A review of Canadian health care and cancer care systems

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May 15, 2011 - health care system with dedicated entities existing in parallel in most ... system performance is enabled through the Canadian Partnership ...
Original Article

A Review of Canadian Health Care and Cancer Care Systems* Simon B. Sutcliffe, BSc, MD

Canada is a westernized, market-economy nation with a publicly funded health care and cancer control system and has health indices reflective of a high-resource economy. Provision of health services is in accord with the Canada Health Act and is implemented through federal, provincial, and territorial relations wherein federal funding partly provides support for the provincial/territorial delivery of health services. Cancer services are provided within the acute health care system with dedicated entities existing in parallel in most provinces to provide services specific to the diagnosis, treatment, and support of cancer patients. Interprovincial and territorial collaboration to enhance and facilitate optimal cancer system performance is enabled through the Canadian Partnership Against Cancer (the Canadian national cancer control initiative). Adolescent and young adult (AYA) cancer patients use both the pediatric and adult cancer systems. There is recognition, however, that although AYA patients are numerically a small portion of all cancer patients, the negative personal, societal, and socioeconomic impacts of potential years of life lost are substantial and can be lessened through attention to awareness, education, redesign of care and care pathways, quality of life, developmental aspects related to adolescent-teen-adult transitions, continuity of care, and surveillance across pediatric and adult settings. Appropriate solutions need to be established within the framework of the Canadian Health Service by innovative rethinking and realignment of system capacity and performance to the special needs of C 2011 American Cancer Society. AYA cancer patients. Cancer 2011;117(10 suppl):2241–4. V KEYWORDS: Canada, health system, cancer control, adolescent, young adult.

Canada enjoys a publicly funded health care and cancer control system that provides an average life expectancy at birth of more than 80 years within a fairly homogeneous pattern of health care outcomes across a complex federal, provincial, and territorial funding and care delivery system.1 However, disparities are evident within Canada health outcomes become more favorable east to west, north to south, and rural or remote to urban, and certain population groups, for example, visible minorities and First Nations, Inuit, and Metis, do not enjoy health outcomes as favorable as other Canadians. Adolescent and young adult (AYA) cancer patients compose a group whose special needs, particularly with regard to survivorship, deserve attention. Although numerically a small group, AYA cancer patients often do not receive the coordinated, integrated, and supportive care befitting the challenges of cancer and its treatment. Furthermore, developmental, educational, and life-choice issues are associated with the teen and young adult years. Canada is a large country (approximately 10 million square kilometers) with a small population (34 million; population density 3.41/km2). According to 2009 estimates, Canada’s gross domestic product per capita adjusted for purchasing power parity was $39,098, with a health care expenditure per person of $3900 (both in Canadian dollars). Average life expectancy at birth is almost 81 years. The Human Development Index (a composite score reflecting life expectancy at birth, literacy, and standard of living) is 0.966, and the Gini coefficient, reflective of wealth distribution within a population, is 0.321 after taxes. Caucasians represent 73.8% of the population, followed by Asians (21%), Aboriginals, First Nations, Inuits, and Me´tis combined (5%), and Hispanic and African ethnicities (5% in the periods from 1992 to 1995 and 2001 to 2004.4 Treatment performance and survival outcomes for AYA cancer patients are not out of line with those achieved within the pediatric and adult populations; however, the rate of improvement during the last decade has been lower for AYA cancer patients. It is very evident that levels of expertise and support necessary for this group (access, process of care, coordination, expertise, rehabilita-

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tion, recognition and support for age, development, and other cancer-related issues) have not been as high in the areas of development, focus, and attention as they have been in younger (pediatric) or older (adult) age groups. There is clear recognition that under the aegis of the Canada Health Act and a cancer control plan for Canadians (CPAC), the disparities experienced by AYA patients require attention. These needs and gaps will require consideration of 1) the elements of comprehensive population-based cancer control, which include primary prevention, early detection, diagnosis and staging, treatment, survivorship support, palliation, end of life care, and primary, tertiary, and community care models of care coordination, and 2) integration within and across facilities and health environments. To meet the breadth of needs across the cancer care spectrum (disease detection and treatment, education, employment, and support for optimal societal engagement), multiple constituencies (including government, NGO, educator, employer, patient, and public) will need to engage with one another to provide both the capacity and the environment needed to enhance AYA patient survivorship. The initiative to improve care and outcomes for AYA oncology patients is not unique to Canada; it is important to other westernized high-resource nations (eg,

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USA, European, Australasian, and Scandinavian countries). The emergence of this initiative probably reflects 1) the medical-health care provider perspective related to the transition of care from a pediatric to an adult care setting (particularly the identification and management of late effects) and 2) the patient-survivor perspective reflecting the unique needs of the AYA patient population with respect to identity, peer environment, customization of care, and quality of life. Given the emergence of patientsurvivor organizations, newsletters, web sites, and blogs, for example, pursuit of these directions without a health system perspective may be construed as advocacy or lobbying. The establishment of a forum in which all perspectives—provider, consumer, health system or services, including policy, socioeconomic and public perspectives—can be explored, synthesized, and prioritized will move the discussion from political advocacy to actual system change. Competing health priorities must be recognized. Furthermore, the involvement of international colleagues will offer cultural and contextual perspectives on the provision of AYA oncology care, broaden the discussion, and offer the potential for innovative and/or alternative solutions to improve care and outcomes. Forums of this nature that lead to broadly supported positions, considered in the context of national cancer control programs (eg, Canadian Partnership Against Cancer ), may be useful models for system-level changes that will achieve patient outcomes of importance. Conclusions Given a clear recognition of the need for system improvements that will address the less favorable experiences of AYA cancer patients compared with other Canadian groups, innovative approaches will be required. To be successful, these approaches will need to be grounded in certain aspects of the Canadian health care system (Canada Health Act; prevailing acute care, pediatric, and adult services) and in population-based cancer control, includ-

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ing comprehensive health and illness management; integrated acute, tertiary, community, and primary care; individualized care; and population health. Solutions to current deficiencies in AYA cancer patient care must not be retrofitted to what has been in place, but rather there must be innovation when rethinking facilities, personnel, education and training, research, support and rehabilitation, coordination of care, and system integration. Given the multiplicity of medical, social, and psychological challenges for AYA cancer patients, a single solution is unlikely to fit all situations. Novel customization to address priorities will be necessary.

FUNDING SOURCES Funding for the national task force on adolescents and young adults with cancer has been made possible by a financial contribution from Health Canada through the Canadian Partnership Against Cancer. Funding for the workshop was provided by C17; the Advisory Board of the Institute for Cancer Research at the Canadian Institutes for Health Research (CIHR); the Public Health Agency of Canada; the Ontario Institute for Cancer Research; the Meetings, Planning and Dissemination Grants program of the CIHR; the Terry Fox Research Institute; LIVESTRONG, formerly the Lance Armstrong Foundation; the Canadian Cancer Society Research Institute; Young Adult Cancer Canada; Hope and Cope; and the Comprehensive Cancer Centre at the Hospital for Sick Children, Toronto, in addition to the support provided by the Canadian Partnership Against Cancer to the Task Force on adolescents and young adults with cancer.

CONFLICT OF INTEREST DISCLOSURES The authors made no disclosures.

REFERENCES 1. Coleman MP, Quaresma M, Berrino F, et al. Cancer survival in five continents: a worldwide population-based study (CONCORD). Lancet Oncol. 2008;9:730-756. 2. Stats Can. Available at: http://www.statcan.gc.ca. Accessed December 2009. 3. Canadian Partnership Against Cancer (CPAC). Available at: http://www.partnershipagainstcancer.ca. Accessed December 2009. 4. Canadian Cancer Society. Canadian Cancer Statistics 2009. Available at: http://www.cancer.ca. Accessed December 2009.

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