cancer patients. Partial funding and training for nurses are provided by
BCCA. Chemotherapy is also administered by nurses or physicians in other smaller
communities that do not have a formal BCCA program e.g. Kitimat, Quesnel, and
Queen Charlotte Islands.

The table following demonstrates the numbers of chemotherapy cases managed


directly by BCCA medical oncologists by community for the years 2002 and 2003.
Differing data capture for other sites make complete comparison of historical
chemotherapy activity difficult.
BCCA Fully Admit Northern Health Authority Cases* With Prescribed Chemotherapy**
By BCCA Site Admit Year and BCCA Referral Treatment Centre***
Site Admit Date Between 01 January 2002 and 31 December 2003

Current Local BCCA Site Admit Year and BCCA Referral Treatment Centre***
Health Area 2002 2003
VCC Pr. Rupert CCSI Terrace Dawson Crk VICC FVCC Total Cases VCC Pr. Rupert CCSI Terrace VICC FVCC Kamloops Total Cases
Burns Lake 6 0 1 1 0 1 0 9 6 0 1 0 0 1 0 8
Fort Nelson 2 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0
Kitimat 6 0 2 1 0 0 0 9 10 0 0 0 1 0 0 11
Nechako 12 0 0 0 0 0 0 12 7 0 3 0 0 0 0 10
Nisga'a 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 1
Peace River North 6 0 5 0 0 1 0 12 10 0 6 0 0 0 0 16
Peace River South 11 0 1 0 1 0 1 14 8 0 1 0 2 1 0 12
Prince George 57 0 10 0 0 1 2 70 59 0 18 0 0 1 1 79
Prince Rupert 11 5 1 0 0 3 2 22 19 5 0 0 2 0 0 26
Queen Charlotte 7 0 0 0 0 0 0 7 4 0 0 0 0 0 0 4
Quesnel 6 0 30 0 0 1 1 38 14 0 10 0 1 2 0 27
Smithers 13 0 0 1 0 0 0 14 11 0 2 2 1 0 0 16
Snow Country 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0
Stikine 3 0 0 0 0 0 0 3 1 0 0 0 0 0 0 1
Telegraph Creek 1 0 1 0 0 0 0 2 3 0 0 0 0 0 0 3
Terrace 27 0 0 6 0 0 0 33 21 0 2 2 1 2 0 28
Upper Skeena 4 0 1 0 0 0 0 5 3 0 0 0 0 0 0 3
Grand Total 174 5 52 9 1 7 6 254 177 5 43 4 8 7 1 245
* BCCA Fully Admit Northern Health Authority Cases:
Cases assessed or treated by a BCCA Oncologist (excludes cases referred for lesser service, eg conference only, special procedure, nutrition only, etc).
Current address postal code is in Northern Health Authority catchment.
** Prescribed Chemotherapy:
Chemotherapy includes IV or oral chemo or hormone therapy. First chemotherapy prescription date on pharmacy database is on or before BCCA site admit date.
*** Referral Treatment Centre:
Patient referred to a BCCA treatment centre or just to a BCCA Communities Oncology Network (CON) clinic.
Chemotherapy may or may not have been administered at the BCCA centre or clinic.

SOURCE: CAIS(Patient Information)


DATA RETRIEVED: 27 January 2005
PREPARED BY: Wendy Robb, Data Analyst - Surveillance & Outcomes Unit, P&PO
DATE PREPARED: 27 January 2005
FILENAME: q05601.xls

The NH chemotherapy program does not provide high dose intensive therapy for
leukemia and does not participate in clinical trials. There is only one internist with
expertise in medical oncology available for consultation in NH. In general, there is
no formal organization for chemotherapy administration across the North, demand
is increasing, resources are limited and standards and guidelines may not be
uniformly applied across the communities.

Family Practice Oncology Network


The Family Practice Oncology Network (FPON) is a partnership between the British
Columbia Cancer Agency and family physicians. The impetus for developing the
FPON has been the recognition of the need for enhanced capability in B.C.’s
communities to care for cancer patients. The FPON promotes understanding and
development of the supports necessary for family physicians to engage in the
longitudinal care of patients with complex, and frequently chronic, health concerns.
The FPON has established a two-month preceptorship program for family
physicians. A number of Northern physicians have completed the preceptorship
program; however more practitioners are needed in the North to support patients
and programs.

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Northern Cancer Control Strategy Final Report

Support Services
Coping with cancer and its treatment involves a range of issues for patients,
families and caregivers. In order to meet their physical, social, emotional, nutritional,
informational, psychological, sexual, spiritual and practical needs throughout the
spectrum of the cancer experience a number of supportive and rehabilitative
services need to be developed. (Canadian Strategy for Cancer Control, 2002).
Pharmacy, nursing and medical consultation is provided in NH. Psychosocial,
nutritional and emotional support is provided by professionals where available, but it
is fragmented and only two communities offer navigation services. Some areas
have support groups and the chemotherapy nurses provide services whenever
possible.

Palliative & Hospice Care


Palliative care is an essential support throughout the cancer journey to provide
expertise in pain management, psychological and spiritual support as well as end of
life care. There is no comprehensive, integrated Palliative Care Program in the
North. Only NI has a full-time coordinator while the other communities access
home care and acute care nurses as the need arises. The Hospice Society works
with NH in several communities to provide palliative care including bereavement
support. Several Hospice Societies exist in the North, such as: North Peace
Hospice, Kitimat, Upper Skeena/Hazelton, Rotary Hospice House in Prince George,
and Dawson Creek.

Canadian Cancer Society


The Canadian Cancer Society provides funding and organizes support groups with
cancer survivors in each HSDA. A new initiative provided funding for a Community
Action Coordinator for NH who will engage community leaders in the development
and promotion of healthy policies and programs.

Telehealth
Telehealth is currently being used in a variety of ways to support cancer control in
the North:
Oncologists involved in provincial tumor groups regularly meet through
video conferencing to discuss and develop individual patient treatment
plans and revise treatment protocols. There are also educational rounds
broadcasted via videoconferencing.
BCCA offers weekly education sessions to oncologists, nurses and other
clinicians practicing within BCCA's cancer centres and communities
involved with cancer care across the province. Clinicians working within
sites that are part of the communities' oncology program, delivering
chemotherapy to patients locally, are a key target audience to access this
specialized education service.
The hereditary cancer program has provided genetic counseling services
linking Vancouver based practitioners with ten clients in Prince George
and will be implementing a similar project servicing Prince George and
Prince Rupert.
The use of telehealth for cancer control is not fully optimized in NH. There are
numerous examples where telehealth has been used in other jurisdictions for
patient consultations, and patient or provider teaching etc. For example, the Victoria
Cancer Centre completed a successful trial of clinical consultation with newly
diagnosed gastrointestinal cancer patients in Nanaimo. There is a plan to

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Northern Cancer Control Strategy Final Report

reintroduce this service between Victoria and Nanaimo and expand it to Campbell
River. A similar service is being implemented between the Cancer Centre in
Kelowna and clients in Cranbrook and Kamloops.

Other
Complementary and alternative medicine, also referred to as integrative medicine,
encompasses a broad range of healing philosophies, approaches and therapies
e.g. massage therapy, mind body therapy, image enhancement, therapeutic touch
and naturopathic treatments. Some of these services are available in the
communities privately e.g. The Centre for Integrated Healing has expressed interest
in developing a satellite centre in Smithers.
(See Section 6.4 of the Appendices for further treatment and care program
information by HSDA.)

Detection, Treatment and Care Themes


• Limited linkages with primary care and diagnostic departments in some Northern
communities negatively impacts citizen’s access to some diagnostic services.
• Diagnostic testing is offered across the three HSDA’s but consistent organization
and quality assurance are limited.
• General and urology surgery is offered in many Northern communities but there
are limited ties to the BCCA Surgical Oncology Network.
• Chemotherapy is offered across Northern Health in many communities.
• Resources are limited e.g. One internist with expertise in medical oncology,
limited trained nursing staff, many sites are challenged to provide relief
nurses skilled in chemotherapy administration.
• Demand is increasing.
• There is no formal NH regional organization for chemotherapy.
• Funding for chemotherapy nurses is partially funded by BCCA.
• Education, standards and guidelines for chemotherapy administration are
provided by BCCA.
• Radiation Therapy services are not available in the North, which presents travel
and social challenges for patients. Some NE residents are referred to Alberta for
consultation and treatment. Initial referrals for radiation treatments fall within
provincial averages, however referrals for subsequent courses e.g. palliative
radiation therapy, are below provincial averages.
• BCCA has trained several family practitioners in oncology but more are needed.
These practitioners are trained to assess and support chemotherapy patients.
• Supportive services are offered but there is no formal program to serve cancer
patients, resources are limited and not all communities can provide support
across the continuum of care e.g. psychosocial support, nutrition counseling for
cancer patients.
• Palliative and hospice care is offered across NH but it is fragmented.
• The use of telehealth for cancer control is limited in NH.

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Northern Cancer Control Strategy Final Report

5. ANALYSIS & RECOMMENDATIONS FOR ENHANCED


CANCER CONTROL IN THE NORTH
In early January, the Northern Cancer Control Strategy Preliminary Findings Report
outlined relevant health and cancer data and contained an inventory of cancer
services and programs operating within NH. This Report was used to determine the
key cancer control issues in the North. The list of priorities for change was
developed by the Sponsors and Steering Committee and was subsequently
validated by a Reference Group consisting of professionals from various
organizations and communities involved in cancer control in the North.
The priorities outlined later in this Section will address the key issues and are linked
to the outcomes of reducing cancer incidence, reducing mortality and/or improving
the quality of life or access to services for cancer patients. This strategy takes a
population health approach with a balanced focus on interventions at each of the
following stages; prevention/population health; early detection and screening; as
well as treatment and care.

5.1. Decision Criteria


The Sponsors and Steering Committee endorse the following criteria for
determining priorities. The initiatives must be:
Supportive of the project vision “To strengthen the capacity to prevent,
detect, and treat cancer and support patients in the North”;
Integrated and planned within the provincial BCCA program;
Based upon evidence for benefit of existing and proposed interventions;
Directed towards improving cancer outcomes;
Based upon interdisciplinary practice within existing professional practice
standards and provincial clinical practice guidelines;
Complementary to existing and proposed practice patterns for the North;
and
Culturally sensitive to the issues that characterize the North.

5.2. Develop a Northern Cancer Program


The North is the only region of BC without a Regional Cancer Program. Improving
cancer control in the North requires new resources to address limitations in current
services, better measurement to support quality improvement in all services, and a
structure to assist the many parts of the cancer services system to serve individuals
and communities in a more coordinated way.
Northern Health and BCCA will jointly establish a Regional Cancer Program for the
North with program leadership reporting at a senior level within both organizations.
This leadership position will be accountable for the implementation of the
recommendations of this report with a high priority given to the coordination of
service to individuals with cancer throughout the system of care.
The Program will develop measurement systems, including ongoing capture of
tumour staging data for improvement of cancer services to Northerners.

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Northern Cancer Control Strategy Final Report

Measurement systems also need to incorporate the patients’ experience of care in a


manner which will enable problems with the planning or coordination of care to be
identified and addressed on an ongoing basis.
The following diagram outlines the mandate for the proposed Northern Cancer
Program including current services and short term priorities for implementation.
The green boxes represent initiatives that NH would lead, yellow BCCA would lead
and pink would be joint initiatives from NH and BCCA.

Program Leadership, Outcomes Measurement, and Quality Improvement

Prevention Screening Detection Treatment Supportive Palliative &


Continuum of & & Care & End of Life
Cancer Control Promotion Diagnosis Rehab Care

Hepatitis B & C Breast Lab Surgical Oncology: FPON


Palliative &
Urology, General
Heart Health Cervical Diagnostic Nutrition Hospice
Imaging services
Current Northern Tobacco Control Colorectal* Radiation Therapy: Pharmacy
available in
Service & Programs Pathology Must be referred to
STD Prostate* Home Care all HSDA’s
other Centres
Environmental Health Women's Rehab
Health Systemic Therapy:
Chronic Disease Mgmt. Psychosocial
Program Available in all
Primary Health Care HSDA’s in several
Initiative communities

Retrospective Enhanced Palliative


Tobacco
Staging Study Consultation Care
Control

Chemo Review
Short Term Priorities Women’s Health Program
Telehealth
Research & Best
Practices to Improve Navigation, Primary Care/Diagnostic Coordination and Transportation
NH Health Status

Surgical
Oncology

*Not currently available as ‘organized’ screening programs in BC.

The following sections outline the short term priorities under the categories:
Prevention, Promotion and Screening;
Detection and Diagnosis; and
Treatment and Care.

5.3. Prevention, Promotion and Screening Priorities


5.3.1. Comprehensive Tobacco Control Strategy
Existing good smoking cessation programs will be expanded across the region to
develop a strategic comprehensive tobacco control strategy across Northern
Health. The framework for this strategy includes four pillars:
1. Education
2. Cessation/Stop Smoking

32
Northern Cancer Control Strategy Final Report

3. Enforcement
4. Policy Development

5.3.2. Women’s Health Program


The Women’s Health Program will continue to be supported and evaluated. This is
a three year project supported by BC Women’s & Children’s through their primary
health transition funds and involves reproductive screening by Pap tests and breast
exams for women who do not access this service through medical practitioners.
Also included is testing for STI’s. This is an ongoing project that is still in the
developmental stages.

5.3.3. Investigate known programs and best practices that reduce the
incidence of cancers amenable to preventive action
Public Health currently works in partnership with a number of other organizations in
the development of health promotion initiatives focused on healthy living. In general,
these initiatives are community or program specific. For example, Northern Health
is involved in Chronic Disease Prevention activities in seven communities involved
in a Chronic Disease Prevention and Management Collaborative Process. This
priority will see NH working with other Health Authorities and BCCA to select and
plan additional effective prevention strategies during next three years.

5.4. Detection and Diagnosis Priorities


5.4.1. Retrospective Staging Study
Examination of cancer five year survival rates, for the five health authority regions,
shows Northern rates to be a little below the provincial average. BCCA will
complete a retrospective staging study to determine if there are delays in diagnosis
and to provide a better understanding of where resources and effort should be
focused to improve survival.

5.4.2. Diagnostic Testing


Currently in the North, patients who present with signs or symptoms may not always
follow the most expedited path to a definitive diagnosis. This not only delays
diagnosis but causes stress for the patient and wastes NH resources. This will be
addressed in an initiative that will improve primary care linkages to develop a
coordinated system from first encounter to screening, detection, treatment and
follow up. BCCA and NH will collaborate on the application of diagnostic protocols.
HSDA’s will work with the diagnostic departments to develop implementation plans
to enable patients to obtain a diagnoses more rapidly through a well coordinated
series of investigations linked with Primary Care physicians and providers.

5.5. Treatment and Care Priorities


5.5.1. Transportation
This priority will see the development of travel assistance strategies, both within the
Region and with southern centers, to reduce the burden of travel for cancer
patients. This recommendation applies to the assessment, treatment, rehabilitation
and palliative components of care. Travel assistance strategies should:
Assist patients being investigated or treated for cancer and their care givers
in accessing information about travel and accommodation options;

33
Northern Cancer Control Strategy Final Report

Create additional alternatives and reduced costs for individuals facing


extensive or frequent travel whether by ground or air; and
Improve availability and reduce costs when accommodations related to
care are required.

5.5.2. Surgical Oncology


BCCA will ensure that, through the Northern Cancer Program and Surgical
Oncology Network, surgeons in the North have access to timely outcomes
information and an opportunity to participate in a surgical oncology best practices
program. The regional medical staff structure within Northern Health will provide a
forum for the surgical community to bring forward requirements for service
improvement.

5.5.3. Systemic Therapy (Chemotherapy)


Chemotherapy is growing in importance in cancer therapy and will expand at a
significantly greater rate than the forecasted growth in incident cases due to the
increase in new drugs and new protocols. BCCA and NH will increase capacity in
this service in the immediate future through the recruitment of additional oncology
nurses.
An external assessment of the delivery of chemotherapy in the North will be
conducted by an expert team (e.g. medical oncologists experienced in broadly
distributed service systems) to provide guidance with respect to clinic services and
the integration of these services into a region wide program.

5.5.4. Radiotherapy
Any discussion of radiation oncology services in the North requires an appreciation
of the scope of radiation oncology practice and an understanding of the essential
elements required to provide a quality service. The scope of radiation oncology
practice spans the entire continuum of cancer care from diagnosis, clinical
assessment and treatment decision making to treatment planning treatment and
follow-up. The complex nature of radiation oncology requires the recruitment of
many specialists and the establishment of appropriate infrastructure.
In recognition of the increasingly complex nature of oncology management,
radiation oncology practice has become increasingly sub specialized by anatomical
tumor site. As such, a radiation oncologist’s practice is typically limited to two or
three tumor sites. It is no longer possible for a single radiation oncologist to do
“general practice” radiation oncology and maintain expertise for all cancers. The
complexity of cancer management also recognizes that oncology management is
multidisciplinary in nature and involves close collaboration with both surgical and
medical oncology specialists.
In addition to the medical management requirements, the practice of radiation
oncology has been dramatically altered by improvements in technology, both
hardware and software, which have fully integrated the quality assurance,
dosimetry, treatment planning and simulation with the final treatment delivery
process. The maintenance and operation of this multi-system infrastructure and
process requires highly skilled technical personnel (medical physicists, electronics
technicians, dosimetrists and radiation therapists). In summary, the modern
practice of radiation oncology requires significant concentration of medical and
technical expertise to support and maintain a high quality service. These specialists
are in short supply across Canada.
The increasingly tertiary nature of a radiation oncology consultation and treatment
service is a reality which must be considered in planning any enhancement of

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Northern Cancer Control Strategy Final Report

services in the North. BCCA guidelines for a radiation service would require the
following:
A population of oncology cases large enough to support and justify a
concentrated resource (BC has typically considered a catchment of
approximately 750,000 to justify a radiotherapy centre. Other jurisdictions
have recommended population estimates of 600,000 to 1,000,000 or a
minimum population to support four linear accelerators and the associated
infrastructure.).
Accessibility through transportation links.
The recruitment of a critical mass of radiation oncologists.
The associated development of a critical mass of surgical and medical
oncologists.
The development of minimum staff numbers for medical physics,
electronics, dosimetry and radiation therapy technologists.
The necessary infrastructure for quality assurance, radiation dosimetry,
treatment planning and simulation.
The necessary treatment capacity (number of linear accelerators) with
sufficient redundancy to accommodate machine downtime on any individual
unit such that patients’ requirements for uninterrupted treatment are not
jeopardized.
Preceding and concurrent with the development of Northern Health’s Cancer
Strategy, there has been considerable public discussion about, and support for, the
establishment of a Prince George based radiation therapy service. When the above
criteria are examined it does not appear that the catchment area for the North is
large enough to support a service at this time. Feedback from Northern physicians
indicates that patients in the Northeast and Northwest are better served by current
arrangements than they would be through a service located centrally in the North
because of the established referral links, full range of specialized care in tertiary
centres, and relative ease of North – South travel. It is also likely that the trend to
refer some of the cancer patients from the Northeast to Alberta will continue. While
the population of NH is close to 300,000, given the referral and travel patterns, a
northern radiation service at this time could respond, at most, to a population of
175,000 or about 25% of the current minimum recommended guideline. A service
of this size would only allow the available sub-specialized radiation oncologists to
treat a portion of the anatomic tumour sites requiring other patients from within this
area to be referred to larger centres.
Population growth, development of other cancer services in the North, adequate
planning for oncology human resource specialists, improvements in East – West
transportation links within the Region, and developments in clinical technology may
combine to improve the feasibility of a Northern service in the future. In particular,
the advancements in digital linkages and the implementation of clinical information
systems may enable new models of service to be feasible. However, some
strategies can be implemented in the short term, which will reduce the demands on
patients and families who face multiple appointments, require information and
support, and face significant travel and accommodations requirements during
investigation, treatment and follow up care.

5.5.5. Navigation
The Northern Cancer Program will provide patient navigation services across the
three HSDA’s through registered nurses knowledgeable in all aspects of cancer

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Northern Cancer Control Strategy Final Report

care. Patients who receive several types of treatment will be supported to ensure
that the planning and organization of their treatment minimizes travel requirements.
Assistance will be available when patients encounter difficulties in the often
complex series of consultations, examinations and treatments required by their
illness. This “navigation service” requires strong communication links within both
BCCA and NH to address process and scheduling issues.

5.5.6. Enhanced consultation


Northern family practitioners will have easier access to BCCA tumor site specific
specialists in radiation, medical and surgical oncology. This will foster improved
and timelier care while reducing travel for patients.

5.5.7. Telehealth
The well-developed infrastructure in telehealth in both the North and at the BCCA
offers the opportunity to reconsider how patient consultative services to BCCA
tumor site specific specialists in radiation, medical and surgical oncology can be
enhanced. Telehealth linkages could also be of value to primary care physicians to
provide assistance and advice on patient management particularly in relation to
many of the clinical problems faced by patients in the post-treatment phase of their
illness.
Year one of this telehealth strategy will focus on improving NH family physicians
access to BCCA specialists for consultation. Year two will focus on improvements
to patient consultation and staff education.

5.5.8. Palliative Care


This strategy will develop and implement a coordinated comprehensive Palliative
Care Program that has linkages with Home Care, the BCCA Palliative Care
Network and other similar rural sites. The NH Palliative Care Strategy, developed
in 2004, identified four broad strategic areas for action. They include:
1. Position Palliative Care services within the organization structure of
Northern Health, establish a system of leadership and integrate activity with
the Provincial Palliative Care Network.
2. Establish a coordinated network of Palliative Care Services supported by
policies and procedures, protocols, and clinical practice guidelines.
3. Build the capacity of Palliative Care service providers.
4. Quality management – develop program performance measures that will be
used to facilitate improvement in the delivery of services.

5.6. Additional Considerations and Enablers of the Strategy


5.6.1. Research and Education
"In the 21st century, health research and innovation will be central to Canada's
future. Harnessing our investments in health research is key to improving the
health of our citizens, building sustainable, evidence-based, leading- edge health
care and public health systems, and developing the transformative new
technologies of tomorrow."1

1
Dr. Alan Bernstein, CIHR President, Newsmaker's Breakfast, Ottawa, January 20,
2004

36
Northern Cancer Control Strategy Final Report

Work in this area will be ongoing. In particular, Northern Health has an opportunity
to build relationships with BCCA, UNBC, UBC and the Northern Medical Program to
work collaboratively to expand research and teaching in the area of cancer control.
Enhancing research and education will improve the ability of NH to recruit and
retain staff, as well as monitor and maintain an up to date level of care based on
evidence. In nursing there is an opportunity to facilitate research into health and
aboriginal health in relation to cancer control. Student practicums can be
developed for both registered nurses and medical students.
The BCCA is engaged in varying degrees of all aspects of research at provincial,
national and international levels. The BCCA undertakes cancer research in
collaboration with organizations representing the North or including the North as a
focus of the research. The BCCA would entertain all opportunities to partner with
Northern Health that fit within the mandate of cancer research and within the
academic setting post-graduate academic associations. As part of the established
ongoing forum, continuing professional health education will be facilitated in
collaboration with Northern Health.

5.6.2. Information Technology


An electronic record is required for the electronic transportation of patient
information, including that required for assessment, diagnostic images and
pathology reports, and subsequently provision of cancer care to the patient. It is
desirable that all aspects of the patient’s care are available electronically; given the
distances some patients will travel for their assessment and perhaps care.
It is understood that the soon to be operational Northern Health patient information
management system, will interface with PHSA-BCCA, Cancer Information System
(CAIS). Facilitation and operationalization of the Electronic Health Record is under
the mandate and responsibility of the PHSA Leadership Council and PHSA Health
Records; as Health Record’s service is provided to the BCCA by PHSA.
Northern Health has been working on implementing its IM/IT Health Strategic Plan.
One of the major initiatives identified in this plan is the implementation of new fully
integrated Clinical Information Systems (CIS) across Northern Health. This initiative
is supported and has linkages to other organizations such as the Aboriginal (Health
Services) Communities, physicians, care providers in the North, and important
initiatives such as the Northern Medical Expansion Program.
Northern Health is working very closely with other Health Authorities, the Ministry of
Health and other health organizations to ensure that the CIS project integrates with
the provincial Health IM/IT Strategic Plan. This is being accomplished through the
Health CIO Council and Provincial Electronic Health Record Steering Committee.
As well, Northern Health has completed excellent preparatory work for the CIS
project to integrate to Physicians’ Office Electronic Patient Record Systems.
Northern Health, through Primary Health Care funding, is currently embarking on
connecting doctors’ offices to Northern Health’s network and data infrastructure.
This project, known as the Physician Connectivity Project, and will connect all
doctors across the North.
Collaboratively with other Health Authorities, PHSA in particular, Northern Health
will be connecting to the BC Bycast Diagnostic Imaging Network. This network will
allow for effective, fast and efficient access to electronic diagnostic images to and
from PHSA, other Health Authorities, and Northern Health. Radiology and
Pathology Telehealth also provide opportunities for improving care. Telehealth is
well established in the North and opportunities exist to link through PHSA for the
provision of diagnostic reports and interpretations.

37
Northern Cancer Control Strategy Final Report

In addition Northern Health is participating in the Provincial Inter-Health Authority


Private Network Gateway (PNG) initiative. This initiative will provide a fully
integrated and secure network for Health Authorities including the Ministry of Health
to access all electronic clinical data.
The above examples of IM/IT initiatives are fundamental infrastructure supports for
the Northern Cancer Program.

5.6.3. Linkages with Yukon and Alberta


Areas with rural and remote populations often share similar characteristics in that
they have low population density, greater unemployment, income inequality and a
higher proportion of Aboriginal persons. It will be important for the leadership of the
Program to engage similar jurisdictions such as the Yukon to determine areas for
collaboration and shared learning.
It will also be important to develop ties with the Alberta Cancer Board to explore
border issues around referral patterns.

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Northern Cancer Control Strategy Final Report

6. APPENDICES
6.1. Data
Canada’s Socio-Economic Health Regions
Northern Health is often compared with other health regions in British Columbia.
While these comparisons are useful for many purposes they can mask the fact that
the Northern and Rural areas of Canada often face challenges that are unique and
absent from the more urban context. Many of these challenges are anchored in the
socio-economic context.
Socio-economic factors are a fundamental determinant of how healthy citizens will
be, the opportunities they will have to make wise and healthy decisions, and how
their lives will unfold.
Because of the positive association between socio-economic status and health,
comparisons between communities are often more useful if they are made among
those that are socio-economically similar.

In 2000, Statistics Canada developed a methodology that permitted analysts to


assign the 139 health regions in Canada Socio-economic Peer-groups. Northern
BC was assigned to Peer Group “F”: a group that included: Yukon, Northwest
Territories, Northern Quebec, Labrador and several areas in the Prairie Provinces.
The most important variables that determined assignment to this peer group were:
The proportion of Aboriginal persons,
The proportion of visible minorities,
Unemployment,
Population density and,
Income inequality.

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Northern Cancer Control Strategy Final Report

Communities served by Northern Health


The vast area served by Northern Health covers approximately 588,000 square
kilometers or two-thirds of BC and, with a population of approximately 299,446
(2005) persons, it has the lowest population density per square kilometer of any BC
Health Area.
Administratively, Northern Health is divided into three Health Service Delivery Areas
(HSDA’s): Northwest, Northern Interior and the Northeast.

Northern Communities Northwest Northeast

10,000 + persons

1000 - 10,000 persons

Predominantly First Nations Community

Northern interior

Major urban centers in the North are shown as stars on the above map and include the
communities of Prince Rupert, Kitimat, Terrace, Prince George, Quesnel, Dawson Creek and
Fort St John. Collectively, these urban areas and their immediate communities are home to
approximately 185,000 persons or just under two-thirds of the Northern population.
A significant number of northerners however, live in much more rural and remote circumstances.
Some communities such as Gitga’at (Hartley Bay) and Lax kw’alaams (Port Simpson) are only
accessible by floatplane or boat, weather permitting. Others such as Good Hope Lake, Takla,
Dease Lake and Lhoosk’uz Dene (Kluskus) are accessible by gravel roads that require driving
times of six to twelve hours under optimum conditions.
The vast geography, the small widely distributed population, and the differing needs of each
community present enormous challenges when it comes to promoting good health, preventing
disease and providing sustainable and integrated health services.

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Northern Cancer Control Strategy Final Report

Northern Demographics

On average the population in the North is considerably younger than the rest of BC.
The average age of people in the north is 34 years whereas the average age of the BC
population is 38 years.

Population Profile 2005

10.0 Northern BC British Columbia

8.0

The graph to the left


Percent of Population

6.0
shows the relative
contribution of each age
group to the overall
4.0 population for both
Northern BC and British
Columbia.
2.0

Age Groups
0.0
90+
<1

15 - 19

20 - 24

25 - 29

30 - 34

35 - 39

40 - 44

45 - 49

50 - 54

55 - 59

60 - 64

65 - 69

70 - 74

75 - 79

80 - 84

85 - 89
1-4

5-9

10 - 14

Source: BC Stats, PEOPLE 29 population projections

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Northern Cancer Control Strategy Final Report

Northern Demographics

Aboriginal Persons as Percentage of Populations 2001

BC

Northwest
Northern Interior
Northeast
North Van Is.
Aboriginal, First Nations and Métis peoples
Central Van Is.
comprise a very significant and important part
South Van Is.
of the Northern population. According to the
NorthShore-CG
Vancouver
most recent Census there are between 35,000
Richmond
and 45,000 Aboriginal First Nations and Métis
Fraser South
persons residing in the area served by
Fraser North Northern Health. This is likely an
Fraser East underestimate.
ThompsonCariboo
Okanagan
Kootenay Boundary
East Kootenay

0.0 4.45.0 10.0 15.0 20.0 25.0 %

Source: Census 2001- acquired through the Health Data Warehouses

Estimated numbers of Status Indian persons

Population
> 15,000 Aboriginal people are on average considerably
10,000 – 14,999 younger than their neighbors. Whereas the
5,000 – 9,999 average age of northerners overall is 34 years
< 5,000 of age, the average age of Aboriginal and First
Nations peoples is 28 years. In fact, almost 45
% of the Aboriginal and First nations
population is between the ages of one to 24
years.
Not only is this population much younger, the
patterns of illness, such as cancer, are
different than those experienced by other
Northerners.

Source: BC Vital Statistics Agency, Regional Analysis of Status Indians in British Columbia 1991 – 2001.

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Northern Cancer Control Strategy Final Report

Life Expectancy
BC

Northeast

Northern Interior

Northwest
Life Expectancy is an expression of
North Vancouver Island
the age to which a baby born today
Central Vancouver Island
is expected to live given the present
South Vancouver Island
mortality experience of the
North Shore/Coast Garibaldi
population. In British Columbia the
Vancouver
current BC life expectancies are 77.3
Richmond
years for males and 82.47 years for
South Fraser
females.
Simon Fraser
Life expectancies for Northerners are
Fraser Valley
from 3 to 4 years shorter than those
Thompson Cariboo
for BC residents overall.
Okanagan

Kootenay Boundary

East Kootenay

75.00 76.00 77.00 78.00 79.00 80.00 81.00 82.00 83.00


79.9

Years of Life
Source: BC Stats, BC Ministry of Management Services

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Northern Cancer Control Strategy Final Report

Leading causes of Death and Patterns of Mortality in Northern BC


1991 - 2001

Northern Residents
The Leading Causes of Death for residents of
Northern BC were similar to those elsewhere in
Infectious/Parasitic North America: Circulatory and Heart Disease,
Diseases
Other
9%
1% Cancers, Respiratory Diseases and external
events such as motor vehicle crashes, falls,
Cancer workplace injuries, suicides, homicides, etc.
External Causes
13% 28%
Cancers are a significant cause of death amongst
northerners.
Digestive System
Diseases Leading Causes of Death during 1991 - 2001
4%

Circulatory System 4597 deaths


Respiratory Diseases Endocrine/Nutritional&
10% Metabolic
3%
All cancers 3977 deaths
External Causes 1667 deaths

Circulatory System
Respiratory system 1391 deaths
Diseases
32%

Northern Status Indians


It is helpful to look at different populations when
Infectious/Parasitic
Diseases undertaking health planning activities.
Other 2%
Cancer
15% Aboriginal persons residing in Northern BC have
17%
markedly different patterns of mortality compared
to other Northern residents living in the same
Endocrine/Nutritional & geographic area.
Metabolic
2%
During the period, 1991 to 2001, there were 3,977
cancer deaths in Northern BC. The 339 cancer
External Causes
25%
deaths that occurred in the Status Indian
population accounted for about 17 % of the total
Circulatory System mortality for this group. Approximately 21% (71 of
Diseases
24%
339 cases) of these cancer deaths were
attributable to lung cancer.
Digestive System
Diseases Respiratory Diseases The 3,638 cancers in the rest of the population
7% 8%
accounted for 28 % of the overall mortality in this
group. Approximately 30% (1,081 of 3,638 cases)
of these cancer deaths were attributable to lung
cancer.

Source: BC Vital Statistics Agency – Regional Analysis of Health Statistics for Status Indians in British Columbia, 1991 – 2001.

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Northern Cancer Control Strategy Final Report

Comparison of Deaths in Northern BC


Standardized Mortality Ratio 1998 - 2002 The Standardized Mortality Ratio (SMR)
is an internationally recognized Health
Status indicator. The SMR is a good
BC
measure for comparing mortality data
Alcohol-Related that are based on a small number of
Suicide cases or for comparing mortality data by
Motor Vehicle geographical area. The SMR is the ratio
Chronic Lung of the actual number of deaths to the
Pneumonia-Influenza
expected number of deaths.
Respiratory An SMR greater than 1.00 (to the right of
Cerebrovascular the line) indicates that more deaths are
Ischemic Heart occurring than would be expected for a
Circulatory specific cause.
Diabetes
The area served by Northern Health is
Metabolic. distinguished by having the highest
Lung Cancer SMRs in British Columbia for most
All Cancers causes of death including All Cancers,
All Causes Lung Cancer, Circulatory System
diseases, Ischemic Heart disease,
0.00 0.50 1.00 1.50 2.00 2.50
Cerebro-vascular system diseases,
Indicates SMR values that are high and statistically Respiratory Diseases, Chronic Lung
significant.
Disease and Pneumonia.

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Northern Cancer Control Strategy Final Report

Age Standardized Incidence Rates for Selected Cancers in Northern BC


Males vs. Females 1998 - 2002

Males Females
80.00
Age Standardized Incidence Rate per 10,000

70.00

60.00

50.00

40.00

30.00

20.00

10.00

.00

Multiple Myeloma
All Other

Non-Hodgkins
Esophagus

Lung
Colorectal

Stomach
Leukemia

Oral
Melanoma, Skin

Pancreas
Cancers

Lymphoma

Age Standardized Mortality Rates for Selected Cancers in Northern BC


Males vs. Females 1998 - 2002

Males Females
70
Age Standardized Mortality Rate per 10,000

60

50

40

30

20

10

0
All Other

Lung

Multiple Myeloma

Non-Hodgkins

Oral

Stomach
Esophagus
Colorectal

Leukemia

Pancreas
Melanoma, Skin
Cancers

Lymphoma

Source: Custom analysis courtesy of BC


Cancer Agency, December 2004

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Northern Cancer Control Strategy Final Report

Estimated Number of New Cancer Diagnosis in Northern Health


2005 and 2015
900
New Diagnoses 2005 New Diagnoses 2015
800 782

700

600
Number of Persons

499
500

400 378
332

300

181
200
119

100 53 53
12 10
0
0 - 19 20 - 39 40 - 59 60 - 79 80 +
Age Groups

Estimated Number of New Cancer Deaths in Northern Health


2005 and 2015

350
322
Deaths 2005 Deaths2015
300

250
Number of Persons

217

200

150
1 27
111
103
100 84

50

9 11
2 3
0
0 - 19 20 - 39 40 - 59 60 - 79 80 +
Age Groups

Data Source: BC Cancer Agency, Projections 2003 - 2017, published April 2003. Data is for the area
served by Northern Health and was prepared by the Surveillance & Outcomes Unit, Population &
Oncology, and BC Cancer Agency. The calculation of projected New Dx and Deaths were undertaken
using BCStats People 27 Methodology.

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Northern Cancer Control Strategy Final Report

Predicted Percentage Change in New Cancer Cases for selected Cancer types
2005 - 2015

Breast

Prostate

Lung

Colorectal

Cervix
Health Authority
Pancreas Interior
Fraser
Stomach

Van Coastal
Ovary
Van Island
Lymph: N-
Hodgkin North

Leukemia

Melanoma

All Other

All Cancers

-10 10 30 50 70
Percentage Change in Cases
Source: Custom Calculation for Northern Health, provided by the BC Cancer Agency Dec 21, 2004

Between 2005 and 2015 the North can expect to see an increase in the number of new
cancer diagnoses. Most of this increase is due to the fact the population is aging.
Percentages can be somewhat misleading however because when there are a small number
of cases involved, a change in just a few cases can result in large percentage changes. For
example, between 2005 and 2015 we can expect the number of stomach cancers to jump
from 21 cases per year to 30 cases per year - this represents a 43% increase in new cases.

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Northern Cancer Control Strategy Final Report

Exposure to Hazardous Tobacco Products, Smoking and Cancer

Persons who are Current Smokers

40 Smoking is the number one


preventable cause of Cancer death in
31.2 % BC
30
Exposure to hazardous Tobacco products is
Percent of Population

a well known risk factors for the


development of many cancers and chronic
20 BC
diseases.
Exposure to Tobacco products exerts a
10 heavy toll on Northerners. Lung cancer is
the most well known of the tobacco caused
cancers. It is known that between 85 – 90%
of lung cancers can be attributed to current
0
Van. Coastal Fraser Interior Van Island Northern and previous smoking habits.
Health Authority
Each year in Northern BC there are
. between 130 and 150 new cases of lung
cancer and each year there are almost as
Source: Smoking Prevalence in British Columbia, Final
Report. Ipsos Reid, 2003. many deaths. Only 13 % of people with a
diagnosis of lung cancer can be expected to
live five years.
Between 1993 and 2003 over 1200
northerners died as a result of lung cancer.
Persons aged 15 – 24 who are Current Smokers
Tobacco is a known and significant risk
factor for numerous other cancers including;
cancers of the lip, oral cavity, pharynx,
40 %
40 esophagus, larynx, trachea, bronchus,
cervix, uterus, pancreas, bladder, and
kidney.
Percent of Persons 15 - 24

30
In 2003, the BC Ministry of Health
conducted a survey of Tobacco use.

20
BC The tobacco survey found that nearly 32 %
of all Northerners were current smokers.
This was by far the highest smoking rate in
the province of BC.
10
The survey also found that nearly 40 % of
persons aged 15 – 24 years, were current
smokers. Again, the highest rate in BC. The
0
Van. Coastal Fraser Interior Van Island Northern
BC average is only 23 %.
Health Authority

Source: Smoking Prevalence in British Columbia, Final


Report. Ipsos Reid, 2003.

49
Northern Cancer Control Strategy Final Report

Exposure to Hazardous Tobacco Products, Smoking and Cancer

Percentage of Homes allowing indoor smoking


40
37 %
The 2003 survey confirmed that Northerners are far
more permissive when it comes to indoor smoking
30 and exposure to second hand smoke. While only
one-in-five (21%) of British Columbians allowed
Percent of Homes

cigarette smoking inside the home, nearly four-in ten


20 BC
(37%) of Northern respondents stated that they
permitted smoking inside their home.

10 Second hand smoke causes 50 lung cancer deaths in


non-smokers annually in BC, 37 from workplace
exposure. Because of the high rates of smoking in
0 the North, a disproportionate burden will be borne by
Van. Coastal Fraser Interior Van Island Northern
exposed non-smokers in NH. Public policies play an
Health Authority
important role in peoples’ exposure to hazardous
tobacco products. For example, many municipalities
in BC have taken leadership roles by enacting
Smoke-free by-laws. The result is that nearly 50 % of
Source: Smoking Prevalence in British Columbia, Final
Report. Ipsos Reid, 2003.
the BC population is protected from tobacco harm in
public places. There are no such municipal bylaws in
Northern BC.

Smoking Attributable Mortality in Northern BC


It is known that smoking contributes not only to
18
Northern BC BC cancers but also heart disease, atherosclerosis,
hypertension, pneumonia, COPD and other diseases.
Age Standardized Mortality Rate per 10,000

The number of deaths that have been influenced by


16
smoking is known as the Smoking Attributable
Mortality (SAM).
14
Age-standardized rates are a convenient way for us
to compare the SAM for Northerners with the rest of
12 BC. In the graph to the left the SAM for Northerners
is considerably higher than for BC overall. During the
10
10 year period shown in the graph there were 2900
SAM deaths in Northern BC.

8 In 2005 NH can expect 136 new lung cancers. By


1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2015 this number will have climbed to 164 new cases
per year. Based on current experience we can
expect that about 1400 Northerners will die as result
Source: BC Vital Statistics, acquired
of lung cancer in the next 10 years. The majority of
through the Health Data Warehouse these projected deaths will be the result of exposure
to tobacco products and hence these deaths should
be considered avoidable.

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Northern Cancer Control Strategy Final Report

Dietary habits, Healthy Body Weight, Physical Inactivity and Cancer


.

BMI Poor dietary habits, physical inactivity and excess


body weight are significant and modifiable risk
BC factors associated with the development of many
Northeast chronic diseases and several types of cancers.
Northern Interior
One way to estimate whether a person has a
Northwest
North Vancouver Island
healthy bodyweight is to calculate the Body Mass
Central Vancouver Island
Index (BMI). The BMI correlates well with the total
South Vancouver Island
of body fat for most people and in general, the
North Shore/Coast Garibaldi higher a person’s BMI is above 25, the greater their
Vancouver weight-related health risks.
Richmond
South Fraser
An elevated BMI alone does not indicate that
Simon Fraser
people are unhealthy. Other risk factors such as
Fraser Valley
high blood-pressure, high cholesterol, smoking,
Thompson Cariboo diabetes, alcohol misuse and family history need to
Okanagan be considered. Nevertheless the BMI is
Kootenay Boundary considered a reasonable indicator of health risk.
East Kootenay
In the year 2015, if current trends continue, NH can
0 5 10 15 20 25 27 30 35 40 45
expect 202 new breast cancers, 190 colorectal
cancers, 34 endometrial (uterus) cancers, 33
pancreatic cancers, seven oral cancers, 30
stomach cancers, seventeen esophageal cancers
Source: Canadian Community Health Survey 2001,
and twelve cancers of the larynx. For each of these
Stats Canada cancers, poor dietary practices, physical inactivity
and unhealthy body weight are known risk factors.

51
Northern Cancer Control Strategy Final Report

Alcohol Consumption and Cancer

Alcohol Related Deaths 1998 - 2002

Alcohol consumption is also a modifiable


275 134 risk factor in the development of cancer.
N
Excessive alcohol consumption specifically
contributes to mouth, throat, esophageal
and liver cancers. Excessive alcohol
consumption is also seen as a modifiable
risk factor for other cancers of the digestive
system such as stomach and colorectal
322
cancers.
People who both smoke and drink are 30
times more likely to develop esophageal
cancer than those who neither smoke nor
drink. Similarly the risk of pancreatic,
76% of 24% of stomach and colorectal cancer increases
deaths deaths with the use of tobacco and alcohol.
Cirrhosis of the liver can be a result of
Source: BC Vital Statistics acquired through the Health Data Warehouse excessive alcohol consumption: a major
predisposing factor for the development of
BC
primary carcinoma of the liver. In fact,
Northeast
persons with cirrhosis of the liver are 40
East Kootenay times more likely to develop cancer than
Northern Interior people with normal livers.
North Vancouver Island
Northwest Between 1998 – 2002 there were 743
Fraser Valley
alcohol-related deaths in the area served
by Northern Health. The majority of these
Kootenay Boundary
deaths occurred in males.
Thompson Cariboo
Central Vancouver Island In the year 2015, we can expect 190 new
South Vancouver Island colorectal cancers, 37 oral cancers, 30
North Shore/Coast Garibaldi stomach cancers, 17 esophageal cancers
Okanagan and 12 cancers of the larynx in
Vancouver
Northerners. For each of these cancers,
South Fraser
alcohol consumption is a risk factor.
Richmond
Simon Fraser

0 5 10 15 20 25 30

Source: Community Health Survey 2001

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Northern Cancer Control Strategy Final Report

Preventable Environmental and Occupational Cancers


There are several important modifiable risk factors for cancer from environmental
exposures:
Radon: Radon gas has been identified in the North, particularly in the Prince
George area through a province wide survey conducted by Chris van Netten UBC,
in 1991-19922 Overall about 1% of homes in the interior of BC exceeded the
Canadian Guidelines for corrective action within a year. About 9% of lung cancer in
areas affected by radon can be attributed to radon. (Bates, 2002, Darby 2004.)
Radon is a carcinogen worth tackling because prevention and mitigation are
relatively easy and inexpensive. The NIHU Environmental Health Program offered
a radon detection program to homeowners for several years. Program activity is
limited by other environmental health priorities.
Sun Exposure: The incidence of skin cancer is increasing worldwide because of
damage to the ozone layer. In BC the incidence of skin cancer has doubled in the
past fifteen years. Protection from sunburn and UV radiation includes wearing
protective clothing, avoiding the sun and using sunscreen. Most people who take
protective measures use sunscreen, but don’t dress properly or avoid the sun.
Arsenic and Disinfection Byproducts in Drinking Water: In some areas, naturally
occurring arsenic levels exceed incoming national guidelines. Trihalomethanes, the
byproducts of chlorination of turbid water are also recently recognized causes of
cancer. The new Drinking Water Protection program has a mandate to manage
these sources of modifiable risk.

6.2. Prevention and Promotion


The following table outlines the programs and services available for Northern
Residents.

Program/Service Northern Northwest Northeast Comments


Interior

Hepatitis B Vaccine Stewart, Dease Lake, Hudson


Program Hope, and Tumblers Ridge have
itinerant visiting public health
services available on a biweekly
or monthly basis

Viral Hepatitis C Referrals to Referrals to Education is provided to Public


Clinic PG PG Health Nurses across the NW

2
Van Netten, C. Preliminary Report of the BC Radon Survey, Phase 2, 1991-1992
University of British Columbia report.

53
Northern Cancer Control Strategy Final Report

Program/Service Northern Northwest Northeast Comments


Interior

Heart Health There is a There is a School age focus on healthy


cardiac cardiac nutrition and activity.
rehab rehab
program in program in Adult focus is “Hearts at Work”
Smithers, FSJ and in
Although these programs are
Prince DC
focused on cardiac rehab they
Rupert and
also do some prevention and risk
a CHF
reduction work.
focus in
Kitimat and
Terrace

Tobacco Control Over 150 counselors have taken


Strategy the NICC training in NH.

WCB Regulations has increased


the number of non-smoking
establishments as well as those
with ventilation rooms.

Canadian Cancer Strategy is to improve population


Society Prevention health by targeting priority risk
Strategy factors through: public education;
community engagement; and
advocacy

Sun Safety No specific program for NH but


various activities organized by
community

Environmental Drinking Water Safety, Tanning


Health Laser Safety, Air Pollution
studies, Radon investigation,
Industrial Chemicals etc.

Nutrition Nutrition and healthy eating is an


area that nurses are involved in
as they are tobacco reduction

Sexually Services vary by community


Transmitted
Disease Clinics

54
Northern Cancer Control Strategy Final Report

Program/Service Northern Northwest Northeast Comments


Interior

Chronic Disease Activities across the region


Management include collaboratives for
diabetes and CHF, Awareness
Inventory Planning Sessions,
Centre for Aging and Healing,
Use of CDM Toolkit etc.

Primary Health Community Health Centres in 7


Care Initiative sites
Prevention Support Programme:
addressing clinical prevention by
physicians with support of
multidisciplinary team –
measures include
overweight/obesity, diet, BP,
smoking, colorectal cancer,
cervical cancer screening, breast
cancer screening

6.3. Screening
The following table outlines the programs and services available for Northern
Residents.

Program/Service Northern Northwest Northeast Comments


Interior

Screening Rates are below provincial


Mammography average particularly in the NW
and NE.

Cervical Cancer Slightly lower than the


Screening Provincial average across all
HSDA’s may indicate access
problems.

Women’s Health Primary Health Care Transition


Care Program Funding is enhancing
reproductive health services
and screening for cancers of
the cervix and breast as well as
Sexually Transmitted Infections
(HPV) in 6 rural communities.
Aboriginal service providers
have also been trained.

55
Northern Cancer Control Strategy Final Report

Program/Service Northern Northwest Northeast Comments


Interior

Colorectal Provided across the Region but


screening and no formal program.
detection

Prostate Screening Limited Limited Limited No formal program.

PSA testing available across


the region. Sporadic
educational sessions provided.

6.4. Detection, Treatment and Care


Facility Diagnostic Procedures by HSDA
Mammography

U/S Aspiration
Breast Biopsy

Lab Services
NM Sentinel
Core Biopsy
Localization

Stereotactic

Breast MRI

Bone Scan
Breast CT
Fine Wire

Nodes
NW Prince
Rupert
(serving
QCI)

Terrace,
Kitimat,
(serving
Dease
Lake,
Stewart
and Atlin)

Smithers, mobile
Hazelton
and
Houston

NI Lakes mobile
District

Omineca mobile

Prince
George

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Northern Cancer Control Strategy Final Report

Mammography

U/S Aspiration
Breast Biopsy

Lab Services
NM Sentinel
Core Biopsy
Localization

Stereotactic

Breast MRI

Bone Scan
Breast CT
Fine Wire

Nodes
Quesnel Future
Plans

Robson mobile
Valley

MacKenzie mobile

NE North
Peace

South
Peace

Treatment and Care Programs and Services

Program/Service Northern Northwest Northeast Comments


Interior

Surgery Cancer surgery is performed across


NH; however, some surgeries are
referred to other regions e.g. thoracic
surgery is referred to Kelowna.

Radiation Therapy not not not Patients must travel to one of the
available available available BCCA sites such as Vancouver,
Kelowna, Victoria or Fraser Valley for
treatments. Some patients,
particularly in the NE, are referred to
Alberta.

Chemotherapy/ In partnership with BCCA,


chemotherapy is offered in many
Systemic Therapy communities in NH.

One internist with expertise in medical


oncology is available for consults.

Family Practice limited limited limited The Family Practice Oncology group
care is working with BCCA to improve the
capabilities of family practitioners in
the communities to manage cancer
patients. Several family practitioners
have taken the oncology training
offered by BCCA.

57
Northern Cancer Control Strategy Final Report

Program/Service Northern Northwest Northeast Comments


Interior

Support Services: limited limited limited Psychosocial support generally comes


from Support Groups and Cancer
Psychosocial nurses.
Rehabilitation No speech language pathologists
available for cancer patients in NH.

3 Lymphapresses are used in PG to


treat lymphedema in breast cancer
patients. Some education is provided.

Nutrition Nutrition advice is generally on an on-


call basis.
Pharmacy

Home Care
Pastoral Care is offered at PGRH,
Pastoral Care other communities coordinate with
local ministries.

Palliative Care, Palliative Care services in Northern


Hospice Care & Health are limited. Only NI has a
Pain Management dedicated palliative coordinator. The
other HSDA’s use home care and acute
care nurses as well as home support
aides as need arises.

Evening and night services are


available only at the end stages of
palliative care by on-call staff.

Each of the HSDA’s has a different


strategy for the use of palliative
care/hospice funding.

Pain management – no specific


program but there are a variety of
nurses within the hospital and in the
community who have some expertise in
pain management.

Canadian Cancer Trained cancer survivors assisting


Society newly diagnosed patients

Financial assistance to patients in need

Telehealth Videoconferencing services in 13


communities across the region used for
education of health care providers and
patients/public.

Other limited limited limited Complementary/Alternative Therapies –


massage therapy, therapeutic touch
and naturopathic treatments available in
some communities privately e.g. The
Centre for Integrated Healing is looking
to develop a satellite centre in Smithers.

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Northern Cancer Control Strategy Final Report

6.4.1. Referral rate for Radiotherapy to BCCA sites within 12 months of


Diagnosis by Cancer Type and HSDA for the Period 2001-2003

2001-2003 Annual Breast Colorectal Lung Prostate Other All


Number Cancers

East 302 37.6 14.5 31.0 38.3 7.9 21.6


Kootenay

Kootenay 384 44.3 20.0 38.6 28.6 17.9 26.5


Boundary

Okanagan 1737 50.4 15.6 41.7 35.7 21.2 29.9

Thompson 996 52.3 14.6 36.9 32.1 23.1 28.9


Cariboo
Shuswap

Fraser East 1041 54.6 14.9 41.3 35.7 22.0 30.7

Fraser North 2091 58.6 18.2 41.3 34.0 23.4 32.2

Fraser South 2335 61.7 14.3 46.2 27.9 24.6 31.7

Richmond 608 64.5 19.6 38.4 24.3 21.2 31.0

Vancouver 2184 63.0 18.7 41.5 31.9 22.0 31.5

North 1204 61.4 13.2 37.9 36.7 18.8 29.8


Shore/Coast
Garibal

South 2177 67.9 17.0 40.7 35.3 22.1 32.5


Vancouver
Island

Central 1354 59.3 19.0 42.3 35.4 21.9 31.7


Vancouver
Island

North 234 67.7 15.8 48.5 42.0 25.2 35.8


Vancouver
Island

Northwest 257 60.6 29.4 38.8 34.8 22.8 34.0

Northern 486 41.4 14.5 25.8 35.4 21.3 26.2


Interior

Northeast* 151 25.4 15.3 13.2 16.7 14.1 16.1

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Northern Cancer Control Strategy Final Report

2001-2003 Annual Breast Colorectal Lung Prostate Other All


Number Cancers

Total 17782 58.8 16.8 40.7 33.2 21.9 30.8

PREPARED BY: Sherry Reid, Data Analyst - Surveillance & Outcomes, PPO
DATE PREPARED: 15 November 2004

*These rates are artificially low as they do not include services provided by the Alberta
Cancer Board. See page 26.

6.4.2. Palliative Radiation Therapy Statistic from BCCA


Palliative radiation therapy utilization by health region (% of total use
per region)
6 0 .0 0 %

5 0 .0 0 %

4 0 .0 0 %

3 0 .0 0 %

2 0 .0 0 %

1 0 .0 0 %

0 .0 0 %
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

In te rio r F ra s e r V a n c o a s ta l V a n Is la n d N o rth e r n

Palliative radiation therapy per total population


0.001600

0.001400

0.001200

0.001000

0.000800

0.000600

0.000400

0.000200

0.000000
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

int f raser van coastal van island northern

60
Northern Cancer Control Strategy Final Report

6.4.3. Radiation Therapy Patients Referred to BCCA Treatment Facilities


The following table represents the numbers of Northern patients referred to other
B.C. Cancer Centres for radiation therapy in 2003 and 2004. Source: BCCA

Total Vancouver Island Fraser Interior


Patients

2003 357 309 2 2 44

2004 (to 306 245 8 3 50


October)

6.4.4. Palliative Care Statistics (Prince George)

Admissions # Active Deaths Consultations


Clients

2002-03 160 401 163 385

2003-04 172 506 162 392

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Northern Cancer Control Strategy Final Report

6.4.5. Palliative Radiation Therapy Utilization Data (Source BCCA)


2000 2001 2002 2003
Palliative RT - percentage of total courses
Interior 44.76% 47.21% 47.51% 48.13%
Fraser 43.66% 45.86% 45.42% 46.54%
Vancouver Coastal 41.66% 39.71% 44.87% 43.94%
Vancouver Island 44.38% 41.04% 44.92% 47.13%
Northern 36.96% 33.68% 39.12% 37.80%

Palliative RT - courses per population


Interior 0.001029 0.001151 0.001223 0.001216
Fraser 0.001002 0.000957 0.000983 0.002064
Vancouver Coastal 0.000966 0.000835 0.000983 0.000959
Vancouver Island 0.001426 0.001428 0.001458 0.001513
Northern 0.000454 0.000437 0.000510 0.000471

6.4.6. Chemotherapy Administration by HSDA


The following table lists the locations where chemotherapy is administered, how many
visits (first parenteral chemotherapy start as well as subsequent visits), as well as the
level of service provided as defined by BCCA.

Location Hospital Centre or Chemo Chemo


Service Visits Visits
2002/03 2003/04

Prince Prince George Regional Hospital Centre 1590 2014


George

Dawson Dawson Creek & District Hospital Service 173 146


Creek

Fort St. Fort St. John Hospital Service 246 169


John

Prince Prince Rupert Regional Hospital Service 157 272


Rupert

Smithers Bulkley Valley District Hospital Service 241 159

Terrace Mills Memorial Hospital Service 139 219

Kitimat Kitimat General Hospital Sites that offer unavailable unavailable


limited
Quesnel Quesnel Health Services chemotherapy
administration
Queen Queen Charlotte Hospital
by physician or
Charlotte
Masset nurse.
Isl.
Northern Cancer Control Strategy Final Report

6.5. Implementing the Priorities


6.5.1. Establish a Cancer Control Program for NH integrated with the BCCA
Provincial Cancer Control Program
The priority: Northern Health and BCCA will jointly establish a Regional Cancer
Program with focused leadership that will be responsive to community needs and assist
with the coordination of services, programs, standards and guidelines across the North.
The NH Regional Cancer Program will operate like a ‘bureau’ that supports and enables
the communities across the three HSDA’s to coordinate and deliver service. It will support
existing local programs e.g. Family Practice Oncology Network, the Community Cancer
Centre and Services, the Surgical Services, Palliative Care etc. by providing the much
needed capacity to share information, evaluate outcomes and implement improvements
and enhancements to services. The Bureau will define and coordinate services that
support clinical care as well as patient and provider education e.g. telehealth, navigation
and transportation. The Bureau will also enable the dissemination of standards and
guidelines across programs e.g. service delivery models, quality improvement plans,
outcome indicator monitoring, etc to ensure that activities and new initiatives are
improving outcomes. The Bureau will also liaise with the Yukon and Alberta to optimize
the ability to share information and services and to monitor travel/referral patterns.
The mandate of the Regional Cancer Structure will be to use data and evidence to
decrease incidence, reduce mortality and/or improve the quality of life and access for
cancer patients in the North. The leadership of the Program will report jointly to BCCA
and NH to ensure coordinated input from both organizations.

BCCA
NH
Yukon and
Alberta

NH Regional
Cancer Program
Leader

Clinical Nurse Specialist Information,


Telehealth
•Navigation Standards Medical Specialist
Coordinator
•Research Coordinator
•Best Practices

Outcomes expected: There will be leadership capacity to coordinate programs and


services, monitor and share results and implement improvements. Guidelines and
standards can minimize inappropriate practice variations, support quality improvements,
and optimize the use of scarce resources. Cancer patients will experience less
fragmented care and care providers will have the knowledge and access to supports and
expertise to deliver the care required in their local areas.
Who, What and When? Northern Health and BCCA will jointly establish the Regional
Cancer Program. A leader will be appointed and will report to a senior level in both
organizations. Staff will be needed to develop and coordinate programs and implement

63
Northern Cancer Control Strategy Final Report

the priorities discussed in the next section e.g. navigation, transportation, telehealth,
information management etc.

6.5.2. Action Plans for Short Term Priorities


6.5.2.1. PREVENTION, PROMOTION AND SCREENING
PRIORITIES
a) Comprehensive Tobacco Control Strategy
The priority: Develop a strategic comprehensive tobacco control strategy across
Northern Health. The current program is led by Northern Health through Public Health.
Current core funding for these positions totals $246,000.
Northern Health has developed a Regional Tobacco Control Strategy. The framework for
this strategy includes four pillars:
1. Education
2. Cessation/Stop Smoking
3. Enforcement
4. Policy Development
Aspects of this Strategy have been implemented successfully over the last five years.
This has included the creation of part time Regional Tobacco Reduction Coordinator
positions (1.6 FTE), responsible for developing and delivering tobacco reduction
programs in the Health Service Delivery Areas and Regional Tobacco Enforcement
Officer positions (1.5 FTE), responsible for enforcing federal and provincial legislation
related to access by minors to tobacco and tobacco products. As well, a Nicotine
Intervention Counseling Centre (NICC) has been initiated in the Northern Interior to
provide smoking cessation services including Nicotine Replacement Therapy. Work is
underway to expand this program to the Northwest and Northeast Health Services
Delivery Areas. The NICC program was developed and funded through a grant from
Health Canada and the Healthy Heart Society. This funding ends March 2005. The NICC
program has been structured around best practices used by the Mayo Clinic and early
evaluation results indicate a successful smoking cessation rate of 25 to 30%.
As of November 2004, over 1500 people accessed the NICC program; of these, 926 are
still active. The age range is from 16 to 75 and over, years with the majority in the 45 to
54 age group range.
Outcomes expected: Clear understanding of the risks of smoking, reduced smoking and
reduced incidence of cancers attributed to tobacco use.
Who, What and When? Northern Health will lead this initiative through the leadership of
the Medical Health Officers. Partnerships with Health Canada, First Nations and Inuit
Health Branch, and the Ministry of Health Services will be critical to successful
implementation.
In order to ensure comprehensive and strategic action related to Tobacco Control,
resources will need to be dedicated to education, cessation/stop smoking, enforcement,
and policy development over the long term. The Tobacco Control Strategy also includes
plans to address the need for Aboriginal focused tobacco cessation program
development and delivery and the need for ongoing program surveillance and evaluation.
Initial work has started in these two areas.

b) Women’s’ Health Program


The priority: This is a project supported by BC Women’s & Children’s through their
primary health transition funds. It is a three year project with a budget of $250,000 over
the three years. The program is in the second year of the three year project and its

64
Northern Cancer Control Strategy Final Report

mandate is to conduct Pap tests and breast exams for women who do not access this
service through medical practitioners. Also included is testing for STIs. This is an ongoing
project that is still in the developmental stages. It involves training public health nurses
and other nurses to provide the service, establishing competencies, and setting up clinics
encouraging women to access the service. The original target was to establish this
service in 6 communities across the North with a special focus on Aboriginal women.
Outcomes expected: Increased percentage of underserved female population will be
screened for cervical cancer and will access mammograms
Who, What and When? Lynda Anderson, Coordinator, Women’s Health Program

c) Programs and best practices


The priority: Investigate known programs and best practices that reduce the incidence of
cancers amenable to preventive action. Currently, Northern Health does not have a
comprehensive strategy focused on healthy living. Over the next couple of years,
Northern Health should work towards the development of such a strategy in conjunction
with the direction emerging from the Ministry of Health Services. A regional strategy will
need to be carefully designed and adequately resourced over a minimum of five years in
order to meet the needs of a diverse population in a large geographic area.
Public Health currently works in partnership with a number of other organizations in the
development of health promotion initiatives focused on healthy living. In general, these
initiatives are community or program specific. For example, Northern Health is involved in
Chronic Disease Prevention activities in 7 communities involved in a Chronic Disease
Prevention and Management Collaborative Process. In addition, Northern Health has
supported a Diabetes Prevention initiative funded by Health Canada, focused on Healthy
Eating, Active Living over the last several years. Some early work has been done with
several Schools/School Districts in relation to food choices available to students.
Northern Health will also be participating in new initiatives focused on healthy living
recently announced by the Ministry of Health Services (Act Now).
Outcomes expected: More Programs in operation across NH that reduce the incidence
of cancer.
Who, What and When? Northern Health – Public Health Programs through the Chief
Medical Health Officer and Regional Director, Preventive Public Health Programs and the
Regional Public Health Operating Council.
This priority will focus on raising awareness, health education, supporting individual risk
reduction, community development, and policy development. A phased-in approach to
strategy implementation will be required in order to account for varying degrees of
community readiness, the variety of community specific partnerships possible, and the
unique needs of particular communities and population groups. Initial steps should
include:
Review of known programs and best practices, particularly those that have been
proven in rural and remote regions
Identification of other initiatives that could be used as a foundation for further
work e.g. Chronic Disease Prevention and Management activities, community
nutrition activities etc.
Identification of potential regional and community partners
6.5.2.2. DETECTION AND DIAGNOSIS PRIORITIES
a) Complete a Retrospective Analysis of Stage of Presentation
The Priority: Generally the region covered by the Northern Health Authority has
standardized incidence rates of cancer which are similar to other regions of British

65
Northern Cancer Control Strategy Final Report

Columbia. These rates reflect the risk of the population to develop cancer and do not
evaluate the efficacy of the medical system in diagnosing and treating cancer. The
potential effectiveness of medical care is more appropriately reflected by cancer survival
rates which measure the likelihood that an individual diagnosed with a particular cancer
will live for a pre-specified time. Examination of cancer survival rates, for the five health
authority regions, shows Northern rates to be a little below the provincial average.
These differences are not dissimilar to those observed between different provinces of
Canada. Because of the relatively small magnitude of the differences it is unlikely due to
large differences in diagnosis or treatment, however in order to investigate this further it
will be necessary to adopt a multi-phasic approach.
Outcomes expected: The outcome of the retrospective study will provide a better
understanding of where resources and effort should be focused to improve survival.
Who, What and When? The following steps are suggested:
1. Identify sentinel cancers. It is not practical or statistically wise to try to
investigate all different types of cancer. Two to three major cancers would
be identified as indicators of underlying patterns of diagnosis and treatment.
These cancers would have the following characteristics: 1-2 would be
cancers for which effective screening exists, multi-modality care is indicated
in their management, and differences in survival exist between North and the
rest of BC.
2. Analysis would be conducted within the North on outcomes for these sentinel
cancers. The objective is to determine whether subgroups can be identified
where differences are greater than the average.
3. Using the groups so identified, analysis of existing data would then be
targeted to identify potential causes. It is anticipated that the cause could fall
into two broad classifications: disease is more advanced at diagnosis in the
North than elsewhere or curative treatment is ineffectively applied.
4. Prospective data would then be collectively within the groups to
independently confirm the validity of the conclusions from step 3.
Personnel Involved: BCCA statistical staff, BCCA clinical experts on sentinel cancers, NH
experts on delivery patterns, NH statistical staff.
Time frame: Step 1: month 1, Step 2: month 2, Step 3: months 3-5, and Step 4: months
6-10, Final report: months 11-12

b) Diagnostic Testing
The priority: Currently in the North, patients who present with signs or symptoms may
not always follow the most expedited path to a definitive diagnosis. This not only delays
diagnosis but causes stress for the patient and wastes NH resources. This initiative will
improve primary care linkages to develop a coordinated system from first encounter to
screening, detection, treatment and follow up. Medical staff and diagnostic departments
will need to develop quality improvements in practice to bring practice to standards as set
by BCCA. Scheduling will also be a focus of this priority. Residents of many of the
smaller communities must travel to larger centres to access screening, imaging and lab
services. The lack of coordinated scheduling requires the patients to attend multiple sites
over a longer period of time resulting in delays and travel inconveniences.
Outcomes expected: Patient is supported and informed and is enabled to access
services in a timely way (e.g. through initial consult to follow up). Standard clinical
pathways will be utilized across the North.

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Northern Cancer Control Strategy Final Report

Who, What and When? BCCA will provide clinical pathways/CPG’s to NH. NH will need
to formalize the use of CPGs related to screening and detection, and then adopt a quality
improvement process with primary care physicians around use of these CPGs.
The NH Medical Director will implement this priority with family practitioners and
diagnostic departments. This work will involve the development of communication
strategies to involve and inform the physicians. The Family Practice Oncology Network
will be a resource in implementation planning. There will need to be an investment in
infrastructure to support implementation, ongoing monitoring and continuous
improvement.

6.5.2.3. TREATMENT AND CARE PRIORITIES


a) Transportation strategy
The priority: Traveling to other facilities in NH or to other cancer centres for treatments
(e.g. radiation therapy) presents financial challenges for patients.
Outcomes expected: Coordination and assistance with transportation costs for access
to screening/diagnosis/care/treatment will reduce the financial hardship on patients
having to travel to access services and treatment.

Who, What and When? The Northern HEALTH CONNECTIONS Program (NHCP) will
be a $4m initiative managed by Northern Health for the residents of the North.
Complementary to, but distinct from, the Provincial Travel Assistance Program the NHCP
will enhance access to health care services for people encountering travel and
accommodation barriers.

The NHCP is open to any resident of Northern Health with no restrictions based on age,
income, or disease type. Persons with access to other travel or accommodation
assistance, e.g. WCB, social assistance, employer-paid, band-paid etc., are expected to
access those funding sources first. NHCP not meant to replace other funding sources.

Although the NHCP will not directly reimburse individuals for expenses incurred, the
NHCP will work with transportation and accommodation providers to provide reduced
rates to persons who have to travel out of their home community to access health
services. Services eligible will be all hospital and physician office based programs, e.g.
laboratory, diagnostic imaging, in and out patient services, scheduled physician office
visits, as directed and required by physician referral.

Northern Health is currently in the process of hiring a manager to oversee the


development and implementation of the NHCP, and is engaging pilot sites in Fort Nelson,
Kitimat, and the Robson Valley in preliminary development consultations.

b) Surgical Oncology

The priority: The Surgical Oncology Network's includes all providers of surgical oncology
services. The Network's goal is the integration of quality surgical oncology services into
the formal cancer care system. It does that through: creating communication tools to
enhance surgical decision making; participating in the identification and/or development
of peer-reviewed, evidence-based guidelines based on "best practice" principles;
developing a high quality continuing education program that meets standards of the
Royal College of Physicians and Surgeons; conducting regionally based research and
outcome analyses to provide vital information for Network initiatives.

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The network council has members for all health regions as does each of its committees
and taskforces. Dr Gil Wankling of Prince George serves on the Executive of the
Network. The network annually has its "annual road show" combining provincial and local
expertise to bring continuing medical education to the surgeons of the region. It is also
provides a venue from surgeons across the health region to meet and discuss common
issues with respect to cancer care. When guidelines are developed it is the input of
surgeons from across all regions that help to ensure that not only are the guidelines
representative of best practice but that the implications on service delivery are known.
The Network is currently undertaking a provincial infrastructure survey so the supports
available to surgeons in the care of cancer patients will be identified by hospital.

As the data shows, for the most part the residents of the north have access to surgical
care for the treatment of their cancer. The guidelines and continuing medical education
supports surgeons to provide the highest quality care. On going monitoring (as is
currently the case for networks current rectal cancer outcome project) provides quality
assurance that residents are indeed getting access to quality care.

Outcomes expected: The Network's goal is the integration of quality surgical oncology
services into the formal cancer care system.
Who, What and When?
BCCA to conduct a provincial infrastructure survey so the supports available to
surgeons in the care of cancer patients will be identified by hospital
BCCA to continue and enhance communication with Northern surgeons

c) Systemic therapy (chemotherapy)


The priority: Review the delivery of chemotherapy across NH including the linkage to the
POHN (to develop appropriate pediatric services). The provision and delivery of
chemotherapy services in the North is provided primarily through the Vancouver and
Southern Interior Regional Centres, Community Cancer Centres/Clinics (Prince George
and Kitimat) Community Cancer Services Nurses (Fort St. John, Dawson Creek,
Smithers, Terrace and Prince Rupert). Recognizing the levels of service provided and
the issues raised at the stakeholders meeting (Prince George, January 28, 2005), it is
desirable that an external review be undertaken.
Outcomes expected: Continuity of care and safety standards that are measured and
met by ensuring the following:
Growth is managed strategically in selected communities
Better coordination/communication with ordering oncologists
Designated chemo certified nurses with capacity for back-up
Sick, vacation, increased workload
System of measuring efficacy of treatment cycle by cycle
Patient satisfaction as measured by an evaluation
Family physician trained in oncology in every community where chemo is
administered
Sustainable care delivery model for chemotherapy that includes:
Traveling oncology nurses
Sufficient medical oncology expertise
Itinerant family physician trained in oncology

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Telehealth
Mobile service
Who, What and When? The Terms of Reference of the External Review would include
familiarization with the current model for the provision and delivery of chemotherapy
services to Northern residents, BCCA documentation regarding standards for delivery of
chemotherapy, PHSA and Northern Health Information Systems (including health
records). The review team would make site visits to communities that house the three
models of care (e.g. Regional Cancer Centre, Community Cancer Centre/Clinic and
Community Cancer Services Nurses). A written report would be presented to NH/BCCA
Steering Committee or designates.
The reviewers will be a team with BCCA Systemic Therapy working knowledge,
Information Systems\Health Records, Rural knowledge and Administration experience. It
is suggested that one member be a BCCA General Practice Oncologists with experience
working with Northern patients and the BCCA, Family Practice Oncology Network. As
Manitoba has established strong community outreach programs for the delivery of
chemotherapy care, a member of the team could be chosen from Manitoba. The third
member should have the skills that are not covered by other members of the team and
fulfill those experiences identified in the first sentence.
The review will take 3 months to complete from initialization to report submission

d) Navigation
The priority: A Patient Navigator is someone who helps patient’s access information and
support throughout the cancer journey by linking them to the formal and informal
networks and resources that exist within their region. By co-coordinating efforts so that a
patient receives information, psychosocial supports, and practical assistance in a timely
manner, patients are helped to develop effective coping strategies that maximize healthy
functioning. Helping a patient access the many support networks that exist outside of the
formal health care system increases adjustment and quality of life. In regions that have
fewer support resources, a Navigator may be required to provide information and support
directly to patients, and therefore must have the professional expertise and skills to do
so. A Navigator may also use community development methods to build capacity for
providing support within communities. The ability to network and build collaborative
relationships is essential.
An effective patient Navigator may have a nursing or social work background as
knowledge about the care process, from start to finish, is essential in communicating to
patients. Basic medical knowledge about cancer is needed (e.g. diagnostic procedures,
test results, treatment options, side effects and management) as is knowledge of
information resources that patients can access to gain more detailed understanding of
their disease and treatments. The ability to assess psychosocial needs is also required.
About one third of cancer patients experience high levels of distress: patients suffering
emotional distress have more difficulty making decisions about treatment, seek more
medical consultation, and are less satisfied with the medical care. Therefore a Navigator
must have sensitivity and superb communication skills in order that she/ he can respond
appropriately to the concerns of distressed patients, can provide emotional support when
needed, and refer to expert counseling if necessary. Knowledge of the practical needs of
cancer patients and helpful resources is needed (e.g. transportation, financial). Lastly,
knowledge of local and distant resources and supports, and a willingness to continuously
access and increase those resources, will enhance the efficacy of the Patient Navigator.
NH will need to develop navigation services across NH using pilot projects to expand to
additional communities.
Outcomes expected: Improved access and movement through the continuum of care
via:

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Identification of navigational needs in communities


Identification of what is already in place
Identification of tools and resources available and/or needed
Cancer care toolkit that can be downloaded into every physician’s computer
Who, What and When? BCCA will provide expertise/funding. NH will provide resources
and funding. Approximately 3.0 FTE additional resources will be required as this service
represents increased roles across the HSDA’s. These positions will be part of the
Northern Cancer Program.

e) Enhanced Consultation
The priority: The Agency currently provides consultation and follow-up for cancer
patients in the North through the attendance of a radiation oncologist at regularly
scheduled consultative clinics in Prince George, Prince Rupert, Terrace, Dawson Creek
and Whitehorse. While these clinics in some cases eliminate the need for patients to
travel to Vancouver for consultation, they are essentially a triage function whereby the
attending oncologist confirms the patient’s need for treatment and then redirects them to
the appropriate radiation oncologist in Vancouver on a tumor-site specific basis. The
resulting delay in many cases is an additional delay in seeing the appropriate individual at
BCCA which negates the value of this service for many patients.
The well-developed infrastructure in telehealth in both the North and at the BCCA offers
the opportunity to reconsider how consultative services to appropriate tumor site specific
specialists in radiation oncology as well as medical and surgical oncologists could be
developed. Telehealth linkage could also be of value to primary care physicians to
provide assistance and advice on patient management particularly in relation to many of
the clinical problems faced by patients in the post-treatment phase of their illness.
Outcomes expected: The potential contribution of telehealth to improving access to sub
specialists in all the oncology disciplines for both specialists and primary care physicians
in the North has not been formally discussed to date. It is recommended that this occur
in the short term as a means of enhancing access to, and quality of, care for patients with
cancer in the Northern Health Region.
Who, What and When? Review effectiveness of existing Consultation Clinics in NH.
Develop and panel of experts with formal slots available for access by NH family
physicians.
NH: Integrate with Transportation and Navigation Strategies
BCCA: to expedite access

f) Telehealth
The priority: Enhance the capability and use of telehealth and information technology to
improve cancer control (e.g. web-based guidelines/standards, telepathology, sub-
specialty consultation, patient and professional education, navigation etc.). Telehealth
offers practical alternatives for the delivery of health care services. Effective use of
telehealth should integrate and support existing structures in rural and remote
communities. It can improve access to specialized high quality cancer care, education,
training and supervision, while decreasing the resource impact on the provider and
recipient. The use of this technology should be outcome-focused and evidence-based,
leading to the development of a model for use internationally.

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NH Mission for Telehealth: Dedicated to improving the health of all Northern


Health residents through an innovative and effective communications network that
provides:

Enhanced access to clinical services for clients


Education for patients and education for health care providers to build capacity
within communities
A more efficient alternative to travel to supplement health care administration and
planning
Outcomes expected: Patients and service providers have equitable access to cancer
services (e.g. from pre-diagnosis to treatment and beyond) based on best practice
requirements for time, expertise and frequency.
Who, What and When?
Designate NH lead for coordination between NH and BCCA
Identify best practice and clinical practice guidelines in telehealth practice
Develop adequate infrastructure for telehealth
Ongoing development of BCCA website (including feedback from NH)
Review any MSP issues around concurrent billing
Review the impact on policy development
Develop an ‘information central’ re surgeries done, availability of resources (e.g.
Surgical Oncology Network)
Year one will focus on NH family physician access to BCCA specialists for consultation.
Year Two of this priority will focus on patient consultation and staff education.

g) Palliative Care
The priority: Develop a coordinated comprehensive Palliative Care Program that has
linkages with Home Care, the BCCA Provincial Palliative Care Network and other similar
rural sites. Northern Health developed a Palliative Care Strategy in 2004. The purpose of
the Palliative Care Strategy is threefold:
To improve access to Palliative Care services.
To increase the quality of Palliative Care services
To improve the integration and coordination of Palliative Care services
throughout the North
The Palliative Care Strategy identifies four broad strategic areas for action. They include:
Position Palliative Care services within the organization structure of Northern
Health and establish a system of leadership.
Establish a coordinated network of Palliative Care Services supported by policies
and procedures, protocols, and clinical practice guidelines.
Build the capacity of Palliative Care service providers.
Quality management – develop program performance measures that will be used
to facilitate improvement in the delivery of services.

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Outcomes expected: Comprehensive regional program that includes:


GP Physician involvement and leadership
Palliative Care and End-of-Life Care
Single point of entry
Delivering 24/7 support for clients and providers
Delivery across acute, residential and community sectors
Consistent use of Palliative Care Norms of Practice
Linkages with BC Cancer Agency, Federal Pallium program, BC Hospice and
Palliative Care Society, BC Nurseline, Victoria Hospice Society
Partnership with Prince George Hospice Society
Who, What and When? Leadership: Northern Health through Executive Director, Home
and Community Care and Chief Operating Officers.
Implementation planning has been started and includes establishing physician
leadership, designing a model of service delivery that will be effective in a large
geographic, rural region, establishing standards, guidelines, and policies, creating skill
development and education plans, and supporting the role of volunteers and community
hospice/palliative care organizations. Additional resources will be required to proceed
with regional implementation of the Palliative Care Strategy in Northern Health. Linkages
have been established with BC Cancer Agency, Federal Pallium Program, BC Hospice
and Palliative Care Society, BC Nurseline, and Victoria Hospice Society.

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6.5.3. Northern Cancer Program 2005-2006 Budget – Working Draft

Northern Cancer Program Activities NH Resourcing MOHS & BCCA

Program Leadership and Measurement:

• Leader with dual reporting (includes support) $75,000 $75,000


• Measurement: Staging Study $50,000
• Access, Travel Support & Communications $400,000
• Program Accommodations, Communications & Start Up $150,000
(mostly capital and non-recurring)

Healthy Living and Cancer Prevention:

• Tobacco Control:
• Transfer of Pilot Program from HC to NH $350,000
• Program Expansion to full region $350,000
• Best Practices Review - Prevention $25,000
Detection and Diagnosis:
• Application of BCCA diagnostic protocols and HSDA $30,000 $5,000
investigation & process redesign
• Mammography screening & Reproductive Health $30,000

Treatment:

• Support for SON and FPOG development in NH $5,000


• Enhanced consultation (radiotherapy) Telehealth Pilot $75,000 $75,000 (plusMD’s)
• External Review Systemic Therapy $25,000
• Nursing Capacity for Navigation & Clinics $375,000
• FPON sessions (1/wk/HSDA) $100,000

Palliative Care:

• Program expansion in 3 HSDA’s per NH PC Plan $500,000

Total

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