National Staging Initiative

Evaluating and improving cancer control with information

Cancer stage describes the severity or extent of the disease. There are four possible stages for any type of cancer. For individual patients, doctors use stage information to assess the probable course of the disease and to plan treatment. At the population level, health-care planners and policy-makers can use stage information to gain deeper insight into trends such as incidence, mortality and survival, which can help evaluate and improve the cancer control system.

Collaborative staging, a complex staging system that captures detailed information about the extent of a patient’s disease, is the Canadian standard for staging cancer cases for surveillance purposes. The granularity of collaborative stage data means that it can be used to better understand cancer patterns over time, demonstrating the effectiveness of screening programs that are detecting cancers earlier and enhancing knowledge of treatment needs.

In partnership with provincial and territorial cancer agencies and programs, the goal of the National Staging Initiative is to implement electronic systems that will enable the collection of national population-based stage data for new cases of breast, colorectal, prostate and lung cancer diagnosed on or after January 1, 2010. Currently the initiative aims to capture collaborative stage data for 90 per cent of these four most common cancers in Canada.

Underway since 2008, the National Staging Initiative focuses on three key areas:

• Pathology and implementing synoptic pathology: Promoting the adoption and implementation of pan-Canadian standards for cancer pathology reporting through the use of synoptic reports, or checklists
• Implementing collaborative staging: Helping provinces build the infrastructure required to expand the scope of stage data collection by using electronic systems to capture and access the complex medical data needed for collaborative staging
• Data quality: Improving data quality to ensure that captured data will be reliable and useful across existing structures that relate to cancer staging

Pathology and implementing synoptic pathology

Pathology is the study of disease, including causes, development and effects on the body.¹Cancer pathology refers to the careful examination of cancer and related tissues using a wide variety of tools including microscopes and genomic analysis to diagnose and classify cancers. Cancer pathology is key to helping determine the stage of an individual’s disease because it provides information on the type of cancer, the size of the tumour and the extent to which the disease has spread to the surrounding area.² Clear and complete pathology reports are therefore critical to the success of a pan-Canadian cancer staging program.

Synoptic pathology is a structured reporting format that leverages best practices within the discipline of pathology. The College of American Pathologists’ (CAP) cancer checklists are structured reports that contain required and optional fields to ensure completeness and uniformity.

Progress to date

• In July 2009, the Canadian Association of Pathologists formally endorsed the College of American Pathologists’ cancer checklists as a Canadian standard for cancer pathology reporting. Adoption and implementation of this clinical standard will result in more complete and timely pathology reporting on an individual’s cancer.
• In July 2010, a partnership was formed between the Canadian Association of Pathologists and College of American Pathologists to ensure Canadian input into the internationally endorsed College of American Pathologists’ cancer checklists, placing Canada at the forefront of the international cancer pathology and stage reporting community.
• Canada’s first-ever expert panels on pathology and cancer staging were established through the Partnership’s leadership. These multidisciplinary panels, comprising pathologists, surgeons and radiation and medical oncologists, provide expert Canadian knowledge to evolving international staging standards and help inform the College of American Pathologists’ cancer checklists, which serve as a guideline for definitive cancer reporting.
• Two provinces have implemented the electronic version of the College of American Pathologists’ cancer checklists to provide more timely and comprehensive data to the medical system.
• The Partnership received Canadian Approved Standards Status for the College of American Pathologists’ cancer and staging checklists from Canada Health Infoway, making the checklists among the first clinically oriented standards to complete this process. The designation allows Canada Health Infoway to promote the checklists and support further uptake.
• To increase awareness of the College of American Pathologists’ cancer checklists within the pathology, clinician and cancer registry communities, the Partnership, the Canadian Association of Pathologists and Cancer Care Ontario launched a series of education sessions. 

Collaborative staging

Cancer stage is a way of describing or classifying a cancer based on the extent of disease or the degree to which it has spread within the body.³There are four possible stages for any type of cancer. The higher the stage value, the more severe a cancer has become — a higher stage often means higher mortality. Detecting cancer at an earlier stage is important to improving survival rates and enhances the lives of those affected by the disease. Doctors use stage information to assess the probable course of a patient’s disease and to plan treatment.

Collaborative staging is a comprehensive process in which a range of medical data is gathered and entered into a database defined by criteria to determine a cancer stage value between one and four. When stage data is standardized and gathered at the population level, as it is through the National Staging Initiative, health-care planners and policy-makers can use the information to gain deeper insight into trends such as incidence, mortality and survival, which can help to evaluate and improve the cancer control system.

Progress to date

• All provincial and territorial central cancer registry staging registrars have been trained in the use of Collaborative Stage Version 2, a new coding language, to ensure that population-based collaborative stage data is captured and later used for evidence-based treatment decisions, planning and research.
• To date, eight provinces have upgraded their central cancer registry systems to collect Collaborative Stage Version 2 data.
• One province will be completing the implementation of a new registry solution in the 2011/12 fiscal year to capture Collaborative Stage Version 2 data.
• The Partnership’s National Staging Steering Committee recommended the minimum Canadian dataset needed for collaborative staging to promote a unified and comprehensive approach for collecting stage data. Initially focused on breast, prostate, colorectal and lung cancers, this work was expanded, completed and endorsed for all disease sites. Statistics Canada and the Canadian Council of Cancer Registries were among the key stakeholders to formally endorse the minimum dataset in February 2010.

Data quality 

Establishing a pan-Canadian cancer staging system is an important step toward being able to evaluate and improve the performance of our cancer care system. Through the National Staging Initiative, the Partnership is helping to ensure the continued reliability and use of stage data. In collaboration with provincial, territorial and national partners, including Statistics Canada, the Partnership has taken

measures to not only improve the state of the data currently captured, but also to ensure the future reliability of collaborative stage data.

Progress to date

• From April 2009 to April 2010, the first-ever pan-Canadian collaborative stage audit was conducted to evaluate and improve the quality of stage data in Canada. The audit reviewed the accuracy of specific coding assessments made by cancer registrars when staging cases.  Gap areas were identified and addressed through training sessions in Partnership with the Public Health Agency of Canada. Collection of this information establishes pan-Canadian consistency in staging and identifies areas for training and improvement.
• A report, Collaborative Stage Baseline Assessment, completed in January 2010, assesses the current state of cancer staging in Canada and identifies opportunities for improvement. A sub-working group was established to review recommendations from the Baseline Assessment and to gauge the feasibility of implementation.
• A follow-up report, Progress Assessment, designed to measure the changes in cancer staging and synoptic pathology reporting in Canada in the past four years, is being developed.
• The Partnership is helping to facilitate Statistics Canada’s development of a Data Quality Protocol. This protocol ensures that the data is of the highest quality both at the registry level and when it is integrated with the Canadian Cancer Registry at Statistics Canada.
• A data quality review was recently conducted on the data presently available within the Canadian Cancer Registry. A report will be generated in the 2011/12 fiscal year that will provide recommendations for improvement and will be input into the Data Quality Protocol.

In October 2010, the Partnership, together with the Canadian Association of Provincial Cancer Agencies, made an announcement to highlight the National Staging Initiative, marking a change that cancer experts have wanted for more than 20 years — and one that will help cancer system decision-makers target areas of greatest need in cancer control.

¹http://info.cancer.ca/glossary/default.aspx?Lang=E&cceid=9331&alias=pathology&culture=en-US
²Adapted from: Canadian Cancer Society. “Pathology and staging of rhabdomyosarcoma,” Canadian Cancer Encyclopedia. Accessed Jan. 6, 2012. http://info.cancer.ca/cce-ecc/
³http://info.cancer.ca/cce-ecc/SearchDetails.aspx?lf=cancer%2520stage&cceid=5&rk=64810817&fp=file%253a%252f%252fcispublicweb%252fe_html%252f1_5.html&sqg=75710afd-93e3-45c1-8b57-ce8b9e77a992