Healthcare Quarterly

Healthcare Quarterly 12(3) May 2009 : 22-25.doi:10.12927/hcq.2013.20874

CIHI Survey: Thoracic Cancer Surgeries

Kira Leeb, Brian Bailey and Raymond Przybysz

In 2005, Cancer Care Ontario (CCO) released Thoracic Surgical Oncology Standards. These standards were aimed at providing the best level of care for those undergoing thoracic surgery and encompass surgeon training, hospital ancillary services and minimum volume thresholds for surgeries of the lung and esophagus.

The objective of the current study was to explore variations in thoracic cancer surgical volumes at the hospital level across Canada. Using data from the Discharge Abstract Database for 2007-2008, the cohort included patients admitted to hospital with a most responsible diagnosis of cancer and who had a lung or esophageal surgery. To determine the volume of surgeries performed per facility, we grouped patients according to the hospital facility performing the surgery.

In Canada (excluding Quebec and Prince Edward Island), there were a total 4,509 lung and 587 esophageal cancer procedures performed in 94 hospitals in 2007-2008. For both types of surgeries, Ontario hospitals performed approximately half of the procedures. Overall, 12 hospitals performed at or over the volume of surgeries for lung cancer as indentified by the CCO standards, while 10 did so for esophageal cancer. Nine hospitals performed both lung and esophageal cancer surgeries at or over the suggested volumes.

Higher volumes of lung and esophageal cancer-related surgeries have been associated with improved patient outcomes. Here we present a snapshot of the distribution of cancer-related lung and esophageal surgeries across Canada (excluding Quebec and Prince Edward Island).

A positive association between surgical volume and improved patient outcomes - often measured by in-hospital or 30-day mortality rates - has been identified for several types of conditions and procedures (Birkmeyer et al. 2002; Committee for Scientific Affairs et al. 2007; Halm et al. 2002; Hillner et al. 2000; Urbach et al. 2004) including cancer-related lung and esophageal surgeries (Bach et al. 2001; Halm et al. 2002). However, the strength of the association varies by both condition and procedure (Halm et al. 2002; Finlayson et al. 2003).


Level One and Two Thoracic Cancer Surgery Centres

In 2005, Cancer Care Ontario (CCO) released guidelines developed by the Expert Panel on Thoracic Surgical Oncology to provide the highest-quality of care in Ontario. The recommendations were set for level one and two thoracic cancer surgery centres, which included standards for surgeon criteria and training, availability of medical specialists, hospital and organizational resources and services and minimum surgical volumes.

Level One Centres
  • Provide the most comprehensive care and manage the most complex cases
  • Have at least three thoracic surgeons on staff to provide care whenever it is needed
  • Perform 150 anatomical pulmonary resections and 20 esophagectomies per year
Level Two Centres
  • Have a formal relationship with a level one centre to which it can refer its most complex cases
  • Have a minimum of one thoracic surgeon who performs routine thoracic procedures
  • Perform 50 anatomical pulmonary resections and seven esophagectomies per year
For complete information on these guidelines see _surg_standards.pdf.


In 2005, Cancer Care Ontario (CCO) released the Thoracic Surgical Oncology Standards, aimed at providing the highest-quality care for this type of complex surgery (CCO 2009). These standards were developed by a panel of experts who reviewed evidence-based literature and recommendations from other jurisdictions and evaluated the distribution of thoracic surgeries in Ontario at the time. Included in the guidelines were recommendations related to surgeon training, hospital ancillary services and minimum volume thresholds in order for institutions to be regarded by the Regional Cancer Program as level one or two regional thoracic centres.

Here we determine the distribution of both lung and esophageal cancer-related surgeries in Canada and consider the volume of each type of surgery by facility.


Table 1. Number of hospitals and thoracic cancer surgeries performed, by province 2007-2008
Province* No. of Hospitals Performing Lung Cancer Surgeries No. of Lung Cancer Surgery Cases No. of Hospitals Performing Esophageal Cancer Surgeries No. of Esophageal Cancer Surgery Cases
Newfoundland 2 61 2 15
Nova Scotia 3 254 5 36
New Brunswick 6 178 5 16
Ontario 41 2,501 29 285
Manitoba 4 282 4 33
Saskatchewan 3 183 8 38
Alberta 6 436 6 50
British Columbia 7 614 12 114
Totals 72 4,509 71 587
*Data were unavailable for Quebec for 2007-2008. Data for Prince Edward Island were suppressed, given small cell size. No surgeries for lung or esophageal cancer-related surgeries were performed in facilities located in Canada's three territories.
Source: Discharge Abstract Database, 2007-2008, Canadian Institute for Health Information.



Using CIHI's Discharge Abstract Database for 2007-2008, patients admitted to hospital with a primary diagnosis of cancer were selected according to whether they had lung or esophageal surgery, using the following Canadian Classification of Health Interventions codes:

  • Lung surgery: 1GR87, 1GR89, 1GR91, 1GT87, 1GT89, 1GT91
  • Esophageal surgery: 1NA87-1NA92

To determine the volume of surgeries performed, we grouped patients according to the facility performing the surgery.


In 2007-2008, 4,509 lung cancer and 587 esophageal cancer procedures were performed in Canada outside of Quebec and Prince Edward Island. For both types of procedures, Ontario hospitals accounted for approximately half of the cases (Table 1).

In 2007-2008, 72 hospitals performed lung cancer-related surgeries. Of these hospitals, 12 performed 150 or more - the suggested minimum number of surgeries to meet the volume criteria for CCO level one centres. A further 17 hospitals met the minimum surgical volumes for a level two designation (50 or more lung cancer-related surgeries). Forty-three facilities performed fewer than 50 lung cancer-related surgeries in 2007-2008 (Figure 1).


[Figure 1]


Similarly, of the 71 hospitals performing esophageal cancer-related surgeries, 10 were at or above CCO's recommended volume standard of 20 esophageal surgeries set for level one centres; a further 17 hospitals had volumes that met the level two designation of seven surgeries. The remaining 44 facilities each performed six or fewer esophageal cancer surgery cases in 2007-2008 (Figure 2).


[Figure 2]


Overall, there were nine hospitals in Canada (excluding Quebec and Prince Edward Island) that performed 150 or more lung surgeries and 20 or more esophageal surgeries. These hospitals were located in and outside of Ontario.


In 2005, CCO moved toward establishing criteria for designated centres of care in order to "accommodate long-range needs and take into account the projected increase in thoracic cancer surgery needs over the next decade due to a growing and aging population" (Sundaresan et al. 2005: 4). How care is organized in Ontario may not directly translate to other jurisdictions in Canada where population demands for these surgeries are less. However, given an established association of improved outcomes with increased surgical volumes for some cancer procedures, regionalizing care has been suggested as a means of improving the quality of care (Simunovic et al. 2006; Urbach and Baxter 2004) and lowering costs (BC Thoracic Surgery 2006).

This analysis shows the variation in the volume of lung and esophageal cancer-related surgeries at the facility level, against the backdrop of CCO's volume guidelines. These findings can inform ongoing discussions regarding what is reasonable and practical in organizing care for those undergoing thoracic surgery in Canada.

About the Author(s)

Kira Leeb is director of health systems analysis at the Canadian Institute for Health Information (CIHI). She has been with CIHI since 2000, and in her capacity as manager and, more recently, director, she has co-produced many healthcare system reports and analyses.

Brian Bailey, MA, is an analyst in health services research at CIHI. In this role, he is responsible for providing analytical and methodological support to projects, as well as for contributing to the writing of reports.

Raymond Przybysz, MSc, is a project lead in health services research at CIHI. He is responsible for the coordination and implementation of project plans and provides support in the field of analytical methods and research techniques. He has previously worked with several research institutes in Ontario and Quebec.


Bach, P.B., L.D. Cramer, D. Schrag, R.J. Downey, S.E. Gelfand and C.B. Begg. 2001. "The Influence of Hospital Volume on Survival after Resection for Lung Cancer." New England Journal of Medicine 345(3): 181-88.

BC Thoracic Surgery. 2006. About Us. Vancouver, BC: Author. Retrieved March 9, 2009. < > .

Birkmeyer, J.D., A.E. Siewers, E.V.A. Finlayson, T.A. Stukel, F.L. Lucas, I. Batista, H.G. Welch and D.E. Wenneberg. 2002. "Hospital Volume and Surgical Mortality in the United States." New England Journal of Medicine 346(15): 1128-37.

Cancer Care Ontario. 2009. Thoracic Surgery Standards. Toronto, ON: Author. Retrieved March 9, 2009. < csqievidence/csqi-standards-adhrere > .

Committee for Scientific Affairs, T. Kazui, H. Osada and H. Fujita. 2007. "An Attempt to Analyze the Relation between Hospital Surgical Volume and Clinical Outcome." General Thoracic and Cardiovascular Surgery 55(12): 483-92.

Finlayson, E.V.A., P.P. Goodney and J.D. Birkemeyer. 2003. "Hospital Volume and Operative Mortality in Cancer Surgery." Archives of Surgery 138: 721-25.

Halm, E.A., C. Lee and M.R. Chassin. 2002. "Is Volume Related to Outcome in Health Care? A Systematic Review and Methodological Critique of the Literature." Annals of Internal Medicine 137: 511-20.

Hillner, B.E., T.J. Smith and C.E. Desch. 2000. "Hospital and Physician Volume or Specialization and Outcomes in Cancer Treatment: Importance of Quality of Cancer Care." Journal of Clinical Oncology 18(11): 2327-40.

Simunovic, M., E. Rempel, M.E. Thériault, A. Coates, T. Whelan, E. Holowaty, B. Langer and M. Levine. 2006. "Influence of Hospital Characteristics on Operative Death and Survival of Patients after Major Cancer Surgery in Ontario." Canadian Journal of Surgery 49(4): 251-58.

Sundaresan, S., B. Langer, T. Oliver, F. Schwartz, M. Brouwers, H. Stern and the Expert Panel on Thoracic Surgical Oncology. 2005. Thoracic Surgical Oncology Standards. Toronto, ON: Cancer Care Ontario.

Urbach, D.R. and N.N. Baxter. 2004. "Does It Matter What a Hospital Is 'High Volume' for? Specificity of Hospital Volume-Outcome Associations for Surgical Procedures: Analysis of Administrative Data." Quality and Safety in Health Care 13(5): 379-83.

Urbach, D.R., T.A. Stukel, R. Croxford et al. 2004. Analysis of Current Research Related to the Impact of Low-Volume Procedures/Surgery and Care on Outcomes of Care. Ottawa, ON: Canadian Institute for Health Information.


Be the first to comment on this!

Note: Please enter a display name. Your email address will not be publically displayed