The Wait That Kills

Delays in breast cancer surgery can be dangerous

In April, 2010, I had a mammogram, only eleven months after a previous one. A biopsy showed that I had a grade 3 tumor (i.e., highly undifferentiated, with a high mitotic ratio) that had already grown to about 2 centimeters. Surgical removal was the obvious next step, but despite the efforts of my family doctor and friend, it was not possible to schedule the operation in less than a month, if not much longer. As too often occurs in cases of backlog and delay, the specialist told me that “there is lots of published evidence that it makes no difference whether you are operated right away or in two months from now.” I was in a daze.

But I work on breast cancer. There is plenty of published evidence showing the importance of early detection and treatment. According to an article published in Lancet (Richards, 1999), a delay of 3 months from detection to surgery increases 5-year mortality (not just relapse…) by 12%! If this were not so, why would the government pay for screening mammograms? Not all breast cancers are slow-growing, and even cancers that advance slowly at the outset, pick up speed as they progress and accumulate mutations. How quickly an invasion will kill is anybody’s guess at the time of the initial biopsy. But, you are supposed to wait your turn as you wonder how quickly your cancer is spreading. I was told to “do yoga” or “go biking” to “deal with the stress of waiting”

Luckily, a surgeon friend operated my cancer off a few days later. I am grateful to him for ever! I had no idea how much the cancer had already spread, so I told my son farewell as I left for surgery. “If I do not see you again, I want you to become a good veterinarian.” My tumor turned out to be among the most aggressive. The whole tissue was cancer, a lobular, pleomorphic, and multicentric variant described in several publications as “particularly lethal,” fast-growing, and fast-invading. Luckily, my lymph nodes were still negative and PET, bone and CAT scans showed no metastases. But it would not have stayed put much longer, and once it reached the lymph nodes my life expectancy would have been, according to the literature, about one year. I have had four more operations and six cycles of very aggressive chemotherapy, but the misery of these was nothing compared to the fear of leaving my children behind as teenagers, 17 and 18.

I have over 20 friends who have had breast cancer, in Germany, France, England, Poland, South Africa, and Greece. All, even with DCIS (ductal carcinoma in situ, a precancerous condition), had surgery within one to three days after the biopsy. All were told that it was critical to have surgery right away. Why are cancer patients in Canada told that waiting does not matter? Why take such chances with patients’ lives? Cancer surgery is not “elective” or cosmetic, but a matter of death or life (death is the default…).

Greece is not a member of the G8 or G-whatever. Yet nobody in Greece is told when they are triaged to “be patient, meditate or go biking” as their cancer spreads. Canada is not a third-world country, but its standards in this matter do not compare with those of most civilized countries. It is not Canadian doctors, of course, who claim that delays caused by the under-funding of hospitals “make no difference”; many, like my surgeon are my heroes, trying to make do with what there is. But it is Canadian politicians, Canadian economists, and ultimately Canadian voters, who vaguely imagine that by restricting the numbers of health-care specialists we save some Canadian dollars. That policy would be unconscionable even if the calculus were valid. But the calculus is not valid, since allowing complications to develop is more, not less costly, and in every sense of the word…


Solving the wait

Queen’s Gazette
Thursday, May 17, 2018

The Conversation: How to solve Canada’s wait time problem

Wednesday May 16, 2018
By Chris Simpson, Acting Dean, Faculty of Health Sciences

Nearly every Canadian family has a wait time story. This is because our system is not designed to provide optimal care for patients with multiple chronic diseases. Canadians are fed up with long wait times for health-care services. A new analysis from the Canadian Institute for Health Information (CIHI) shows wait times for hip and knee replacements and also cataract surgeries have increased across Canada since 2015. But we love our health care system. In particular, we take pride in the principle that care should be provided on the basis of need, rather than ability to pay.

Our system and its virtues have become part of our collective identity. We even named Tommy Douglas, the architect of medicare, “The Greatest Canadian of all time.”

Are long wait times simply the price we must pay in order to uphold our Canadian values of equity and fairness?

As a doctor of medicine and professor who has spent a career in health policy and advocacy, I disagree. Our health system — designed in the 1960s — is in dire need of an overhaul. Canadians and their health needs have changed, but the system hasn’t changed with them. Wait times are not the core problem. They are a symptom of the problem. And, like every doctor, I would rather cure the problem than just treat the symptoms.

A nation of perpetual pilot projects

It can be difficult to challenge the status quo, particularly when the health system has become so iconic.

Critics argue, however, that our “system” is not really a system at all — our public investment is largely confined to doctors and hospitals while home and community care, drugs, rehabilitation, long term care, dentistry and many other important health services are paid for from a mixed bag of public, private and out-of-pocket sources.

Our federated model has created provincial and territorial silos, and our attempts at integration and reform have largely fallen flat. Monique Bégin famously said that we are a country of perpetual pilot projects, lamenting our inability to scale-up and spread new ways of doing things.

The highly respected Commonwealth Fund has consistently ranked our system either ninth or 10th out of 11 peer countries for many years now.

On one issue in particular — wait times — we rank dead last.

The ‘wait time problem’

Nearly every Canadian family has a wait-time story. We wait in emergency departments. We wait to see family physicians. We wait for tests, procedures and surgeries. We wait to see specialists. We even wait to get out of hospital — an increasing number of Canadian seniors find themselves in acute care hospital beds not because they are sick, but because they cannot live independently and have nowhere else to go.

Successive provincial, territorial and federal governments have all acknowledged and addressed the wait-time problem. In 2004, Prime Minister Paul Martin announced a 10-year health accord with the provinces, touting it as the fix for a generation.

The Wait Time Alliance (WTA), a national federation of medical specialty societies and the Canadian Medical Association, developed a list of evidence-based wait-time benchmarks for nearly 1,000 health services so that progress could be measured.

A total of $41.3 billion was spent by the federal government over 10 years, including $5.5 billion to specifically address wait times in five key areas: Cancer, cardiac, sight restoration, medical imaging (CT and MRIs) and joint replacement.

Some provinces, notably Ontario, saw improvement. Annual report cards from the WTA and Canadian Institutes for Health Information (CIHI) showed modest improvements across the country.

A ‘national seniors’ strategy’ could help fix the system to reduce wait times.

A landscape of chronic disease

But now we are seeing slippage. Performance on wait times is holding steady at best. It’s increasingly clear that all this money bought us time, but did not fix the problem. And no wonder. Because the problem is not a lack of investment. Canada has the fifth most expensive health-care system in the world. In 2017, we spent around 11.5 per cent of our GDP on health care.

Spending more is not the solution. Spending smarter is.

The underlying problem is the system itself (or, rather, the lack of a system). The hodgepodge of bureaucracies, budgets, facilities and providers that collectively carry out the business of health care in this country are more disconnected than ever before.

At the same time, patients’ health-care experiences are changing. No longer is the health-care landscape dominated by acute illness — where you get sick, you get treated and then you get better.

Increasingly, the landscape is dominated by chronic disease. In fact, most patients with chronic disease actually have multiple chronic diseases.

How to fix the system

Our system is not designed to provide optimal care for these patients and, as a result, everything slows down. Patients with complex needs who are not really acutely ill wind up in emergency departments and hospitals.

Emergency departments and hospitals, in turn, experience overcrowding and can’t do what they are designed to do. Surgeries and procedures get cancelled, wait times increase and everyone gets delayed care.

Fixing the system is the only way we will ever get wait times to come down. History has shown that spending more money doing the same things over and over does not work. A great place to start would be to develop and implement a national seniors’ strategy. Such a strategy would acknowledge that the new health-care landscape is one of multiple chronic diseases driven by our aging population. It would work to develop a properly integrated, transdisciplinary model of care in the community.

Doing so would free up hospitals to do what they are supposed to be doing — looking after acutely ill people and performing procedures and surgeries. Budgets that align with patient trajectories, wherever they are in the system, rather than with institutions or programs, will allow smarter, more efficient spending.

And building in incentives for better patient outcomes, shorter waits and enhanced satisfaction will help realign our primary accountability — to the patients we serve rather than to the institutions where we work.

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Dr. Chris Simpson is a professor in the School of Medicine’s Division of Cardiology is a past president (2014-15) of the Canadian Medical Association (CMA).

This article was originally published on The Conversation, which provides news and views from the academic and research community. Queen’s University is a founding partner. Queen’s researchers, faculty, and students are regular contributors.

The Conversation is seeking new academic contributors. Researchers wishing to write articles should contact Melinda Knox, Associate Director, Research Profile and Initiatives, at knoxm@queensu.ca.

See also: thestar.com/news/queenspark/2018/06/03/how-ontarios-next-government-could-relieve-overcrowded-hospitals.html