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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.

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10 comments

  1. D. Amormino

    Well said Chris. %featured%Sadly, most critical decisions are blindly made by the government without consulting those in the trenches. Detroit health care centers look more appealing each and every time an ignorant political decision is implemented replacing any health priority here in Ontario. Rather than turn to the experts in the field, money rules at the end of the day. %featured%Continue to keep the public informed, Chris. Thank you.

  2. Dr. Stubbards-Fox

    As a physician in a cancer-related discipline, I can say with aplomb that Cancer Care Ontario is causing more problems for patients than it is solving.

  3. Dr Bill Taylor

    Chris

    What a well researched and expertly written article. Please send this to the Windsor Star !!

  4. Christina Cass

    Thank you Christopher!!
    Please submit your article to the Windsor Star!!

  5. E. Filice

    Very well said! Hopefully Prem. Wynne will read this as well as the Board of CCO, who obviously does not have all of the facts straight!

  6. Jesse

    Without a more serious analysis proving the cost-effectiveness of a separate thoracic surgery program, I find this paper’s argument underwhelming. Sentimentality reigns here and the author’s critique of this being a point of theory versus reality becomes shallow and lacks a refined understanding of medical decision making and public administration.

    Already, the author states that the ‘ scenarios requiring urgent thoracic surgery or input from a thoracic surgeon are rare.’ Bringing up one of the Canada Health Act’s principles is equally met by my question about the author’s depth of understanding of this principle of ‘accessibility’; how does he understand this decision in the light of increasing health budgets? Wanting everything sometimes leads to one having none of it. London is two hours from Windsor by vehicle traveling at a normal highway speed. Surely, ORNGE and EMS can reduce this travel time down to nothing. Further, I’m not convinced that centralization of this program in Southwestern Ontario fails to meet the principle of accessibility defined as provision of ‘reasonable’ services; neither is he, given his points on rarity.

    It already sounds as if Windsor is having massive health infrastructure investments and one wonders whether this author’s more appropriate message to Premier Wynne might be: “Thank you”.

  7. Chris Byrne

    Hello Jesse,

    I am happy that this opinion piece is generating discussion.

    By far the biggest motivator for me to write this opinion piece was the letter Michael Sherar, President and CEO of Cancer Care Ontario (CCO), wrote to Ken Deane back in September. The letter is linked in the article above. The threatening nature of Mr. Sherar’s letter, as Teresa Piruzza (Windsor-West MPP and Liberal cabinet minister) puts it eloquently in her November 13 letter to Deb Matthews, “was unacceptable and outside of [CCO’s] mandate. This tactic hurts the very people they are mandated to help – cancer patients.” At the very least, Mr. Sherar owes the people of Windsor-Essex an apology, as these comments are unbecoming of a leader in his position.

    Jesse, I think your attack on my theory versus reality statement is a bit strongly worded. CCO insists its decisions are evidence-based, yet a request by the Windsor Star for data comparing patient outcomes in Windsor and London was met with an email reply that CCO could not provide those numbers because the small sample size for individual hospitals “creates a large amount of variability and unreliability in the measure as it can change significantly from year to year.”

    Since this article was published, Windsor Regional Hospital has decided to defy CCO’s imperative. I quote Windsor Regional Hospital CEO David Musyj – a refreshing beaurocrat whom I am coming to respect greatly for his leadership over the years – in explaining why he believes Windsor should receive a Level 2 designation:

    “1. There is no substantive reason why Windsor Regional Hospital should not be granted a Level 2 designation as mandated by the 2005 Report. There was no suggestion in the Report to limit the number of Level 2 centers just as there was no suggestion that Level 1 centers should be limited;

    2. The impact of moving the thoracic cancer patients to another center (London or further East) is not just limited to the 50 annual thoracic cancer patients. Hundreds of thoracic cancer and non-cancer thoracic patients will be negatively impacted;

    3. The Cancer Quality Council of Ontario (CQCO), an advisory group that guides Cancer Care Ontario and the Ministry of Health and Long-Term Care estimates in 2013 that the incidence of age-standardized rates for lung and bronchus cancer for Erie St Clair will be 53.8 as compared to an Ontario average of 46.1. The highest in the Province is 55.3 and the lowest is 35.2.

    The age-standardized incidence rate is the number of new cases of cancer that would occur in a specified population if it had the same age-distribution as a given standard population, per 100,000 people, during a defined time period;

    4. With the average thoracic surgeon in Ontario only performing 22.9 lobectomy procedures annually, WRH is host to one of the top performing thoracic surgeons at 18.5 per annum;

    5. Four of the current twelve designated Level 1 centers do not even reach the 150 minimum volumes and one of the two Level 2 centers does not reach the minimum 50 thoracic cancer volumes;

    6. If we adhere to CCO’s suggestion the Erie St Clair LHIN will become one of only two LHINs which does not have a Level 1 or Level 2 center. The other LHIN (North Simcoe Muskoka) only performed 15 thoracic cancer patients at their highest level and only 43 thoracic cancer surgeries over a four year period (2004-2007). In North Simcoe Muskoka, the thoracic cancer surgeries were moved from the Royal Victoria Hospital in Barrie to the Level 1 center in Southlake Regional Health Center which is only 43 minutes away. The travel time between Windsor Regional Hospital and LHSC is 2 hours 6 minutes;

    7. Since the original decision was made by CCO regarding this issue the hospital healthcare system in Windsor has dramatically changed with Windsor Regional Hospital becoming responsible for all acute care services in Windsor and moving towards the design and construction of a new state of the art acute care hospital.

    Now WRH is the third largest community teaching hospital in the Province of Ontario. This Ministry lauded realignment of hospital healthcare services in Windsor and plans for the future of hospital healthcare in Windsor/Essex needs to now be taken into consideration; and

    8. Since the original decision was made by CCO regarding this issue the Schulich School of Medicine & Dentistry (Windsor Program) officially graduated its inaugural class in 2012. This Program has been a huge success for the Province and the Windsor/Essex community. Losing the thoracic surgical program in Windsor has the potential to negatively impact learners at the Schulich School of Medicine & Dentistry (Windsor Program).”

    Jesse, I also disagree with your comment “Surely, ORNGE and EMS can reduce this travel time down to nothing.” This statement reflects disconnect from the reality faced by front line healthcare workers.

  8. Tracy Baselj, MLT, BSc.

    Chris, congratulations on an expertly written piece. You certainly lend a voice to concerns that a lot of Windsorites share. Hopefully your insight will generate a second look in our direction. All the best to you in your academics.

  9. Elizabeth Rankin BScN

    I’m curious to know how patients are more interested to stay in Windsor when the risks are higher for death by a significant 12% greater than those treated and compared with a centre like London for the same type of surgery and having a better outcome? This doesn’t make sense. Even if patients agreed to take on more risk, I personally wouldn’t endorse any health minister to agree to have services that couldn’t match at least the same standard for care and outcomes. I’d insist that a known measure of risk for the same procedure for the same type of patient and their critical state could be achieved using better protocols .

    It does make sense that Windsor could offer more to its community if they address the issues related to patient safety and quality care. The reputation that Windsor has, particularly at Hotel Dieu will be remembered for a long time and perhaps the comments you make that reveal patients want to stay local despite the known local risks is, for me, difficult to believe. I live closer to Windsor than I do London but would choose London for specific needs over Windsor based on what I know and the connections I have to London.

    However, I would like to see Windsor become a leader in what they are setting out to do but this takes more than setting out what you want, it means defining how you’re going to get there. The medical hierarchy and administration know the problems, they have to deal with them before they can build their dreams.

    Elizabeth Rankin BScN

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