In early 2023, I had the privilege of being part of the Melanoma Delphi Panel, which worked to identify outcomes and quality indicators for melanoma patients in Ontario.
The pandemic negatively impacted melanoma care, leading to a decrease in reported incidence and prevalence rates – likely due to postponed or delayed diagnoses. There is also significant variation in the management of melanoma during both the treatment and follow-up phases of care in Ontario. Developing an up-to-date and accurate understanding of the quality of care for melanoma patients is important for:
- Guiding clinical care decisions
- Informing strategic planning and policy development within Ontario’s cancer care system
- Ensuring improved treatment for all melanoma patients
Key Indicators Identified
To put this in my own words, this project was critical in identifying measurable indicators that help us determine whether the health system is meeting established standards and expectations. These include things like:
- Survival rates
- Time to complete surgical excisions
- Initiation of adjuvant treatment after surgery
For a complete list of indicators, refer to Table 1 below.¹
The Cancer System Quality Index (CSQI) is a publicly available web-based report that tracks the performance of Ontario’s cancer system for priority disease sites, including melanoma, and benchmarks it against other health systems where data is available. This information helps inform strategic priorities and objectives for Ontario Health (Cancer Care Ontario).
The final project report was finalized in June 2024, and the CSQI also aims to share information with other jurisdictions to enable national and international benchmarking.
You can access the CSQI-2024-Report here.
Findings and Insights
Once quality measures were identified, data was collected and analyzed to assess where the health system stood in relation to those measures.
The report highlights several areas of strength (“Bright Spots”), including high survival rates and minimal post-surgery acute care visits. Conversely, it also identifies challenges (“Room for Improvement”), such as the timely initiation of first treatment (surgery) after diagnosis, timely access to planned adjuvant systemic therapy post-surgery, and equitable access to follow-up skin assessment care (including dermatologists and skin specialists), especially in rural and remote communities.
The report also highlights data limitations, including missing or outdated information on preventive measures like sun protection behaviours and UV exposure, gaps in comprehensive pathology reporting, and the absence of recent data for First Nations, Inuit, Métis, and urban Indigenous (FNIMUI) populations.
Next Steps
Based on the findings from CSQI 2024, areas for improvement that will be prioritized include the diagnostic phase, survivorship care and improving data access. There is also an opportunity to re-examine the CSQI indicators in four years to evaluate progress and the impact on the performance of Ontario’s cancer system. These indicators mark a significant step forward in improving and standardizing care for melanoma patients. A big thanks to all the dedicated professionals who made this happen.
Melanoma Delphi Panel Members
The panel included a distinguished group of professionals, such as: Dr. Frances Wright (Chair), Susan Blacker, Cholly Boland, Dr. Marcus Butler, Dr. Darren Cargill, Dr. An-Wen Chan, Annette Cyr, Dr. Leta Forbes, Dr. Tim Hanna, Dr. Renee Hanrahan, Dr. Brian Hasegawa, Dr. Kevin Higgins, Dr. Wade Mitchell, Dr. Christian Murray, Dr. Carolyn Nessim, Dr. Teresa Petrella, Dr. Aaron Pollett, Dr. Brandon Sheffield.
Other contributors included representation from the Melanoma Expert Panel, the Ontario Health (Cancer Care Ontario) Skin Cancer Advisory Committee, the Cancer Quality Council of Ontario, as well as Ontario Health (Cancer Care Ontario) Program Heads, Clinical Leads, and Patient and Family Advisors.
Table 1. Melanoma indicators prioritized following assessment for measurability using Ontario administrative health care databases
| Final melanoma indicators | |
| 1 | Percentage of patients with cutaneous melanoma who had a wide local excision within 84 days of their complete diagnostic biopsy |
| 2 | Percentage of patients undergoing adjuvant systematic therapy within 12 weeks after completion of surgery |
| 3 | Within two years of treatment, percentage of patients that are screened for symptoms using patient-reported outcomes and quality of life. |
| 4 | Number of cancer survivors by age group and sex |
| 5 | Proportion of melanoma patients aged <80 with a >1 mm depth tumour (at time of excisional biopsy or wide local excision) who had a sentinel lymph node biopsy (SLNB) within 6 months of initial biopsy or excision. |
| 6 | Percentage of melanoma patients that receive imaging observation for five years after a positive sentinel node biopsy |
| 7 | Stage 3 or positive sentinel lymph node biopsy (SLNB) melanoma patients that had a medical oncology consult within 6 weeks after surgery |
| 8 | Patients with melanoma greater than 2 mm should have their BRAF status checked |
| 9 | Percentage of patients who see a dermatologist or a family doctor with special training in skin within a year of diagnosis of melanoma to assess for other new primary skin malignancies |
| 10 | Percentage of patients who had cancer surgery and an unplanned ED visit or were readmitted within 30 days after surgery |
By Annette Cyr
Annette is founder and Chair of the Board for Melanoma Network of Canada, as well as a 3 time survivor of melanoma. She has volunteered on a full time basis at the organization since its inception in 2009.
References
1 Cancer System Quality Index 2024- Ontario Cancer System Performance: Melanoma June 2024
