June 9, 2021
Dr. Bishal Gyawali, based at Queen’s University, is an expert in global oncology, cancer policy, evidence-based oncology, financial toxicities of cancer treatment, clinical trial methods, supportive care, and global oncology.
The emergence of new cancer therapies and improved methods to screen for and diagnose cancer have led to marked improvements in survival rates for cancer patients. However, survival rates do not tell the whole story – a patient’s quality of life can be just as important. That is why Dr. Bishal Gyawali is interested in taking a value-based approach to cancer care. Gyawali, a newly appointed OICR Investigator based at Queen’s University, is using evidence, education and communication to deliver his message to stakeholders in the cancer care system.
“Every society has a limited amount of resources that they can devote to cancer care. We need to be sure that we are using these resources wisely by selecting proven, high-value interventions that have evidence of improving the duration and quality of patients’ lives,” says Gyawali. “When we are making policy and clinical decisions about a new cancer drug, we need to be asking what the societal value is. For many of the new cancer drugs there isn’t strong evidence that they actual improve a patient’s survival or quality of life.”
Gyawali, who is from Nepal, explains that he first became interested in this area of research working in Japan and then in the U.S. “Working in these high-income countries was eye-opening. I saw that yes, there were lots of resources, but a significant amount was being spent on things that were not helping patients,” says Gyawali.
To combat this issue, Gyawali has published several research articles to inform policy and has personally been involved in advocacy and policy works through his membership in committees and working groups of organizations such as the American Society for Clinical Oncology, the European Society for Clinical Oncology and the WHO-Essential Medicines List for Cancer Drugs with the ultimate goal to identify and reduce the use of unhelpful and low-value treatments and to educate physicians through these groups.
Gyawali is also trying to increase stakeholders’ understanding of clinical trial results. “My goal is to educate patients, clinicians and advocates about how to properly interpret the results of a clinical trial, so they have a clear picture of a drug’s potential benefits as well as its risks,” explains Gyawali. “Only when we truly understand what the data is telling us and how the trial was conducted can we best choose the right course of action.”
Making decisions about their treatment is just one of a number of challenges faced by cancer patients and their families. “There is a financial toxicity associated with cancer treatment,” says Gyawali. “Even though some of the costs of treatment may be covered by universal healthcare systems or private insurance, there are still many other financially damaging effects from cancer treatment. For example, the loss of wages, the costs of travel and parking as well as supportive care if needed. This added stress can have a significant negative impact on a patient’s quality of life. I want to help find ways to address these issues.”
Through his research, Gyawali wants to not only improve cancer care in Ontario, but worldwide, with a focus on low- and middle-income countries. “The global burden of cancer is immense and growing. Identifying interventions that are proven and affordable that can be deployed in these countries is essential to increasing equity in cancer care. There are lessons we can learn from low-and-middle-income countries for the benefit of Ontario and lessons Ontario can teach to the world as a leader in cancer care and research,” says Gyawali, a member of the Queen’s University Global Oncology Program.
Since coming to Ontario as a Clinical Fellow at Queen’s in 2019, Gyawali has gained an appreciation of the elements that make Ontario an ideal place to carry out this type of research. “Ontario has a world class community of researchers and some unique resources that have proven very beneficial to my research,” says Gyawali. “For example, the database maintained by ICES is an invaluable resource for finding evidence to support a value-based approach to care.”
Gyawali, who is now an Associate Professor in the Department of Medical Oncology at Queen’s is happy to be continuing his research in Ontario with the support of OICR. “This award from OICR helped me secure a faculty position at Queen’s and has allowed me to confidently plan my academic work. It also provided a sense of validation about my research and is great encouragement to continue,” says Gyawali. “It is fantastic that the Institute is supporting young researchers such as myself. I am excited to immerse myself in the OICR community and contribute to improved cancer policy and care in Ontario and worldwide.”
February 26, 2021
Text-based online support groups augmented with a new tool for detecting distress
Therapist-led online support groups can provide a safe space for people affected by cancer to discuss fear, normalize stress, build resilience and enhance coping. Cancer Chat Canada offers real time text-based support groups, but therapists who lead these groups often feel challenged to address the needs of each participant in the absence of visual cues. Recent Ontario-made advances in artificial intelligence (AI) may offer potential solutions.
In a paper recently published in JMIR Research Protocols, an Ontario-based research group outlines their new AI-enabled virtual therapy cofacilitator tool for online cancer support groups. The tool uses a machine learning algorithm based on interpreting patterns of speech and language to track support group participants’ progress in real-time, while providing feedback to the leading therapist.
The research initiative was supported by OICR through the OICR-Cancer Care Ontario (Ontario Health) Health Services Research Network, and led by Drs. Yvonne Leung and Mary Jane Esplen, experts in the psychological impact of cancer.
“Online support groups are accessible and effective at reducing cancer-related emotional distress, but it can be challenging to monitor individual participant distress and engagement while responding to multiple participants’ messages simultaneously,” says project lead Esplen, Professor and Vice-Chair, Equity and Mentorship in the Department of Psychiatry, University of Toronto and former Lead of the de Souza Institute. “With multiple participants typing at the same time, nuances of text messages and red flags for distress can sometimes be missed. Our tool serves as an AI-enabled cofacilitator that can enhance the therapist’s ability to address these concerns.”
With a tool that can detect and flag issues, therapists could prioritize concerns more effectively, provide more individualized support in real time, and direct treatment accordingly in a timely manner.
In 2020, the research group completed the first phase of their study, during which they developed the AI-enabled cofacilitator tool. Now, in the second phase, they are evaluating the tool’s effectiveness by scoring its ability to accurately output psychometric measures, such as fear, sadness and hopelessness.
“The goal is to visualize emotions and sentiments throughout therapy to make online group therapy more effective,” says first author Leung, who is an Assistant Professor at the University of Toronto. “We believe these tools and technologies can be used to strengthen person-centred care by attending to individual needs and expanding access to high-quality virtual health care. We’re delighted to be in the process of validating such a cutting-edge tool.”
Should effectiveness be demonstrated in their clinical studies, the group plans to integrate their AI-enabled cofacilitator into Cancer Chat Canada’s online psychosocial oncology services, and potentially adapt the cofacilitator algorithm for other cancer-related support services.
“We’re proud of the progress made so far,” says Esplen. “Our team was strategically built to incorporate different areas of expertise and different perspectives. We’ve tested each step along the way, and we look forward to building more tools to enhance patient therapy and care.”
November 13, 2020
Research team develops a Google maps-like algorithm to pinpoint when cancer patients may diverge from the standard course of treatment
Every cancer patient’s experience is unique but there are standard sequences of steps that help patients and their care teams navigate through screening, diagnosis, treatment and monitoring. These steps are published in pathway maps but are these maps followed in practice? Researchers supported by OICR’s Health Services Research Network, led by Drs. Timothy Chan and Claire Holloway, are working to answer that question.
Chan and collaborators at Ontario Health have developed new methods to measure the difference between a standard clinical pathway map and the actual care that a patient receives in practice. They leveraged real-world health data from Ontario patients to develop these methods, which could potentially be used to identify targets for quality-improvement initiatives.
“Pathway maps help optimize patient survival, healthcare costs and wait times at a population level,” says Holloway, co-principal investigator of the project and Provincial Clinical Lead of Disease Pathway Management (DPM) at Ontario Health.
“We have now derived a way to measure the alignment between actual care and the care described in a pathway map, analogous to measuring how a driver’s route differs from the Google Maps-suggested route,” says Chan, co-principal investigator of the project, Professor at the University of Toronto and Canada Research Chair in Novel Optimization and Analytics in Health.
To address this challenge, the team based their algorithm on an inverse optimization framework, a type of framework used to solve problems across a variety of disciplines, including telecommunications routing, medical radiation therapy planning, and investment portfolio management.
The research team first applied their methods to stage III colon cancer patient data and is now applying their methods to breast cancer care. The ultimate goal would be to use these methods across different cancer sites and potentially different diseases to help promote and implement best practices along the care continuum in Ontario’s healthcare system.
“We’re proud to apply our framework at a large scale to help provide meaningful quantitative measures of system efficiency and variation,” says Chan. “It’s exciting to see that these methods could allow Ontario Health to monitor and evaluate complex practice patterns at a population level.”
“Variations between a patient’s experience and the standard clinical pathway map isn’t necessarily a bad thing but it may prompt us to investigate further,” says Dr. Katharina Forster, Team Lead of DPM at Ontario Health. “We can look into why, when and where the variation is occurring. In this way these new methods and tools are allowing us to generate hypotheses about the causes of variation so we can better understand our care practices, make data-driven decisions and ultimately improve our cancer care system.”
“Ultimately, we’re looking to measure, monitor and improve our system across the province,” says Holloway. “Our rich data in Ontario and our capabilities in machine learning are outstanding. Thanks to OICR, we can bring these disciplines together to make a positive impact on our health system.”
The Health Services Research Network is co-funded by OICR and Cancer Care Ontario, now part of Ontario Health.
November 5, 2020
Study finds that every month delay in cancer treatment can raise risk of death by around 10 per cent
Research led by Dr. Timothy Hanna suggests that minimizing delays to treatment could improve cancer survival rates
Many countries have needed to defer cancer surgeries, radiotherapy and other treatments through the COVID-19 pandemic, which has brought the impact of treatment delays into sharp focus. In a study published today in The BMJ, Dr. Timothy Hanna and collaborators report that people whose cancer treatment is delayed by even four weeks have in many cases a six to 13 per cent higher risk of dying – a risk that keeps rising the longer their treatment does not begin.
“We know that delay matters and now we understand how much it matters,” says Hanna, Radiation Oncologist at the Cancer Centre of Southeastern Ontario, Faculty of Queen’s Cancer Research Institute, OICR Clinician Scientists and lead of the study. “With these data, we can now quantify the impact of treatment delays – including those that we’re experiencing now throughout the COVID-19 pandemic.”
The research group reviewed and analyzed relevant studies from around the world that were published over the last two decades. They found that there was a significant impact on a person’s risk of death if their treatment was delayed, whether the treatment was surgical, chemotherapy or radiotherapy. They observed this impact across all seven types of cancer analyzed – breast, bladder, colon, rectum, lung, cervix and head and neck cancers.
For example, with cancer surgery, they saw a six to eight per cent increase in the risk of death for every four-week treatment delay, meaning that a three-month delay could increase the risk of death by about 25 per cent. The impact was even greater for specific treatments – such as bowel cancer chemotherapy – where a three-month delay could cause a 44 per cent increase in risk of death.
“As we move towards the second COVID-19 wave in many countries, the results emphasize the need to prioritize cancer services including surgery, drug treatments and radiotherapy as even a four-week delay can significantly increase the risk of cancer death,” says Dr. Ajay Aggarwal, co-lead of the study from King’s College London and the London School of Hygiene and Tropical Medicine.
Hanna hopes this study will help inform cancer treatment backlog management and prioritization. His prior work on prioritizing treatment during COVID-19, published in Nature Reviews Clinical Oncology, has been incorporated into health system planning and management in Ontario and around the world.
“The impact of cancer treatment delays will persist long after the threat of this pandemic subsides,” says Hanna. “As a clinician, a patient, an administrator or a decision-maker in our cancer care system, these results should encourage us all to put resources and efforts in place to minimize system level delays in cancer treatment.”
July 23, 2020
Prevention before treatment: How an OICR investigator is shifting the paradigm of chronic disease in Canada
The BETTER Program for chronic disease prevention and screening now customized for young adults, women and cancer survivors across the country
Cancer doctors are extensively trained to find and treat the disease, but what about preventing cancer in the first place?
Dr. Eva Grunfeld is dedicated to making prevention a priority.
In 2012, Grunfeld established the BETTER Program and today, this Canada-wide initiative is expanding and adapting to serve more individuals across the country.
Since its inception, BETTER has trained nearly 250 health professionals to become Prevention Practitioners who specialize in chronic disease prevention and screening. These Prevention Practitioners work in the primary care setting to develop personalized “prevention prescriptions” that are tailored to each patient based on an in-depth analysis of their medical history, family history, lifestyle factors, and other risk factors for diabetes, cardiovascular disease and cancer.Continue reading – Prevention before treatment: How an OICR investigator is shifting the paradigm of chronic disease in Canada
August 29, 2019
OICR and Cancer Care Ontario’s Health Services Research Network releases the 2019 Synthesis Report, summarizing 14 studies that address high priority issues in cancer care
An excerpt from the foreword by Drs. Christine Williams and Eva Grunfeld:
Optimal cancer care across Ontario cannot be solely provided by a clinician or implemented by a researcher, enacted by a policy maker or attained by a patient. To improve the delivery of cancer services, we need to work together with stakeholders from across our rich cancer care ecosystem and involve them in prioritizing concerns, designing interventions and implementing solutions. For these reasons, OICR and Cancer Care Ontario (CCO) teamed up to co-create the OICR-CCO Health Services Research Network (HSRN).
Now, a decade later, we present our second Synthesis Report with an additional 14 studies that have emerged from this network. These studies have addressed high priority issues in cancer care including the gap in follow up after a positive colorectal cancer screening test, and the challenges that cancer patients face with co-existing chronic conditions like diabetes. The studies have led to the development of new methods to determine the burden of cancer in Ontario, and new resources to facilitate health services research across the province. This report provides summaries of these studies and others and their impact to date.
June 10, 2019
OICR-supported researcher Dr. Nicole Mittmann leads collaborative initiative to determine the value of new cancer solutions and the burden of cancer care on Canada’s healthcare system
Canada is well known for its publicly funded healthcare system, its universal health coverage, and in most recent news – for the Toronto Raptors.
What is less recognized, however, is that with its distinctive healthcare system, Canada has unique healthcare reimbursement processes and resource needs, especially for the delivery of cancer care. While Canada collects some of the most robust and comprehensive healthcare data, Canadian datasets are underutilized in research and policy decision making.
Dr. Nicole Mittmann has set out to close this gap and, in turn, transform our administrative health information into tangible healthcare improvements.
“As cancer-drug costs continue to rise, there is – now more than ever before – a need to understand the Canadian context with respect to costs and health system resource use,” she writes in Current Oncology.
Turning data into action
Mittmann, who was recently appointed as the Chief Scientist and Vice-President of Evidence Standards at the Canadian Agency for Drugs and Technologies in Health (CADTH), sees Canada’s rich data as a goldmine for improving the management of diseases and the delivery of care.
“This information can be used to help us make decisions, help us plan and help us understand the value of new technologies,” she says. “It could also show us areas where we need to improve, or problems that weren’t apparent through practice alone, but we needed to reduce the barriers to using these data for research.”Continue reading – It’s our health information: a goldmine for improving the quality of cancer care
June 4, 2019
New research projects to drive clinical adoption of novel cancer technologies and find ways to better deliver cancer services
10 projects to receive funding through OICR-CCO Health Services Research Network
Toronto (June 4, 2019) – The Ontario Institute for Cancer Research (OICR) today announced funding for 10 projects as part of the OICR-Cancer Care Ontario (CCO) Health Services Research Network (HSRN). As part of the HSRN, these projects are focused on optimizing the delivery of existing cancer services and guiding the dissemination of new practices and technologies in cancer prevention, screening and care in Ontario.
The funded projects, which involve 103 researchers and clinicians based at 29 institutions across Ontario, as well as five institutions outside of the province, focus on at least one of six priority areas: using real-world evidence to advance innovations; data infrastructure, integration and mobilization studies; use of artificial intelligence and digital health tools; the adoption of accepted best practices related to precision medicine; knowledge translation and dissemination; and population health studies.
“Improving the delivery of cancer-related healthcare and ensuring that new innovations are properly introduced into clinical use is an essential part of improving outcomes for cancer patients,” says Dr. Christine Williams, Deputy Director and Interim Head, Clinical Translation, OICR. “The projects funded today will help integrate more leading-edge technologies and practices – such as artificial intelligence, immunotherapies and precision medicine – into Ontario’s healthcare system. OICR is proud to help enable improvements in frontline care for the people of Ontario through these projects.”
In total, the projects announced today will receive more than $2.7 million in funding over the next two years. These projects were awarded funding after a competitive process, including review by an expert panel. Together, these projects are a key arm of OICR’s Clinical Translation initiative, which is driving the translation of research findings into patient impact by partnering with the healthcare system.
“I congratulate the researchers who have received funding today and laud their efforts to optimize how we prevent, diagnose and treat cancer in Ontario,” says Hon. Merrilee Fullerton, Ontario’s Minister of Training, Colleges and Universities. “As new technologies and best practices emerge, it is important that Ontario use its research expertise to deliver these advancements to the people as quickly and efficiently as possible.”
For details about the funded projects please visit: https://oicr.on.ca/research-portfolio/health-services-research/Continue reading – New research projects to drive clinical adoption of novel cancer technologies and find ways to better deliver cancer services
May 27, 2019
Dr. Monika Krzyzanowska and collaborators develop app for cancer patients to manage and understand their treatment symptoms from the comfort of their own home
Patients undergoing cancer treatment face a lot of uncertainty. They often experience symptoms and treatment side effects at home, which often leads them to the emergency room. But in many cases, their side effects could have been better managed remotely and prevented from getting worse. Dr. Monika Krzyzanowska, Medical Oncologist at the Princess Margaret Cancer Centre, wanted a better option for her patients to understand and manage their symptoms comfortably at home.
“Almost half of women undergoing treatment for breast cancer visit the emergency room between treatment sessions and many of these visits can be avoided,” says Krzyzanowska. “We give our patients a lot of information up front, but we can do a better job at remote monitoring and providing them with the information they need when they need it. There’s a clear need for decision aids, self-management support, improved communication and options in care delivery.”
Krzyzanowska teamed up with the University Health Network’s Healthcare Human Factors team to explore how to improve symptom management for patients with a more personalized approach. In response to this need, they created bridges, a web-based app to facilitate remote management of chemotherapy-related side effects.
As recently described in the Journal of Medical Internet Research, the team refined their design over two rounds of usability testing with patients. They incorporated toxicity tracking, self-management advice and health care provider communication functionalities so that both physicians and patients can track and manage the patient’s symptoms.
With their pilot complete, Krzyzanowska is looking to partner with health care providers and decision makers to expand the project and explore how to integrate bridges into current systems and processes.
“Bringing bridges into the hands of patients is going to require a coordinated effort between decision makers, patients, care providers and hospitals,” says Krzyzanowska. “Helping patients who need it when they need it is our top priority and I look forward to developing bridges to help in that goal.”
Krzyzanowska’s project is one of the many research projects funded through OICR and Cancer Care Ontario’s Health Services Research Network.
April 11, 2019
Research group identifies the nuanced barriers that prevent patients from following up on a positive colorectal cancer screening test
Colorectal cancer (CRC) is often detectable and beatable, yet it still remains the second leading cause of cancer-related death in Canada. Ontario offers an at-home CRC screening test, however not all patients who have abnormal test results receive the necessary follow-up care due to a number of factors. This means that there are missed opportunities to treat – and cure – some of these cancers.
Dr. Jill Tinmouth at the Sunnybrook Research Institute has set out to improve follow-up after a positive CRC screening test. The first step, Tinmouth says, is to understand why patients may be reluctant to follow up in the first place.
“The screening test for colorectal cancer is an easy, safe, painless, at-home fecal occult blood test (FOBT) but without proper follow-up of abnormal tests, it is all for naught,” says Tinmouth. The FOBT checks a person’s stool for tiny drops of blood, which can be caused by CRC. Colonoscopy is the recommended next step for anyone who has an abnormal FOBT. “Looking at the administrative data, we saw that nearly one in three people with an abnormal FOBT don’t follow up with colonoscopy within six months. We are working to both understand and fix this gap.”
In this first study, Tinmouth and collaborators looked into Ontario’s administrative health data to try to improve the lack of follow-up. These initial findings suggested that physicians may not be adhering to screening guidelines and led to better articulation of CRC screening and follow-up protocols to primary care providers.
“We made some modifications to our screening program to encourage physicians to follow up on positive FOBT results in a timely manner, but we recognized that these strategies wouldn’t solve every problem,” says Tinmouth. “To fully understand the gaps and barriers to following up, we knew we had to speak directly to patients and those in this position.”
In their most recent study on the subject, published in the American Journal of Gastroenterology, Tinmouth teamed up with Dr. Diego Llovet from Cancer Care Ontario to interview patients who failed to follow-up on positive FOBT results and physicians who care for those patients. Many of the patients believed that their test results were a false positive and others experienced fear, anxiety or uneasiness about the next step in CRC screening – a colonoscopy. Often, patients were reluctant to have a colonoscopy and physicians were unable to persuade their patients to follow through.
Tinmouth is now working with health system decision-makers and Cancer Care Ontario to test and pilot four different interventions that could help improve proper follow-up, including patient navigation through the screening process and reminders sent to physicians of patients who test positive but fail to follow up. This research group is evaluating the feasibility of these interventions and how Ontario could implement them across the province.
“Better colon cancer screening and care starts with understanding the barriers and then effectively implementing this new knowledge,” says Tinmouth. “On these projects, researchers worked hand-in-hand with policy-makers – in so doing, we were able to integrate our expertise and collective wisdom to improve colorectal cancer screening for Ontarians today and in the future.”
November 22, 2018
Dr. Lorraine Lipscombe investigates why the 20 per cent of cancer patients with diabetes often experience worse outcomes
Several studies show that health outcomes – such as overall survival and preventable hospitalizations – are worse for cancer patients who also have diabetes. However, the reasoning behind this disparity is unclear. Dr. Lorraine Lipscombe, an endocrinologist at Women’s College Hospital and Diabetes Canada Investigator Award holder, is investigating why these differences exist and what we can do to avoid preventable complications.
July 9, 2018
The BETTER program has been awarded almost $3 million to train primary care providers as prevention experts across Canada
As the number of Canadians at risk of cancer and other chronic diseases continues to grow, so does the need for health professionals to deliver effective disease prevention and screening recommendations.