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Background: Little is known about the association between the COVID-19 pandemic and early survival among newly diagnosed cancer patients. Methods: This retrospective population-based cohort study used linked administrative datasets from Ontario, Canada. Adults (=18 years) who received a cancer diagnosis between March 15 and December 31, 2020, were included in a pandemic cohort, while those diagnosed during the same dates in 2018/2019 were included in a pre-pandemic cohort. All patients were followed for one full year after the date of diagnosis. Cox proportional hazards regression models were used to assess survival in relation to the pandemic, patient characteristics at diagnosis, and the modality of first cancer treatment as a time-varying covariate. Interaction terms were explored to measure the pandemic association with survival for each cancer type. Results: Among 179,746 patients, 53,387 (29.7%) were in the pandemic cohort and 37,741 (21.0%) died over the first post-diagnosis year. No association between the pandemic and survival was found when adjusting for patient characteristics at diagnosis (HR 0.99 [95% CI 0.96-1.01]), while marginally better survival was found for the pandemic cohort when the modality of treatment was additionally considered (HR 0.97 [95% CI 0.95-0.99]). When examining each cancer type, only a new melanoma diagnosis was associated with a worse survival in the pandemic cohort (HR 1.25 [95% CI 1.05-1.49]). Conclusions: Among patients able to receive a cancer diagnosis during the pandemic, one-year overall survival was not different than those diagnosed in the previous 2 years. This study highlights the complex nature of the COVID-19 pandemic impact on cancer care. [ABSTRACT FROM AUTHOR]

Background: With the declaration of the global pandemic, surgical slowdowns were instituted to conserve health care resources for anticipated surges in patients with COVID-19. The long-term implications on survival of these slowdowns for patients with cancer in Canada is unknown. Methods: We constructed a microsimulation model based on real-world population data on cancer care from Ontario, Canada, from 2019 and 2020. Our model estimated wait times for cancer surgery over a 6-month period during the pandemic by simulating a slowdown in operating room capacity (60% operating room resources in month 1, 70% in month 2, 85% in months 3-6), as compared with simulated prepandemic conditions with 100% resources. We used incremental differences in simulated wait times to model survival using per-day hazard ratios for risk of death. Primary outcomes included life-years lost per patient and per cancer population. We conducted scenario analyses to evaluate alternative, hypothetical scenarios of different levels of surgical slowdowns on risk of death. Results: The simulated model population comprised 22 799 patients waiting for cancer surgery before the pandemic and 20 177 patients during the pandemic. Mean wait time to surgery prepandemic was 25 days and during the pandemic was 32 days. Excess wait time led to 0.01-0.07 life-years lost per patient across cancer sites, translating to 843 (95% credible interval 646-950) life-years lost among patients with cancer in Ontario. Interpretation: Pandemic-related slowdowns of cancer surgeries were projected to result in decreased longterm survival for many patients with cancer. Measures to preserve surgical resources and health care capacity for affected patients are critical to mitigate unintended consequences. [ABSTRACT FROM AUTHOR]

There is a global rise in skin cancer incidence, resulting in an increase in patient care needs and healthcare costs. To optimize health care planning, costs, and patient care, Ontario Health developed a provincial skin cancer plan to streamline the quality of care. We conducted a systematic review and a grey literature search to evaluate the definitions and management of skin cancer within other jurisdictions, as well as a provincial survey of skin cancer care practices, to identify care gaps. The systematic review did not identify any published comprehensive skin cancer management plans. The grey literature search revealed skin cancer plans in isolated regions of the United Kingdom (U.K.), National Institute for Health and Care Excellence (NICE) guidelines for skin cancer quality indicators and regional skin cancer biopsy clinics, and wait time guidelines in Australia and the U.K. With the input of the Ontario Cancer Advisory Committee (CAC), unique definitions for complex and non-complex skin cancers and the appropriate cancer services were created. A provincial survey of skin cancer care yielded 44 responses and demonstrated gaps in biopsy access. A skin cancer pathway map was created and a recommendation was made for regional skin cancer biopsy clinics. We have created unique definitions for complex and non-complex skin cancer and a skin cancer pathways map, which will allow for the implementation of both process and performance metrics to address identified gaps in care. [ABSTRACT FROM AUTHOR]

Background: To mitigate the effects of coronavirus disease 2019 (COVID-19), jurisdictions worldwide ramped down nonemergent surgeries, creating a global surgical backlog. We sought to estimate the size of the nonemergent surgical backlog during COVID-19 in Ontario, Canada, and the time and resources required to clear the backlog.Methods: We used 6 Ontario or Canadian population administrative sources to obtain data covering part or all of the period between Jan. 1, 2017, and June 13, 2020, on historical volumes and operating room throughput distributions by surgery type and region, and lengths of stay in ward and intensive care unit (ICU) beds. We used time series forecasting, queuing models and probabilistic sensitivity analysis to estimate the size of the backlog and clearance time for a +10% (+1 day per week at 50% capacity) surge scenario.Results: Between Mar. 15 and June 13, 2020, the estimated backlog in Ontario was 148 364 surgeries (95% prediction interval 124 508-174 589), an average weekly increase of 11 413 surgeries. Estimated backlog clearance time is 84 weeks (95% confidence interval [CI] 46-145), with an estimated weekly throughput of 717 patients (95% CI 326-1367) requiring 719 operating room hours (95% CI 431-1038), 265 ward beds (95% CI 87-678) and 9 ICU beds (95% CI 4-20) per week.Interpretation: The magnitude of the surgical backlog from COVID-19 raises serious implications for the recovery phase in Ontario. Our framework for modelling surgical backlog recovery can be adapted to other jurisdictions, using local data to assist with planning. [ABSTRACT FROM AUTHOR]

Background At the request of the Head and Neck Cancers Advisory Committee of Ontario Health (Cancer Care Ontario), a working group and expert panel of clinicians with expertise in the management of head-and-neck cancer developed the present guideline. The purpose of the guideline is to provide advice about the organization and delivery of health care services for adult patients with head-and-neck cancer. Methods This document updates the recommendations published in the Ontario Health (Cancer Care Ontario) 2009 organizational guideline The Management of Head and Neck Cancer in Ontario. The guideline development methods included an updated literature search, internal review by content and methodology experts, and external review by relevant health care providers and potential users. Results To ensure that all patients have access to the highest standard of care available in Ontario, the guideline establishes the minimum requirements to maintain a head-and-neck disease site program. Recommendations are made about the membership of core and extended provider teams, minimum skill sets and experience of practitioners, cancer centre-specific and practitioner-specific volumes, multidisciplinary care requirements, and unique infrastructure demands. Conclusions The recommendations contained in this document offer guidance for clinicians and institutions providing care for patients with head-and-neck cancer in Ontario, and for policymakers and other stakeholders involved in the delivery of health care services for head-and-neck cancer. [ABSTRACT FROM AUTHOR]

Background: Care for patients with thyroid nodules is complex and multidisciplinary, and research demonstrates variation in care. The objective was to develop clinical guidelines and quality metrics to reduce unwarranted variation and improve quality. Methods: Multidisciplinary expert consensus and modified Delphi approach. Source documents were workflow algorithms from Kaiser Permanente Northern California and Cancer Care of Ontario based on the 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. Results: A consensus‐based, unified preoperative, perioperative, and postoperative workflow was developed for North American use. Twenty‐one panelists achieved consensus on 16 statements about workflow‐embedded process and outcomes metrics addressing safety, access, appropriateness, efficiency, effectiveness, and patient centeredness of care. Conclusion: A panel of Canadian and United States experts achieved consensus on workflows and quality metric statements to help reduce unwarranted variation in care, improving overall quality of care for patients diagnosed with thyroid nodules. [ABSTRACT FROM AUTHOR]

Background The pupose of this study was to describe variations in incidence and resection rates of patients with oral cavity squamous cell carcinoma (SCC) in Ontario. Methods All oral cavity SCCs in Ontario between 2003 and 2010 were identified from the Ontario Cancer Registry. Incidence and resection rates along with variations in care were compared by sociodemographic factors and Ontario health regions. Results The 8-year incidence rates for oral cavity SCC was 21.3 per 100,000 with variations by sex, age group, neighborhood income, and community size. Seventy-four percent of patients underwent an oral cavity cancer resection, of which 91% were at a regional head and neck cancer center. Variations in resection rates existed by region of residence and treatment. Conclusion Oral cavity cancer incidence rates vary by sex, age, neighborhood income, community size, and health region. Resection rates vary by age and health region. Oral cavity cancer care is highly regionalized in Ontario. © 2015 Wiley Periodicals, Inc. Head Neck 38: 1113-1118, 2016 [ABSTRACT FROM AUTHOR]

Background The purpose of this study was to measure adherence rates to guideline-recommended process measures in patients with head and neck cancer. Methods A total of 5720 patients who underwent surgery for head and neck cancer in Ontario between 1993 and 2010 were identified from administrative databases. Adherence to 4 guideline-recommended processes of care was measured and stratified by hospital and physician case volume. Results Seventy-two percent of patients received preoperative head and neck imaging, 83% received preoperative chest imaging, 58% received preoperative multidisciplinary consultation, and 77% had appropriate follow-up visits. Higher surgeon and hospital surgical volumes were associated with higher adherence rates. Conclusion Adherence rates to guideline-recommended processes of care in the surgical management of patients with head and neck cancer in Ontario were moderate and should be improved. Although adherence rates seem proportional to surgical volume, even the highest volume centers have room to improve. © 2016 Wiley Periodicals, Inc. Head Neck 38: E1987-E1992, 2016 [ABSTRACT FROM AUTHOR]

Background: The primary objective of this study is to describe variations in incidence rates, resection rates, and types of surgical ablations performed on patients diagnosed with major salivary gland cancers in Ontario. Methods: All major salivary gland cancer cases in Ontario (2003–2010) were identified from the Ontario Cancer Registry (n = 1,241). Variations in incidence rates, resection rates, and type of surgical therapy were compared by sex, age group, neighbourhood income, community population, health region, and physician specialty. Results: Eight-year incidence rates per 100,000 vary significantly by sex (male: 15.5, female: 9.7), age (18–54 years: 6.7, 75+ years: 53.4), neighborhood income (lowest quintile: 11.8, highest quintile: 13.7), and community size (cities with a population greater than 1.5 million: 10.6, cities with a population of less than 100,000: 14.7). There was a significant correlation between the likelihood to receive a resection and age with the elderly (75+ years) being the least likely to receive resection (69%). Large differences in incidence and resection rates were observed by health region. Otolaryngology-Head & Neck surgeons provide the majority of total/radical resections (95%). Conclusions: Major salivary gland cancer incidence rates vary by sex, age, neighborhood income, community size, and health region. Resection rates vary by age and health region. These disparities warrant further evaluation. Otolaryngology-Head & Neck Surgeons provide the majority of major salivary gland cancer surgical care. [ABSTRACT FROM AUTHOR]

Background. The extent of treatment for differentiated thyroid cancer remains controversial. The objective of this study was to describe the variations in practice prior to diagnosis and for the first year after diagnosis, including the investigations, the extent of surgery and the use of RAI 131, for all patients with thyroid cancer (TC) treated Jan 1 2000 to Dec 2008 across Ontario Canada. Method. Population-based study of all patients who had a therapeutic surgical procedure for TC based on the data holdings of the Institute of Clinical Investigative Sciences (ICES) linking the Ontario Cancer Registry to the Ontario Health Insurance Plan and to the Canadian Institutes of Health Information. The analysis includes comparisons between health care utilization/geographic regions and between treating specialties. The study population was 12957 patients. Results. There was a 112% increase in case detection over 9 years. Overall the initial (index) surgery was less-than-total thyroidectomy (LTT) in 37.6% and 63.4% of the patients who had total thyroidectomy (TT) as an index surgery went on to adjuvant RAI, however there was wide variation in all aspects of patient care across the province, between Local Health Networks and between surgical specialties. Conclusion. In Ontario, there was wide variation for most aspects of the management of TC and, as the incidence of TC is increasing at least 7% per year in females, these data provide a foundation for future discussions, the provision of health care services and research. [ABSTRACT FROM AUTHOR]

Survivors of lung or head and neck cancers often change tobacco and alcohol consumption after diagnosis, but few studies have examined other positive health changes (PHCs) or their determinants in these groups. The present study aims to: (a) document PHCs in survivors of lung (n = 107) or head and neck cancers (n = 99) and (b) examine behavioural self-blame and stigma as determinants of PHCs. We hypothesised that: (a) survivors would make a variety of PHCs; (b) behavioural self-blame for the disease would positively predict making PHCs; and (c) stigma would negatively predict making PHCs. Methods: Respondents self-administered measures of PHC, behavioural self-blame, and stigma. Hierarchical multiple regression analysis tested the hypotheses. Results:More than 65% of respondents reported making PHCs, the most common being changes in diet (25%), exercise (23%) and tobacco consumption (16.5%). Behavioural self-blame significantly predicted PHCs but stigma did not. However, both behavioural self-blame and stigma significantly predicted changes in tobacco consumption. Conclusions: Many survivors of lung or head and neck cancers engage in PHCs, but those who do not attribute the disease to their behaviour are less likely to do so. Attention to this problem and additional counselling may help people to adopt PHCs. [ABSTRACT FROM PUBLISHER]

Background The purpose of this study was to identify prognostic factors predicting outcomes in sebaceous gland carcinomas. Methods We conducted a retrospective medical chart review of patients with sebaceous carcinomas of periorbital ( n = 33) and extraorbital sites ( n = 13). Results Patients with periorbital tumors had higher recurrence rates than did patients with extraorbital tumors (64% vs 23%; p = .032). Patients who were older than 60 years ( p = .035) and had lower eyelid tumors ( p < .0001) had a lower disease-free survival rate than did patients with upper eyelid tumors. Patients with sebaceous carcinomas had a high rate (60%) of occult lymph node metastases. Conclusion Periorbital tumors are associated with poorer outcomes than are extraorbital tumors. Lower eyelid carcinomas have the worst prognosis and should be treated more aggressively. Our findings of a high incidence of occult neck disease and a high rate of regional recurrence in patients with sebaceous carcinomas support the consideration of prophylactic elective neck dissections for treating such patients. © 2012 Wiley Periodicals, Inc. © 2012 Wiley Periodicals, Inc. Head Neck, 2013 [ABSTRACT FROM AUTHOR]

Background: Regionalization of the practice of thoracic surgery into designated centers was carried out in Ontario to manage volume, improve outcomes, and facilitate comprehensive care. This article describes the process used by Cancer Care Ontario (CCO) to regionalize thoracic surgery practice and reports early results. Methods: A thoracic surgery standard was created by CCO, specifying criteria for level I (tertiary) and level II (secondary) thoracic surgery centers based on current volumes and projected population growth and referral patterns, and then implemented the standard using various incentives and disincentives. Results: Before regionalization (2004), 46 hospitals performed thoracic surgical procedures compared with 13 level I and 2 level II centers in 2010. From 2007 to 2011, a mean $8.4 million was distributed annually to designated centers to fund a mean 625 additional thoracic operations annually. By 2009 to 2010, the number of esophagectomies performed at designated centers increased from 212 to 285 (89% being performed in designated centers). Correspondingly, the number of lung resections increased from 1,396 to 1,858 (94% being performed in designated centers). Median wait time for lung cancer resection did not change. Regionalization achieved a significant reduction in 30-day mortality after pneumonectomy (10.9%–5.6%; p = 0.03) but no change for esophagectomy (5.9%–5.8%; p = 0. 96) or lobectomy (2.2%–1.9%; p = 0. 37). Conclusions: Regionalization was challenging but feasible and was associated with reduced 30-day mortality after pneumonectomy. More data are required to evaluate other short- and long-term outcome measures to further validate benefits from regionalization. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this study was to determine the frequency of complications in median and paramedian mandibulotomies. In addition, the interdental space in the median and paramedian region was calculated. Study design: Retrospective study. Setting: Tertiary care center. Methods: A retrospective chart review was performed for all cases where a mandibulotomy was performed from 2002 to 2010. 117 charts (61 paramedian and 56 median) were identified. We included data on complications, which fell in the following 2 categories: plate and dental complications. For our second objective, we evaluated 40 different patients with base of tongue or tonsillar cancer treated with intensity modulated radiation therapy (IMRT). The interdental space between the lateral incisors and the canines was electronically calculated on the digital Panorex images. Main outcome measures: Dental and plate complications were evaluated. We also assessed interdental space. Results: Patient characteristics were not significantly different. The median group had significantly more dental complications (p=0.0375, RD=0.19 and 95% CI (0.0139-0.3661)). The paramedian group had significantly more plate complications (p=0.0375, RD=0.082 and 95% CI (0.0131-0.1508). The distance between the central incisors was significantly less than the distance between the lateral incisors and canines both at the crestal and apical levels (p=0.0086 and p<0.001). Conclusions: There are significantly more dental complications in the median approach. There were significantly more plate complications in the paramedian group. In addition, there is significantly less space in the between the median region as compared to the paramedian region. This is the first study that documents the advantage of the paramedian approach for dental complications. [ABSTRACT FROM AUTHOR]

Background. The purpose of this study was to test the Union Internationale Contre le Cancer (UICC)/TNM category–based head and neck cancer stage grouping systems proposed in the literature for their ability to create clinically relevant prognostic groups of like-patients with cancer of the hypopharynx. Methods. Population-based retrospective survival study of 595 patients with squamous cell carcinoma of the hypopharynx across Ontario, Canada, from January 1990 to January 2000. The grouping systems of UICC/TNM, T and N Integer Score (TANIS), Hart, Berg, Snyderman, Kiricuta, and Hall were tested and compared for prognostic ability using hazard consistency, hazard discrimination, percent variance explained, outcome prediction, and balance. Results. All 8 systems predicted disease-specific survival. The system proposed by Snyderman performed the best, and UICC/TNM sixth edition did not perform as well as most. Conclusion. The UICC/TNM stage group classification, although successful in creating statistically distinct groups, did not perform as well as other stage grouping systems, continuing a theme that has been reported previously. © 2008 Wiley Periodicals, Inc. Head Neck, 2009 [ABSTRACT FROM AUTHOR]

Background.The purpose of this study was to determine the detection rate of lung metastasis or a synchronous lung primary tumor in patients with newly diagnosed head and neck mucosal squamous cell carcinoma (SCC) and to determine factors that are associated with positive findings. Methods.This was a prospective cohort study of 102 patients with head and neck mucosal SCC diagnosed in a tertiary cancer center. Chest x-rays and a CT scan of the thorax were performed. An indeterminate nodule on CT scan was followed with either a repeat scan to assess progression or a CT-guided needle biopsy. Metastasis or synchronous lung primary tumor were determined by CT scan. The findings were correlated with age, sex, duration of symptoms, site of primary tumor, grade of tumor, T classification, and N classification. Results.A CT scan of the thorax showed abnormalities or suspicious nodules in 20 patients (19.6%). With either follow-up scans or CT-guided biopsy, 10 patients were eventually proven to have pulmonary metastasis and one a synchronous lung primary tumor. Of those eleven patients (10.8%), seven had normal chest x-ray. Eight (72.7%) of 11 patients with a positive CT scan had N2 or N3 disease in contrast to 32 (35.2%) of 91 patients with a normal CT scan (p = .02). Seven patients (63.6%) with a positive CT scan had T4 disease, whereas 34 (37.4%) with a normal CT scan had T4 disease (p = .08). Primary tumors arising in the oropharynx, hypopharynx, and supraglottis had a greater risk of a positive CT scan than tumors arising in the oral cavity, glottis, or unknown sites (OR = 5.4; 95% CI, 1.3–21.9). Age, sex, duration of symptoms, and grade of disease did not predict a positive CT scan. Conclusions.The detection rate of lung metastasis or a synchronous lung primary tumor by CT scan is 10.8%. We recommend the use of CT scans of the thorax in screening the lungs of newly diagnosed patients with T4 and/or N2 or N3 oropharyngeal, hypopharyngeal, and supraglottic SCC. © 2005 Wiley Periodicals, Inc. Head Neck27: XXX–XXX, 2005 [ABSTRACT FROM AUTHOR]

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Studies the diagnosis, treatment and outcome measures in adult patients presenting with acute epiglottitis in the Toronto Hospital, University of Toronto. Demographic description of patient population, presenting symptoms and signs, investigations performed, treatment provided and incidence of complications; Abnormality of soft-tissue lateral neck x-rays; Accuracy of indirect, direct or flexible laryngoscopy.

Context In Ontario, we identified that few hospitals have developed multi-disciplinary case conferences or forums for discussion of patients with palliative care issues. Objective We describe the process of creating a province-wide standards document for palliative care multidisciplinary case conferences (pMCCs). Methods A provincial survey and a multidisciplinary cancer conference symposium identified pMCCs as a priority. A literature search focusing on pMCCs and their implementation was completed as well as a current state assessment (survey and interviews) to understand challenges with existing pMCCs in Ontario. A working group was then assembled to draft a recommendation report that was finalized by an expert panel. Results A total of 22 articles were identified and 10 were used by the working group to create a framework for the pMCC guideline. The current state assessment identified substantial variability in pMCC structure and function. The expert panel made recommendations about meeting format (multidisciplinary discussion encouraged), frequency (at least every two weeks), type of cases to present, attendees (palliative care, nursing, primary care, social work, and community nursing), provider roles and responsibilities, and institutional requirements (pMCC coordinator, meeting room and videoconference capability). All patients (not just those with cancer) with palliative care needs were to be discussed at the pMCC, and pMCCs should serve as a crucial link between the hospital and community. Conclusion We have described the process of creating the first pMCC guideline. A key component of this guideline is that pMCCs should serve as a link between the hospital and community. [ABSTRACT FROM AUTHOR]

Purpose: Health care organizations and professionals are being called on to develop clear and transparent measures of quality and to demonstrate the application of the data to performance improvement at the system and provider levels. Materials and Methods: Cancer Care Ontario (CCO) initiated a pathology reporting project aimed at improving the quality of cancer pathology by standardizing the content, format, and transmission of reports to a central registry and enabling the information to be available for planning, quality measurement, and quality improvement. This population-based quality-improvement project involved more than 400 Ontario pathologists and more than 100 hospitals. Clinically relevant quality indicators that used the newly available data were developed and shared. Synoptic pathology data were electronically captured at the point of report development and used to automate the timely generation of clinical performance indicators that support quality improvement in surgical oncology. These reports provided comparison data at the organizational, regional, and population levels. Results: Monthly quality indicator reports are generated and distributed to each cancer center and are used to generate dialogue at the professional, organizational, and regional levels regarding evidence-informed quality-improvement opportunities. Since the launch of the project, colorectal lymph node retrieval rates have increased from 76% to 87%, and pT2 prostatectomy margin positivity rates have decreased from 37% to 21%. Conclusion: High-quality, complete cancer pathology reports are important not only for contemporary oncological practice, but also for secondary users of pathology information including tumor registries, health planners, epidemiologists, and others involved in quality-improvement activities and research. [ABSTRACT FROM AUTHOR]

Abstract: Aims: We conducted a population-based study of practice patterns and outcome across the regional cancer centres providing care to patients with laryngeal cancer in the Province of Ontario, Canada. Materials and methods: : This was a retrospective cohort study of 1547 patients with cancers of the glottic or supraglottic larynx diagnosed between 1982 and 1995. Data were collected via chart review, including: patient and disease characteristics, treatment, waiting times and treatment volumes. Vital status was obtained from the Ontario Cancer Registry. Variations across the nine regional cancer centres are described and their effect on outcome explored. All analyses were stratified by stage I and II separately from stage III and IV. Results: Treatments differed across centres (P <0.0001); for instance, in the stage I and II group, use of a daily dose of >2.54Gy varied from 0 to 87.6% and in the stage III and IV group, total laryngectomy rates varied from a low of 6% to a high of 53%. The percentage of patients waiting more than 6 weeks from diagnosis to first treatment varied from 17 to 49% (P <0.0001). Multivariate analysis revealed cause-specific survival differences that were not explained by control for case mix, treatment or waiting times. Differences ranged from an 82% risk reduction in one centre compared with the reference (stage I and II group, P =0.008) to a 153% increase in risk (stage III and IV group, P =0.02). Centre case volumes were not associated with cause-specific survival. Conclusions: This study quantifies the degree of variation that can occur in the treatment and outcome of people with cancer. We cannot properly assess whether care delivery is of high quality until we have a better understanding of the factors that drive such variations. [Copyright &y& Elsevier]