Welcome

1. Welcome Dr. Pierre Major Co-Chair, CACC

2. About the CACC • The Cancer Advocacy Coalition of Canada is a registered, non-profit cancer group dedicated to advocacy and education • CACC’s volunteer Board of Directors is comprised of patient advocates, oncologists and health sector executives • CACC operates on unrestricted grants from sponsors based on guidelines that ensure the organization’s autonomy • CACC publishes the annual Report Card on Cancer in Canada™, the only independent evaluation of our cancer systems’ performance

3. 2010-2011 Report Card • Fighting cancer is a tough enough battle … • In this year’s Report Card we ask, “Why are governments making it even harder for cancer patients and their caregivers?”

4. Prevention Cancer Prevention in Canada: The Sooner the Better Joseph Ragaz, MD, FRCP Board Member, CACC Medical Oncologist & Clinical Professor,  Faculty of Medicine & School of Population & Public Health, University of British Columbia Adjunct Professor, Medicine & Oncology, McGill University

5. Background • Breast cancer mortality has decreased by 25-30% over the last 20 years due to: • Widespread public education leading to earlier diagnosis • Evidence-based therapy • Despite decreasing mortality rates, 23,000 women are still diagnosed each year in Canada, and over 4,000 will die, with absolute numbers increasing • Prevention has the potential to reduce the number of new patients with breast cancer in Canada

6. What We Know • Breast cancer prevention can work • Lifestyle and medical interventions improve outcomes • Prevention programs are currently aimed at individuals and families with a genetic predisposition to breast cancer (5%) • For the remaining 95% of women at risk for breast cancer, lifestyle and medical interventions could also reduce the risk, but there are no dedicated prevention programs

7. What We Need to Do • Identify which prevention interventions are evidence based and most cost-effective • Identify women at high-risk: • Family history • Suspicious breast pathology (atypia, etc.) • Survivors of breast cancer • Determine the logistics for cancer prevention awareness: • Who should provide funding • Who should do the counseling

8. Conclusions and Recommendations • Prevention is the “orphan” of breast cancer care • No medical specialty has a mandate for practising breast cancer prevention • No dedicated breast cancer prevention programs • If prevention is not practiced now, Canadians will face several thousand additional breast cancers each year • Governments should support the creation of breast cancer prevention programs • Cancer prevention: potential for one of the most cost-effective health intervention programs in Canada….

9. How We Can Make a Difference? • Educate women about lifestyle factors linked to breast cancer and impact of counseling: • Diet and nutrition (20-60% reduction in new breast cancers) • Exercise (30-40% reduction) • Alcohol (20-30% reduction) • Consider preventative medical interventions: • Anti-estrogens (Tamoxifen / Raloxifen: 40-50% reduction) • Anti-inflammatories (Aspirin: 20-30% reduction) • Result: avoidance of several thousand new breast cancers each year

10. Conclusions and Recommendations • Prevention is the “orphan” of breast cancer care • No medical specialty has a mandate for practising breast cancer prevention • No dedicated breast cancer prevention programs • If prevention is not practiced now, Canadians will face several thousand additional breast cancers each year • Governments should support the creation of breast cancer prevention programs based on compelling scientific evidence • Cancer prevention: one of the most cost-effective health interventions

11. Clinical Trials Should Clinical Trials Be Considered Part of the “Standard of Care” for Cancer Patients? Dr. Susan Dent, MD, FRCPC Medical Oncologist, Ottawa Hospital Cancer Centre Sandi Yurichuk, BS, MBA Vice-Chair, CACC

12. Background • Institutions with high participation rates in clinical trials have better patient outcomes • Clinical trials contribute to high quality care • Participation in clinical trials allows patients to access potentially effective new treatments

13. What We Found • Less than 7% of Canadian adults with cancer are enrolled in clinical trials • CCO reports that between 2007-2009 cancer patient participation in clinical trials in Ontario decreased 28%, citing a “changing environment for supporting clinical trials” • Clinical trials conducted throughout Canada are under an increasing threat • Canada’s participation in international clinical trials in 2007 decreased 12%

14. The Barriers • Barriers to conducting clinical trials are increasing: • Lack of sustainable funding for clinical research • Declining ability of hospitals to support clinical trial infrastructure • Increase in ethics and regulatory requirements • Increasing timelines for conducting a clinical trial • Industry-sponsored trials decreasing due to increasing international competition

15. Impact of Declining Trial Participation • Reduced access to new treatments • Failure to materialize potential survival gains • Missed opportunity for improving delivery of optimal patient care through the discipline of clinical trials

16. Recommendations • Gain long-term financial commitments from governments to support clinical trials in both academic and community centres • Ensure adequate institutional infrastructure support for conducting clinical trials • Encourage more clinical trial collaboration across Canada and internationally • Improve timeliness of conducting clinical trials to remain competitive internationally

17. The Answer • Patients with cancer should be offered a clinical trial as part of a standard treatment option to improve outcomes for themselves and for others

18. Collaborative Care The Role of the Nurse Practitioner and Clinical Pharmacist David Saltman, MD, PhD Board Member, CACC Chair and Professor of the Discipline of Oncology, Faculty of Medicine, Memorial University, St. John’s, NL

19. Background • Despite decreasing rates of some cancers, the absolute number of new cancer cases is on the rise, as is the number of people living with cancer • Expansion of oncology services is essential • Current and anticipated shortage of cancer specialists

20. Potential Solutions Expanding the role of Pharmacists: • pharmacology • drug toxicities • order entry systems • patient education • drug funding Expanding the role of Nurse Practitioners: • patient assessment • psychosocial care • procedures • patient education • ability to prescribe

21. Collaborative Agreements • Developing a collaborative practice agreement involves: • Making changes to provincial Pharmacy Acts • Gaining approval by provincial pharmacy and medical boards and host institutions • Establishing educational and competency requirements • Defining the scope of practice

22. What We Did • Surveyed cancer centres from each province • Telephone interview or e-mail with follow-up telephone call • Responses collected from one cancer centre in each of the 10 provinces • Survey started November 2010 and completed January 2011

23. What We Found • Six centres had Nurse Practitioners in collaborative practice, and four centres had Pharmacists • AB, ON, NS and NB had both NPs and Pharmacists in collaborative practices, but only NPs had prescribing privileges • SK and QC did not have NPs in their cancer centres

24. What We Found (Cont’d) • Six centres reported Nurse Practitioners prescribing one or more types of oncology medications (IV, oral, hormone or supportive care medications) • In only two centres (AB and NS) were NPs prescribing all forms of cancer medications • No centres permitted NPs to prescribe narcotics

25. What This Means • Nurse Practitioners and Pharmacists are entering into collaborative agreements within cancer centres to improve patient care by: • Reducing patient waiting times • Enhancing patient safety • Freeing up physician time for more new patients • More provinces need to develop collaborative agreements

26. Recommendations • Amend Pharmacy Acts in each province to allow Pharmacists to prescribe • Standardize educational and competency requirements • Formalize written collaborative practice agreements • Include ability to order laboratory tests • Ensure quality assurance and confirm outcomes

27. Advocacy Walking the Tightrope: Physician Advocacy and Institutional Fidelity Pierre Major, MD Medical Oncologist, Hamilton, ON Co-Chair, Board of Directors, CACC Vice-Chair, 2010-2011 Report Card Committee

28. Physicians as Advocates “As health advocates, physicians should responsibly use their expertise and influence to advance the health and wellbeing of individual patients, communities and populations.” - Royal College of Physicians & Surgeons of Canada May, 2008

29. General Standards of Accreditation Health Advocate “5.1 The program must be able to demonstrate that residents are able to understand, respond to and promote the health needs of their patients, their communities and the populations they serve.” - Royal College of Physicians & Surgeons of Canada - College of Family Physicians of Canada - Collège des médecins du Québec 2010

30. Background • Medical educators and professional medical associations publicly endorse physician advocacy • But, physicians infrequently engage in advocacy activities • We are more likely to endorse or celebrate a physician’s scientific or patient care achievements than efforts to change public policy

31. The Reality • Physicians have always had the responsibility to advocate for individual patients and their families • Community and societal advocacy is now a requirement for completion of undergraduate medical training and many residency programs • But … institutional barriers remain and in some cases are being strengthened

32. Barriers to Physician Advocacy • Formal or informal fidelity agreements limit advocate’s ability to speak publicly about a number of issues • Most oncologists are employees of government healthcare institutions • Concern about job security and career advancement • Advocacy may put physicians in conflict with employer/institution and government healthcare priorities • Corporate loyalty can override best interests of the patient, community and society • Lack of formal advocacy training

33. Recommendations • Healthcare leaders and educators need to support and implement physician advocacy activities • Public discourse about healthcare issues, including funding, access to medicines, wait times, etc. should be transparent and not seen as an attempt to undermine institutions or political processes • CACC will ask professional bodies to interact with healthcare authorities and government to remove barriers to physician advocacy

34. Patient Perspective Living with Cancer - Testicular Cancer, Ovarian Cancer and CLL Dr. James Gowing, MD Hematologist / Oncologist, Cambridge, ON Immediate Past Co-Chair, Board of Directors, CACC

35. Living with Cancer • The authors share their own stories about the unique barriers that they face in their fight for equitable access to cancer innovation across the country • Updates on last year’s articles on the patient experience with rare cancers: multiple myeloma, gastrointestinal stromal tumour, neuroendocrine tumours and chronic myelogenous leukemia • This year’s Report Card provides new patient insights into living with testicular cancer, ovarian cancer and chronic lymphocytic leukemia

36. Patient Contributors • Thank you to our 2010-2011 Report Card patient contributors: • Peter Laneas, The Canadian Testicular Cancer Association • Elisabeth Ross, Ovarian Cancer Canada • Derek Caine, CLL Patient Advocacy Group • And to our returning patient contributors : • David Josephy, GIST Sarcoma Life Raft Group Canada • Cheryl-Anne Simoneau, CML Society of Canada • Jim Kormos, CNETS Canada

37. Questions? Please visit www.canceradvocacy.ca to view the full 2010-2011 Report Card on Cancer