Cancer surgery: Ontario does not end at London
I am writing this piece as a Windsor native and current fourth-year medical student at the SchulichSchool of Medicine & Dentistry in London.
Over the last week, I have read with concern the Wynne government’s decision to move all thoracic (esophageal and lung) cancer surgery care out of Windsor. The government declares it is centralizing all thoracic cancer surgeries at Level 1 centres because “We know the more surgeries that are performed, the better the outcomes are and that’s why the decision that’s been made has been made“. While volume-outcome links are established in the literature, the government cannot distinguish theory from reality without providing data to suggest outcomes in Windsor are unlike Level 1 centres across the province.
Perhaps more alarming was the manner in which Cancer Care Ontario wrote to hospital administrators in Windsor. The content of the letter was in essence a threat to remove all incremental funding the agency provides should Windsor’s hospitals continue to provide thoracic cancer surgical care to local patients. Last year, this funding covered 281 of the nearly 1400 cancer surgeries performed.
I have a number of concerns aside from the obvious fact that it necessitates an annual census of at least 50 cancer patients to travel to a location away from their support network for surgery.
Firstly, the government seems to be ignoring access as a dimension of quality care.
The importance of access is highlighted by a study exploring how patients with pancreatic cancer viewed the trade-off between lower operative mortality risk at a regional high volume cancer centre compared to local care. In this study, nearly half of patients preferred local surgery when the local operative mortality risk was twice that of a regional centre (6% vs. 3%). Almost a quarter of patients were willing to undergo local surgery even if the operative risk were four times (12%) the regional risk.
Patients can be informed and seek cancer care in Windsor or London, depending on how heavily they weigh local care versus improved outcomes. Of course, this presumes data on outcomes can be made public.
The government has also set an unfair precedent by making exceptions to the Level 1 rule in Kingston (because it houses a medical school) and Thunder Bay (because of the distance patients would have to travel to the closest Level 1 centre). Windsor is also the site of a medical school campus and it would be a disservice to the 152 students and growing cohort of resident physicians in training to lose out on the opportunity to have exposure to thoracic surgical care where they train.
Is it a coincidence that the Cancer Care Ontario board of directors includes one member from Kingston and one from Thunder Bay?
In addition, the Windsor medical community has expressed sincere concern that this decision will lead to the city losing expertise in thoracic surgical care in general. One of the three thoracic surgeons in Windsor has stated he would be forced to leave the community, while the other two have said they would stop performing thoracic surgeries entirely and focus on other aspects of their practice.
Windsor is designated a Level 1 trauma centre. Accreditation guidelines do not necessitate a thoracic surgical care service, but it is recommended. Discussions with experts in trauma care confirm that scenarios requiring urgent thoracic surgery or input from a thoracic surgeon are rare. Nonetheless, Windsor would be the only Level 1 trauma centre in the province without local access to this potentially life-saving capability.
As recently as last year, the Windsor-Essex community praised the life-saving efforts of an astute emergency physician, who bypassed CritiCall red-tape and a prolonged ORNGE transport to London Health Sciences Centre by arranging for immediate transport of a critically ill child to Detroit for surgery. This story may become all too familiar should Windsor lose access to reliable emergency thoracic surgical services.
With a new and flourishing medical school campus, a proposed ‘mega-hospital’ to consolidate acute-care services in Windsor-Essex, and unique and evolving cross-border relationships with respected medical institutions in Detroit, Windsor is well-positioned to become an innovator in healthcare and medical education.
Instead, the Wynne government is sending a message that it has turned its back on the community, patient care and opportunity.
My message to Premier Wynne: Ontario does not end at London.
Christopher Byrne is a medical student at Schulich School of Medicine & Dentistry.