Lorraine Glover inside her home in Victoria, on April 27.Melissa Renwick/The Globe and Mail
Insiders at British Columbia’s cancer care agency – including past presidents whose leadership span 25 years – are sounding the alarm on a system that they say is plummeting in quality of care and international repute.
Growing wait times have meant that, as of this summer, only one in five patients referred to an oncologist receive a first consultation within the recommended two weeks, according to internal data obtained by The Globe and Mail. And when it comes to beginning radiation treatment, B.C.’s average wait times are the longest in Canada. Timely treatment can be critical for survival and recovery, and a delay at one stage can compound overall wait times.
While the COVID-19 pandemic forced the postponement of thousands of scheduled surgeries across the province and exacerbated existing pressures on all health care, those working in B.C.’s cancer care system say the delays existed long before and will only worsen without urgent action.
The Globe spoke with dozens of people intimately familiar with the situation, including the past presidents of BC Cancer, patients, current and former oncologists, radiologists and nurses.
They cite shortages of medical staff, support staff and machines used to detect and treat cancer as causes of the backlog. And, as the province’s growing and aging population leads to an increase in diagnoses each year – going up a projected 57 per cent between 2012 and 2030 (to 37,095 from 23,521) – the pressure on oncologists, radiologists and nurses has led those health care professionals working in B.C. to report the highest levels of stress and burnout among all cancer centres in Canada.
Wait times for cancer treatment occur at several stages, from first symptoms to a visit with a family doctor, to a referral for diagnostic imaging or a surgeon, to a first consultation with an oncologist, and from a decision to treat to commencement of treatment.
The B.C. government does not make wait times for these various stages publicly available, but The Globe obtained data from medical staff at BC Cancer and from the Canadian Institute for Health Information (CIHI).
The data show that, in September, only 20 per cent of patients referred to an oncologist were seen within two weeks. About 50 per cent had been seen at the four-week mark. In comparison, about 75 per cent of patients in Ontario are seen within two weeks.
After a consult, about half of patients with cancer will receive radiation therapy as part of their treatment. Once such a decision has been made, 88 per cent of patients in B.C. are able to start within four weeks – the national benchmark for the maximum amount of time deemed appropriate to wait. This makes B.C. the poorest performing province in a country where the national average is 97 per cent.
Patients receiving cancer radiation treatment
within benchmark
2021, by province, per cent
90% benchmark
MB
100
AB
99
NL
99
QC
99
PEI
99
ON
98
SK
98
CAN
97.6
NB
92
NS
89
BC
88
the globe and mail, Source: cihi
Patients receiving cancer radiation treatment
within benchmark
2021, by province, per cent
90% benchmark
MB
100
AB
99
NL
99
QC
99
PEI
99
ON
98
SK
98
CAN
97.6
NB
92
NS
89
BC
88
the globe and mail, Source: cihi
Patients receiving cancer radiation treatment within benchmark
2021, by province, per cent
90% benchmark
MB
100
AB
99
NL
99
QC
99
PEI
99
ON
98
SK
98
CAN
97.6
NB
92
NS
89
BC
88
the globe and mail, Source: cihi
Alberta, Saskatchewan, Manitoba, Ontario, Quebec, Prince Edward Island and Newfoundland and Labrador all came in at 98 per cent or above; New Brunswick was at 92 per cent and Nova Scotia at 89 per cent, according to data from 2021.
Of patients requiring chemotherapy, about 77 per cent start treatment within the recommended two weeks of a decision to treat and 95 per cent within four weeks, the data show.
Cancer cases in Canada expected to climb as population increases, ages, study says
The Canadian Association of Radiologists has repeatedly warned of staff shortages, aging equipment and severe backlogs in medical imaging, which president Gilles Soulez emphasized is “the cornerstone of any medical decision.” When the pandemic began in March, 2020, Canadians were already waiting 50 to 82 days for a CT scan and 89 days for an MRI – far more than the recommended one-month benchmark.
Charlotte Yong-Hing, president of the BC Radiological Society and president-elect of the Canadian Society of Breast Imaging, said radiology volumes have gone up in the last five years, but the number of technologists has not.
“The downstream impact is that people have a huge amount of anxiety because of the waiting,” she said. “And in the process of waiting, their disease progresses and then they have to have more invasive testing, more invasive treatment. And, you know, there’s years of life lost, at the end of the day.”
A study published in the British Medical Journal in November, 2020, found that delaying treatment for cancer by even a month can increase a person’s risk of dying by 6 to 13 per cent. Further delays were associated with higher mortality; an eight-week delay in breast cancer surgery, for example, would increase the risk of death by 17 per cent, and a 12-week delay by 26 per cent, the researchers found. In Canada, that difference would lead to 700 excess deaths a year.
'When I discovered my lump in June [2021], my first feelings of concern were tempered by the fact that we live in B.C., have a wonderful medical system in place, and it would be okay,' said Ms. Glover. 'I’m afraid those feelings [have] rapidly deteriorated.'Melissa Renwick/The Globe and Mail
Lorraine Glover, 71, faced just such a delay last year. When the retired office administrator in Victoria discovered a lump in her breast in June, 2021, she immediately thought of her first brush with cancer nearly three decades earlier. That time, she had undergone a needle biopsy within hours of the discovery and, within a few days, had the lump excised and confirmed as cancerous. Surgery came a week later, followed shortly by a three-week course of radiation.
It had been a frightening time for Ms. Glover, then in her early 40s and a mother of two young children. But the process was manageable – and over within two months.
“When I discovered my lump in June, my first feelings of concern were tempered by the fact that we live in B.C., have a wonderful medical system in place, and it would be okay,” said Ms. Glover. “I’m afraid those feelings [have] rapidly deteriorated.”
What she experienced this time was a stumbling journey through a cancer care system under pressure, beset by delays and uncertainty.
Ms. Glover saw her family doctor in July and was scheduled that month for a mammogram, ultrasound and biopsy. But the cancer clinic still required an MRI scan that couldn’t be scheduled until late August; the results in early September showed possible spread of cancer cells into neighbouring tissues. At that point, Ms. Glover said the cancer clinic accepted her and assigned her a surgeon, whose office her doctor advised her to “start badgering” for an appointment.
The surgeon quickly identified Ms. Glover as having spindle cell sarcoma, a rare soft-tissue tumour that can spread quickly to other areas of the body, and excised the lump at the end of September. But further surgery would be needed and an operating room couldn’t be booked until mid-October. The biopsy pathology report from that procedure took another four weeks – more than double the typical maximum in times of adequate staffing.
She underwent a mastectomy in early December, waiting another three weeks for a biopsy pathology report to see if any cancer remained. Two days before Christmas, Ms. Glover said her surgeon phoned to say she was cancer-free but she would need to come in to discuss the biopsy results – an appointment that was postponed three times over the following month.
“I’m not that worried because I’m cancer free,” she remembers thinking at the time. “I thought it was just a mop-up. Just, you know, ‘Okay, great, your scar looks good. Good luck with the rest of your life.’”
That wasn’t the case. At the appointment in late January, Ms. Glover’s surgeon advised her that she had a high level of HER2, a protein that can cause breast cancer cells to grow quickly. Her files were sent to oncology, and an appointment scheduled for mid-February.
“The very first words [the oncologist] said to me were, ‘Why did you wait so long to come? Your window of opportunity is nearly closed. We like to start chemotherapy four to six weeks after surgery for best results. You’re closing in on three months.’”
Ms. Glover was stunned.
“Well, I’m probably going to die,” she thought. “I have cancer. It’s not gone. It’s growing inside me, and I’m probably going to die.”
She began chemotherapy in early March.
There had long been hints of tension at B.C.’s provincial cancer agency, which saw several past presidents cut short their terms without giving convincing, public explanations as to why – until now.
Max Coppes was named president of BC Cancer, then called the BC Cancer Agency, in the summer of 2012. In his first year on the job, Dr. Coppes liaised with cancer care staff across the province, B.C. health authority representatives and his predecessors to determine the organization’s current and future needs. Wait times were already longer than he would have liked, and the province’s growing and aging population meant that a significant increase in cancer incidence was on the horizon.
Dr. Coppes said his team pulled data to estimate future cancer numbers and he presented the findings to leadership at the Provincial Health Services Authority (PHSA), which governs BC Cancer. He spoke frankly of an impending crisis that would require planning for new treatment infrastructure and the recruitment of new specialists. It was a necessary but costly endeavour that would put significant fiscal pressures on the health care system.
Opinion: B.C.’s health care crisis keeps getting worse
PHSA leadership didn’t seem to view the matter as urgent and no formal discussions about options or next steps took place, Dr. Coppes said. Conversations with senior executives became increasingly uncomfortable after that, which Dr. Coppes suspects was due to the overwhelming magnitude of the problem he described.
Dr. Coppes resigned from BC Cancer in 2014, two years into what is typically a five-year, renewable term.
“I honestly could not look in the mirror because I felt that I was cornered to be a person that I wasn’t,” he said. “Talking to people who would call or e-mail that they had such long waiting times, I couldn’t answer anymore because I couldn’t say, ‘Yeah, I hear your pain and I’m trying to do something about it.’ I actually felt that I couldn’t.”
In a final effort to draw attention to the looming surge in cancer cases, Dr. Coppes and his team turned their findings into an article and submitted it to the BC Medical Journal, where it was published in June, 2015.
“The expected rise in new cancer cases and deaths between 2012 and 2030 is substantial and means B.C. will need to prepare for increased cancer-related demands in laboratory and diagnostic services, surgical and radiation treatment, systemic therapy, pain services and palliative care,” the authors wrote. “Given the complexity and growing cost of cancer care overall, a provincial strategy is needed to address future demand for services.”
By the time Malcolm Moore replaced Dr. Coppes as BC Cancer president in the fall of 2015, the deteriorating working conditions at the organization had entered the political arena. Insiders were speaking out about growing wait times, surging staff burnout and plummeting morale that were compromising patient care, and the then-opposition NDP amplified the concerns in the legislature.
In an interview, Dr. Moore said his biggest worry when he took the post was that the system was already “pretty much full,” with limited capital projects planned for new capacity.
”To get approval for major capital projects and to build cancer centres is a five- or 10- year horizon,” Dr. Moore said. “I was quite concerned about that, and inevitably, what that starts to do is it starts to reduce access.”
In 2018, Dr. Moore submitted to the PHSA board a provincial cancer plan that highlighted as a key priority the creation of a quality council, an external body that would monitor and report on cancer system performance, such as wait-time metrics. The board did not approve the quality council.
“It wasn’t that people said no; it was more that they didn’t say yes,” Dr. Moore said. He resigned from BC Cancer after three-and-a-half years.
“I’m impatient,” Dr. Moore said. “I wanted to get things done, I wanted to build a system. I felt like I was concerned and motivated and wanted to make these changes, and I did get the sense that it was going to take a long time.”
Cancer survival gains are largest
in Alberta and Ontario
Changes in the five-year Cancer Survival Index (CSI) estimates
over time, ages 15 to 99, both sexes, selected provinces,
from 1992-96 to 2013-17
Prov.
Five-year change in CSI (percentage points)
Net CSI (%)
Alta.
8.7
63.3
Ont.
8.6
64.1
N.B.
6.9
62.1
B.C.
6.1
62.5
Man.
6.0
62.2
N.S.
6.0
60.8
Sask.
5.9
61.6
Nfld.
5.9
61.8
the globe and mail, Source: statistics canada
Cancer survival gains are largest
in Alberta and Ontario
Changes in the five-year Cancer Survival Index (CSI) estimates
over time, ages 15 to 99, both sexes, selected provinces,
from 1992-96 to 2013-17
Prov.
Five-year change in CSI (percentage points)
Net CSI (%)
Alta.
8.7
63.3
Ont.
8.6
64.1
N.B.
6.9
62.1
B.C.
6.1
62.5
Man.
6.0
62.2
N.S.
6.0
60.8
Sask.
5.9
61.6
Nfld.
5.9
61.8
the globe and mail, Source: statistics canada
Cancer survival gains are largest in Alberta and Ontario
Changes in the five-year Cancer Survival Index (CSI) estimates over time,
ages 15 to 99, both sexes, selected provinces, from 1992-96 to 2013-17
Prov.
Five-year change in CSI (percentage points)
Net CSI (%)
Alta.
8.7
63.3
Ont.
8.6
64.1
N.B.
6.9
62.1
B.C.
6.1
62.5
Man.
6.0
62.2
N.S.
6.0
60.8
Sask.
5.9
61.6
Nfld.
5.9
61.8
the globe and mail, Source: statistics canada
BC Cancer is a provincial, government-funded treatment and research organization, with six regional cancer centres in the province. The agency once had its own board of directors and a direct line to B.C.’s Ministry of Health, but it was folded under the umbrella of PHSA when the health authority was established in 2001.
Don Carlow, who served as BC Cancer president from 1994 to 2000, noted that B.C. led the country in five-year relative survival rates for several major cancers in the 1990s but has since plateaued while other provinces improved their outcomes. He is certain that B.C.’s performance is stagnating, and he attributes it to the change in governance structure.
“Cancer is buried within a bureaucracy, at about a third or fourth level of reporting, and the perception has been that there’s greater focus on the bureaucracy than there is on the actual nature of the business that PHSA ought to be in, and that’s delivering major programs, like cancer,” he said.
Dr. Coppes felt similarly, saying that the extra “layers” of bureaucracy made him question whether the health care leadership of the province were aware of what was happening in cancer.
“In the past, the president of BC Cancer reported to the Minister of Health, one-to-one,” he said. “When I came there, there was one layer, and then they added another layer. In my opinion, that is a reflection of how you view the significance of the cancer problem.”
A request to interview PHSA president and chief executive David Byres was deferred to Kim Nguyen Chi, who was named chief medical officer at BC Cancer and vice-president of PHSA in 2019. (The agency did away with the title of BC Cancer president after Dr. Moore’s departure.) Dr. Chi, a medical oncologist and an internationally recognized prostate cancer researcher, began his career at the agency in the late 1990s.
Dr. Chi acknowledges that B.C. is not currently equipped to deal with the projected surge in cancer cases. However, he’s confident that a number of planned initiatives will meet the need. That includes $41-million committed this year, and $25-million last year to hire more general practitioners in oncology, licensed practical nurses, radiation therapists and other staff to build up team-based care. As well, 37 new oncologist positions have been announced in the past year, of which 23 have so far been filled, he said.
A 10-year provincial cancer plan announced by the B.C. government in 2020 also commits to build new cancer centres in Surrey and Burnaby, tentatively scheduled for completion in 2027 and 2028, respectively. Cancer centres in Kamloops and Nanaimo are in the concept planning stage. And a new lung cancer screening program, which began rolling out at 36 sites across B.C. in late May, is expected to diagnose about 150 cases annually.
Asked about the agency’s governance structure, Dr. Chi said he has found it to be effective.
“I’ve been at BC Cancer my entire career, and so I’ve witnessed the changes that have happened over time,” he said. “I can say that, at this time, I really feel that PHSA, the ministry, the minister – we’re all in alignment about the need that exists and the urgency to improve on it.”
Dr. Chi said he empathized with anyone navigating a cancer diagnosis, and that he understood that even a day of waiting is stressful.
“I can’t stress how much we – me and the entire system – want to shorten wait times as much as possible,” he said. “But, of course, we do live in an age of wait times in a publicly funded health care system, so we’re trying to manage those as best as possible.”
A report on a national survey of oncology physicians conducted just prior to the COVID-19 pandemic, presented to BC Cancer leadership and obtained by The Globe, provides an illuminating look at how those working in B.C. perceive their working conditions compared to their counterparts across the country.
“When compared to radiation oncologists working in other provinces in Canada, [BC Cancer] oncologists have the highest levels of disengagement and burnout among oncologists in the country,” the report found. “The results indicated that [BC Cancer] oncologists reported serious issues with wellbeing, excessive workload and work environment inefficiencies.”
Three-quarters of BC Cancer physicians surveyed felt that there were not enough physicians to meet workload demands, compared to 29 per cent of radiation oncologists in other provinces. BC Cancer physicians also reported less time to complete necessary work documentation, poor workplace efficiency and described their work atmosphere as “hectic and chaotic,” the report found.
Respondents said the work environment could be improved with lighter workloads, more support staff – such as nurses, secretaries and radiation therapists – more efficient care models, and more resources available for patients, such as timely imaging and more radiation therapy resources.
The survey was authored by seven researchers, six of whom are members of the BC Cancer Medical and Dental Staff Association, with funding from the BC Cancer Medical Cancer Staff Engagement Society and the Canadian Radiation Oncology Association. One hundred sixty BC Cancer oncology physicians and 241 CARO members completed the survey, which was conducted between November, 2019, and March, 2020.
Dr. Chi said he recognizes the feelings that physicians were having at the time of the survey, and the fact that burnout likely worsened over the course of the pandemic. He believes the new hires, and the investments in building up team-based care, will alleviate those pressures.
But with the cancer case load growing every year and more capacity still at least five years away, it’s a race against time some fear the province is losing.
“Survival outcomes have not kept pace and stress levels are high,” Mr. Carlow said. “There will be further slipping in all parameters.”
In Victoria, Ms. Glover completed 12 weeks of chemotherapy in the spring and began a targeted therapy that will be administered every three weeks for nine months. Normally an active, high-energy person, she now grapples with fatigue and a “chemo fog” that sometimes leaves her searching for words.
“I hate it, I’m tired of it, but I guess I’m doing alright,” she said. “Hopefully I’m alright. Hopefully the chemo has done its job. But you know who I worry about? There are a lot of people behind me that have cancer right now. So what’s going to happen to them?”