Growing wait times for cancer care in British Columbia are worsening outcomes for patients and leaving some to die before their first medical consultations, a situation doctors say is causing both themselves and those they treat to lose faith in the cancer system.
Since the beginning of 2020, 18 medical and radiation oncologists have left BC Cancer, the province’s cancer agency. Some told The Globe and Mail they did so because they felt they could no longer provide the appropriate level of care. Other doctors said patients with terminal diagnoses are turning to medical assistance in dying, or MAID, when their pain and anxiety grow unbearable.
A Globe investigation found that some cancer patients in B.C. are now waiting months to begin treatment. As of this fall, only one in five patients referred to an oncologist received a first consultation within the recommended period of two weeks, The Globe found. In comparison, about 75 per cent of patients in Ontario are seen within two weeks.
BC Cancer physicians, working to compensate for system pressures, are self-reporting the highest levels of stress, burnout and disengagement among oncologists across Canada.
Christopher Applewhaite, a family doctor on Salt Spring Island, recalled a patient in his 70s, diagnosed in June with metastatic cholangiocarcinoma, also called bile-duct cancer. The recently retired farmer and carpenter, otherwise healthy, was still active at the time and continued working in his yard as he awaited a first consultation with an oncologist.
“But he waited until almost the end of September before speaking to an oncologist, by which time he was bedridden, basically unable to mobilize on his own and definitely too weak to travel from Salt Spring Island to Victoria to receive treatment,” Dr. Applewhaite said. “He went ahead with MAID, I believe, three or four days after speaking to the oncologist.”
Four past presidents of BC Cancer, along with dozens of doctors, nurses, radiologists and other medical staff members who have spoken with The Globe, have said today’s system pressures can be traced back to the 2000s, when the provincial government made changes in leadership at the cancer agency. The cancer system, then already nearing capacity, did not plan for the surge in cancer cases anticipated as the province’s population grew larger and older, they said.
Dr. Applewhaite said increased wait times have led to “very, very significant” psychological suffering for patients.
“Many patients are choosing MAID because of both their physical suffering with their disease and the mental suffering of not knowing when they’ll hear their options, and whether they’ll be able to take up those options when they’re offered to them,” he said. “I’ve seen it many times now, and it’s heartbreaking. It should not be that way.”
Amy Tan, a palliative-care physician in Victoria, said months-long wait times mean patients are being left both in limbo and in pain when treatments could help them. For example, she said, palliative chemotherapy or a clinical trial could improve quality of life for a patient with an incurable cancer, or extend their life. She has seen patients as young as 40 die before their first consultations.
Those patients are able to access MAID in as little as two days, allowing them the choice of death before the disease progresses and their pain worsens.
“I’m not opposed to MAID at all,” she said. “I’m just seeing it being used more and differently, and sooner after diagnosis, than ever before.”
In a normal year before the pandemic, Dr. Tan said, she would spend around 80 per cent of her time with patients making end-of-life decisions. Now, with patients waiting so long for appointments, they no longer have information to base those decisions on.
“We can deal with the symptoms, I can give them medication, I can treat their pain. That’s the easy part,” she said. “It’s all of this decision-making that’s so individual and so personal to a patient and their family that I can’t help them with, because we don’t have all the information, when before we would have.”
Sarah Finlayson, who is the division head of gynecologic oncology at the University of British Columbia and the gynecologic oncology representative at BC Cancer, has felt the pressure of growing wait times acutely.
From April to June, just 4.7 per cent of patients with endometrial cancer on B.C.’s mainland were able to have surgery within the target time of eight weeks from diagnosis. Only 3.9 per cent of patients with Grade 1 and 2 tumours were able to have surgery within the target time of six weeks from referral, while no patients with Grade 3 tumours were able to have surgery within the target time of four weeks from referral.
A cancer’s grade describes how abnormal its cells and tissue look compared with normal cells. Higher-grade cancers are faster growing and more likely to spread.
Dr. Finlayson said these waits allow cancers to progress, or even become incurable.
“It certainly means increased anxiety and fear in patients,” she said. “In addition to the progression of cancer and moral grief to those of us who care for these women, it also costs the system more time, money and resources if that happens. Instead of having the straightforward surgical cure, we’re now looking at women that are facing chemo and radiation that they may not have needed if the cancer had been dealt with in a timely way.”
As reasons for the delays, she cited a shortage of gynecological oncologists and nurses, as well as challenges accessing operating rooms.
“It’s really ghastly to be at a point where surgeons are experiencing career-high levels of moral distress and burnout,” she said. “It’s really heartbreaking to not be able to deliver the world-class care we used to provide.”
During an online meeting held with oncology staff at Victoria’s cancer centre in May, BC Cancer head Kim Nguyen Chi said he had spoken with B.C. Health Minister Adrian Dix about the oncologist departures, of which there had been 15 at the time. He said he and the government were in discussions about the province’s model of cancer care, workplace efficiency and work-life balance, according to minutes of the meeting, which were obtained by The Globe.
Dr. Chi told oncologists the growing wait lists were no fault of physicians, and he said he understood the moral distress and anxiety that they have caused, according to the minutes.
One oncologist who recently left BC Cancer told The Globe that he felt a lack of leadership had led to workplace dysfunction, and burnout and disengagement among staff. He said he left the agency because he felt it had “no goals, no vision” and no longer supported the quality of work he wanted to do. Two other former oncologists from the agency shared similar thoughts. The Globe is not naming them because they fear professional repercussions for speaking publicly.
In a statement to The Globe, Dr. Chi said BC Cancer is actively filling vacancies and has added 72.3 full-time equivalent (FTE) physician roles since April, 2021, already exceeding earlier projections. He said the agency has also added 325.8 FTE clinical and support staff roles since April, 2021. The overall allocation for medical and radiation oncologists has increased to 283.6, he said.
“Like many areas within health care, BC Cancer is facing steep national and international competition in the recruitment of talented and skilled medical staff,” Dr. Chi said. He noted that it takes an average of eight to 12 months to recruit a new oncologist. “In this difficult recruitment environment, BC Cancer has been successful at filling many of these new and highly specialized positions.”
Mr. Dix, the Health Minister, acknowledged the concerns from BC Cancer staff about leadership and governance structure, but he said the bigger issue is one of increasing demand, owing to the province’s growing and aging population. He said the province aims to address this with “dramatic” recruitment.
“Given the number of cancers that are age-related, we can expect a 50- to 75-per-cent increase, and that means we need more specialist nurses, more oncologists, more support for the cancer system,” he said. “We’re facing a challenge now, absolutely, and it’s our goal to address that, in the midst of many, many challenges of demand.”