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Lung Cancer in Canada

      A Perspective From Canada

      Canada is a nation with a population of 37 million distributed over 9.1 million km2 with the majority of our population density located near the Southern border (Fig. 1). Within our large geographic territory, 19% of people live in rural communities of less than or equal to 1000. The nation is divided into 10 provinces with 3 territories in northern areas, the latter comprising 39% of the country’s land mass but only 0.3% of the population. Our composition includes 15.9% of people aged 65 years or older; 21.8% individuals immigrated from other countries; and the median household income is CAN$70,336. Our country has a unique and varied population to engage in health care promotion and delivery.
      Figure thumbnail gr1
      Figure 1Population distribution in Canada, provided by 2016 Census. Courtesy of Statistics Canada (https://www12.statcan.gc.ca/census-recensement/2016/dp-pd/index-eng.cfm).
      Canada is characterized by a universal health care system, exclusive of outpatient pharmaceutical coverage. Funded by the federal and provincial governments through taxation, Canadians receive health care with no payment at the point of care. Decisions regarding implementation of programs and drug funding occur at the provincial/territory level supported by transfer payments from the federal government. Therefore, whereas the national system supports universal access, there are some geographic variations in coverage for therapy.
      The strengths and challenges in Canada lie in our socialized provision of care and unique geographic distribution.

      Smoking Cessation

      Health promotion is a key mandate for the Canadian government. The Canadian Community Health Survey has enabled the tracking of smoking cessation over time with implementation of programs including prohibiting sales to youth (1988), graphic package warnings (2000), tobacco display bans (2005), and bans on smoking in indoor public places and workplaces (2006). Through the Canadian Partnership Against Cancer (CPAC), the steward of the Canadian Strategy for Cancer Control, information regarding prevention programs is shared to improve the effectiveness and efficiency of cancer control.
      Canadian Partnership Against Cancer
      Canadian Partnership Against Cancer.
      Smoking cessation tools including nicotine replacement therapy and medication to reduce withdrawal and cravings are funded by many provinces for individuals who wish to quit or are available over the counter at pharmacies. The national daily or occasionally smoking rate in 2017 decreased to 16.2% compared to 19.4% in 2011, when many of the smoking cessation programs were initiated (Fig. 2). The federal government is aiming for a smoking rate of less than 5% by 2035.
      Figure thumbnail gr2
      Figure 2Geographic variation in smoking prevalence and lung cancer incidence in Canada . Courtesy of the Canadian Partnership Against Cancer (https://www.systemperformance.ca/report/2018-cancer-system-performance-report/).
      Canada has legalized cannabis as of October 2018. Individuals older than the age of 18 years are allowed to carry, share, grow, and sell cannabis. Before this legislation, cannabis was available under the Marihuana for Medical Purposes Regulations in 2013 that were subsequently updated in August 2016 with the Access to Cannabis for Medical Purposes Regulations. Vaping is regulated under the Tobacco and Vaping Products Act updated in May 2018. These laws set rules about promoting vaping products, including not promoting flavors that appeal to youth and not misleading consumers about the health effects of these products. The negative health consequences of regular cannabis use and vaping will become apparent in the decades to come.

      Lung Cancer Screening

      Lung cancer screening activities have been significant in Canada, in particular on the academic front. Building on earlier screening research performed at BC Cancer, risk-prediction tools developed at Brock University (St. Catharines, Ontario, Canada) and clinical experience under the International Early Lung Cancer Action Program in Toronto, the Pan-Canadian Lung Cancer Screening Study recruited a cohort of more than 2500 participants between 2008 and 2010. This study prospectively validated the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial lung cancer risk model, led to the development of the PANCAN Nodule Malignancy Risk Calculator, showed the limited utility of auto-fluorescence bronchoscopy in the screening setting, provided important data on anxiety and quality of life indicators, and contributed to a detailed cost-effectiveness analyses.
      • Tammemagi M.C.
      • Schmidt H.
      • Martel S.
      • et al.
      Participant selection for lung cancer screening by risk modelling (the Pan-Canadian Early Detection of Lung Cancer [PanCan] study): a single-arm, prospective study.
      • McWilliams A.
      • Tammemagi M.C.
      • Mayo J.R.
      • et al.
      Probability of cancer in pulmonary nodules detected on first screening CT.
      • Tremblay A.
      • Taghizadeh N.
      • McWilliams A.M.
      • et al.
      Low prevalence of high-grade lesions detected with autofluorescence bronchoscopy in the setting of lung cancer screening in the Pan-Canadian Lung Cancer Screening Study.
      • Cressman S.
      • Peacock S.J.
      • Tammemagi M.C.
      • et al.
      The cost-effectiveness of high-risk lung cancer screening and drivers of program efficiency.
      After the publication of the National Lung Screening Trial, a Pan-Canadian Lung Cancer Screening Network was established under the leadership of CPAC. This led to the publication of a Lung Cancer Screening Framework document for Canada in 2014, updated in 2016, to be used as a tool for various jurisdictions in their deliberations and/or in planning for lung cancer screening by outlining the key elements for consideration and quality indicators for programs.
      Canadian Partnership Against Cancer (CPAC). Pan-Canadian Lung Cancer Screening Initiative lung cancer screening framework for Canada: Summary and key considerations.
      In 2016, the Canadian Task Force on Preventative Health Care updated their lung cancer screening guidelines to support low-dose computed tomography (CT) screening for individuals meeting National Lung Screening Trial study criteria (current or former heavy smokers aged 55 to 74 years) and in health care settings with expertise in early diagnosis and treatment of lung cancer.
      • Lewin G.
      • Morissette K.
      • Dickinson J.
      • et al.
      Recommendations on screening for lung cancer.
      Funding and implementation of screening programs in Canada remain the responsibility of each provincial or territory’s public health care system. The initiation of such large-scale screening programs within public/universal health care systems already facing significant cost constraints is not without challenges. As such, to date, no full-scale lung cancer screening program exists in this country. Our largest province of Ontario has taken the lead in implementation, with a publicly funded pilot program initiated in April 2017. In other provinces, various screening opportunities have been available through research initiatives or through philanthropic funding.

      Diagnosis

      Given the complexities and variation in presentation there is no single diagnostic algorithm for lung cancer. The imaging modality and biopsy technique for diagnosis and or staging are dependent on local expertise and resources, as well as institution and health system factors, which influence the approach taken. Canada has an expansive geography and each province is challenged with providing access to rural and remote communities that lack the resources and expertise in the diagnosis and management of lung cancer. This often requires patients to travel long distances to larger centers. Telehealth using a video link between patient and provider is widely available for consultation between patients and experts, which can reduce the travel burden for remote patients, but does not negate travel for physical biopsy or imaging.
      The Pan-Canadian Standards for Thoracic Surgery were created by CPAC and Canadian Association of Thoracic Surgeons (CATS) recommending thoracic oncology centers of excellence be regionalized within the geographic limitations of each health authority.
      • Ambroggi M.
      • Biasini C.
      • Del Giovane C.
      • Fornari F.
      • Cavanna L.
      Distance as a barrier to cancer diagnosis and treatment: review of the literature.
      These thoracic oncology centers across Canada provide rapid access to expertise in lung cancer diagnosis and imaging with multidisciplinary teams and resources such as positron-emission tomography (PET) scans, CT-guided percutaneous biopsies, bronchoscopy, and endoscopic ultrasound that facilitate diagnosis and staging within defined wait times for lung cancer diagnoses.
      • Al-Sahaf M.
      • Lim E.
      The association between surgical volume, survival and quality of care.
      Despite regionalization, provincial differences in resource availability persist. For example, there are currently 51 publicly funded CT-PET units in Canada; nine provinces have at least 1 (range: 1 to 16 units/province). There are also private PET centers within several provinces where patients can pay for a timelier PET scan.
      Molecular testing including single-gene EGFR testing, multigene panels, fusion testing, and programmed death ligand 1 immunohistochemistry are available across the nation at centralized accredited centers to optimize resourcing and expertise. Reimbursement of Canadian laboratories for testing is variable from province to province and often can be tied to decisions regarding reimbursement of therapeutic agents. Many of the existing testing platforms were developed on the backbone of research to provide timely options and validate cost effective laboratory-based testing.

      Thoracic Surgery

      Thoracic surgery culture and models for delivery of care are very unique in Canada compared to counterparts in Europe and the United States, where amalgamation with cardiac and general foregut surgery is commonplace. Canadian thoracic surgeons comprise a small community of collaborative board-certified thoracic surgical subspecialists with a unique scope of practice recognized by the Royal College of Physicians and Surgeons of Canada; most of whom are active members of CATS.
      Several studies have shown improved patient outcomes for complex procedures when performed by high-volume surgeons at high-volume centers. This has also borne true for thoracic surgery in Canada, where regionalization of delivery of thoracic surgical care has led to improved patient outcomes in lung cancer surgery.
      • Sundaresan S.
      • Langer B.
      • Oliver T.
      • et al.
      Standards for thoracic surgical oncology in a single-payer healthcare system.
      • Finley C.J.
      • Bendzsak A.
      • Tomlinson G.
      • Keshavjee S.
      • Urbach D.R.
      • Darling G.E.
      The effect of regionalization on outcome in pulmonary lobectomy: a Canadian national study.
      Regionalization of thoracic surgery in Canada has been driven by the resource-intensive nature of practice, requirements for specialized care, volume-outcome relationships, and costs. Canadian thoracic surgical care is delivered for optimal quality and clinical outcomes by a minimum of three board-certified thoracic surgeons per regional center, leading to improved quality and delivery of care.
      • Sundaresan S.
      • Langer B.
      • Oliver T.
      • et al.
      Standards for thoracic surgical oncology in a single-payer healthcare system.
      • Finley C.J.
      • Bendzsak A.
      • Tomlinson G.
      • Keshavjee S.
      • Urbach D.R.
      • Darling G.E.
      The effect of regionalization on outcome in pulmonary lobectomy: a Canadian national study.
      The time Canadian patients wait for lung cancer surgery is an issue of utmost concern. Surveys of CATS members in 2012 revealed the most common rate-limiting step for patient-definitive care was operating room availability in both community and university hospitals.
      • Grondin S.C.
      • Schieman C.
      • Kelly E.
      • et al.
      A look at the thoracic surgery workforce in Canada: how demographics and scope of practice may impact future workforce needs.
      This is in contrast to private practice models in other countries where access to operating room resources is not a rate-limiting step in delivery of lung cancer care.
      Canadian Institute for Health Information (CIHI)
      Benchmarks for treatment and wait time in canada: Lung cancer surgery.
      Video-assisted thoracic surgery (VATS) lobectomy for lung cancer is the standard of care in Canada for stages I and II NSCLC. Because almost all lobectomies are being performed by dedicated, board-certified thoracic surgeons, all thoracic surgical centers nationally routinely offer VATS lobectomies. Robotic-assisted thoracic surgery lobectomy is not widely available in Canada due to associated direct financial costs per procedure as well as capital costs in a single-payer socialized system when outcomes with VATS are equivalent.
      Canadian thoracic surgeons are highly specialized experts in lung cancer care from diagnosis to palliation, working in collaborative regional centers of excellence to provide Canadians the highest-quality lung cancer surgical care. In the context of the Canadian single-payer socialized health care system, remaining challenges to the continued delivery of timely thoracic surgical intervention for lung cancer include access to operating room time and access to diagnostic imaging resources.

      Radiation Oncology

      There are 51 radiotherapy centers in Canada; the vast majority of them are academic with a university affiliation. Across the country, high-energy linear accelerators with immobilization devices and image-guidance techniques are available to provide intensity-modulated radiation therapy and stereotactic radiotherapy. Approximately half of the cancer centers have access to endobronchial brachytherapy. Proton therapy, however, is not currently available in Canada for lung cancer. Radiotherapy services are entirely publicly-funded; therefore, insurance approvals are not required when using newer modalities such as intensity-modulated radiation therapy. Access to these modalities is usually determined at the departmental or institutional level. The centralized nature of radiation oncology practice provides some advantages, such as most centers are considered high-volume, with on-site access to multidisciplinary teams and tumor boards, academic medical physics collaborators on-site, and oncologist peer-review of radiation plans as part of the quality-assurance process.
      Canadian radiation oncology practice has largely evolved from United Kingdom practice, where hypofractionated regimens are favored (i.e., larger daily doses with shorter treatment times), and remuneration is not generally based on the number of fractions. This has led to a legacy of shorter treatment courses. For limited-stage SCLC, for example, 40 Gy in 15 daily fractions (over 3 weeks) is commonly used which is biologically similar to the 45-Gy 3-week twice-daily regimen used elsewhere, but with less burden on patients and institutions. Similarly, single-fraction palliative treatments are standard for painful bone metastases.
      Challenges in Canadian radiation oncology practice have historically included a longer-than-ideal waiting list for radiation. Efforts to mitigate wait times include increasing the radiation oncology workforce and number of treatment units, and establishing acceptable wait times for consultation and treatment. Recently, variable PET-CT access across the country has led to upstream delays before referral to radiation oncology.
      A major triumph for Canadian radiation oncology is the strong history of academic collaboration, including through the Canadian Cancer Trials Group and the newer Canadian Pulmonary Radiotherapy Investigators group. Participation in recent trials has provided a method to introduce newer technologies, such as stereotactic radiation, in a controlled manner nationwide with robust quality assurance.

      Medical Oncology

      With a single-payer health care system, the delivery of expensive cancer therapy needs to achieve a balance between access and affordability. Canada is a country that relies on health technology assessment (HTA) through the pan–Canadian Oncology Drug Review (pCODR) before oncology drug program implementation. pCODR evaluates new oncologic therapies in four key domains including clinical benefit, alignment with patient values, economic evaluation, and adoption feasibility.
      Canadian Agency for Drugs and Technologies in Health
      Pan Canadian oncology drug review.
      National price negotiations through the pan-Canadian Pharmaceutical Alliance ensure equal pricing for all provinces. All provinces have agreed to abide by the decisions of pCODR. Furthermore, the Canadian Association of Provincial Cancer Agencies are considering developing national guidelines for treatment to collaboratively address issues that affect the delivery of cancer care in Canada.
      The advantages of the system are generally universal access to treatment; however, there are some disparities among provinces, primarily related to variable coverage for oral cancer therapies. Furthermore, the process can take up to 2 years between the publication of evidence and funding. To address the gap in financial coverage, pharmaceutical companies frequently offer bridging patient-assistance programs and this has become part of standard cancer treatment in Canada. Oncologists also use clinical trials as a means of improving knowledge and accessing care through trials sponsored by pharmaceutical companies or our national Canadian Cancer Trials Group.
      Canadian Cancer Trials Group
      Canadian Cancer Trials Group (CCTG).
      Given the financial constraints of the system, the bar for evidence is high for HTA approval. This has resulted in unfavorable decisions not to reimburse targeted therapies for small molecular subsets, such as dabrafenib/trametinib for BRAF V600E in NSCLC, because the evidence consists of phase I and II data. Balancing opportunity costs, sustainability, and cost-effectiveness are guiding principles of systemic therapy funding in Canada. Despite these limitations, newer therapies for lung cancer including immunotherapy, EGFR inhibitors, and ALK inhibitors are available for the majority of Canadians (Fig. 3).
      Figure thumbnail gr3
      Figure 3Systemic therapy options for metastatic NSCLC in Canada as of January 2019. ALK, ALK receptor tyrosine kinase; PD-L1, programmed death ligand 1; pCODR, pan–Canadian Oncology Drug Review.

      Summary

      The provision of lung cancer care in Canada is through our socialized medical system that ensures that all citizens of the country have access to care but also results in significant limitations including wait times, lengthy health technology assessment processes, and financial constraints that impede program implementation such as lung cancer screening. As providers of care, Canadian physicians and researchers have adapted to these challenges by using research programs and clinical trials not only to improve our lung cancer knowledge and develop cost effective strategies, but to provide timely access to advances in care.
      Our geographic area requires that Canadians be creative about care provision using collaborative partnerships with regional hospitals to provide local provision of specialized care under the guidance of specialists in tertiary centers. Telehealth is increasingly used to facilitate treatment discussions and decision-making to reduce patient travel. Recognizing the need for interaction with key health care providers including respirologists, thoracic surgeons, radiation oncologists, and medical oncologists at specialized centers, travel subsidies and subsidized temporary accommodation may be provided through the government and the support of charitable organizations.
      Despite the challenges faced by our health care system, our cancer outcomes rival that of other leading nations. The provision of care is innovative with multiple partnerships throughout the health care system to provide the best possible outcomes for all Canadians.

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