World Class Personalized Cancer Medicine The Princess Margaret Cancer Centre

Strategy 2013-2018

Contents

4

The Princess Margaret Cancer Centre

6 Accountability

7

Our Resources snd Activity

8 Research 9 Education 10

Emerging Trends in Cancer Care

13

Achieving Our Vision: One Strategy, Five Themes

14 The Princess Margaret Cancer Centre Strategy 2013-2018 15

Transform Patient Care

23

Augment Correlative Cancer Biology

29

Accelerate Guided Therapeutics

37

Expand Novel Therapeutics

45

Drive Outreach and Education

50

The Path Ahead

52 Acknowledgements

We are pleased to present the Princess Margaret Cancer Centre Strategy 2013-2018: World Class Personalized Cancer Medicine. This strategy summarizes our goals across five key strategic themes: transforming patient care; augmenting correlative cancer biology; accelerating guided therapeutics; expanding novel therapeutics; and driving outreach and education. The earlier iteration of our strategy, “Translating the Science of Cancer into Practice”, has been under implementation since 2008 and significant progress has been made. Examples of major initiatives aimed at addressing these themes include the redesign of our ambulatory care model, establishment of our Phase I clinical trials unit, development of our translational image-guided operating rooms, implementation of the TECHNA Institute for the Advancement of Technology for Health, and international programs including partnership with Kuwait.

The Princess Margaret Cancer Centre Strategy 2013-2018

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As we approached the halfway mark of the strategic plan, we embarked on a revision of our strategy looking forward. We undertook extensive internal and external consultations to evaluate our current context and refresh the directions that we have set. We wished to ensure that our strategy is aligned with the recently updated strategic plans of the University Health Network, the Ontario Cancer Plan III, the Ontario Cancer Institute, and the University of Toronto. Most especially, we want to align with the Princess Margaret Cancer Foundation’s “Believe It” campaign for personalized cancer medicine. We look forward to achieving our goals and delivering world class personalized cancer medicine at the Princess Margaret Cancer Centre.

MARNIE ESCAF, MHA, HBBA Executive Lead, Princess Margaret Cancer Centre Senior Vice President, University Health Network

MARY GOSPODAROWICZ, MD, FRPC, FRCR (Hon) Medical Director, Princess Margaret Cancer Centre University Health Network

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The Princess Margaret Cancer Centre at the University Health Network (UHN) in Toronto, Canada is a comprehensive cancer centre that offers a full suite of cancer services at the community, regional, provincial and international levels. We are a key resource for complex cancer care spanning the continuum from diagnosis to palliation and survivorship, across all disease sites. Under the auspices of Cancer Care Ontario, the Princess Margaret is responsible for the Toronto Central South Regional Cancer Program, which includes the Princess Margaret and UHN, Mount Sinai Hospital, St. Joseph’s Health Centre, St. Michael’s Hospital and Women’s College Hospital, in collaboration with Toronto Central Community Care Access Centre and Toronto Central Palliative Care Network. The Princess Margaret is organized by disease site groups and clinical departments, including allied health professionals, medical-, radiation- and surgical oncologists, oncology nurses, psychiatrists, and other clinical staff.

The Princess Margaret Cancer Centre

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PRINCESS MARGARET CANCER CENTRE

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As a publicly funded cancer centre, the Princess Margaret is accountable to its patients, the provincial government, its donors and other external funders. We are a University of Toronto teaching hospital and are accountable to the university in this regard. We are responsible for quality of care and equity imperatives and are committed to meeting provincial targets for access to care, treatment volumes and financial benchmarks. With the increase in our patient populations, it is expected that our cancer centre will continue to grow at a rate of approximately 1-3% per year for the foreseeable future; we must secure adequate resources required to deliver the highest quality care as safely and efficiently as possible.

accountability

7

The Princess Margaret has 218 inpatient beds, 350 ambulatory clinics, approximately 398,000 sq. ft. of research space and 800,000 sq. ft. of clinical space, employing over 3,000 staff. Our 2012 clinical activity is summarized below: 2012 Volume

12,818 Cancer Surgeries . . . . . . . . . . . . . . . . . . . . . . 4,047 Outpatient Chemotherapy Treatments . . 31,022 Courses of Radiation Treatment . . . . . . . 10,150 Stem Cell Transplants. . . . . . . . . . . . . . . . . . . . 319 New Patients. . . . . . . . . . . . . . . . . . . . . . . .

We opened over 100 clinical research studies in 2012 and more than 3,800 subjects participated in clinical research at the Princess Margaret during that period.

our resources and activity

8

Our research institute, the Ontario Cancer Institute (OCI), employs over 300 scientists who conduct research in genomics, proteomics, structural biology, molecular biology, biophysics, stem cell biology, and behavioural sciences. OCI provides education at the undergraduate, graduate and postgraduate levels. We trained over 400 graduate students and research fellows in 2012. Our researchers employ leading edge tools to analyze cancerous cells at the molecular level, test gene and cellular therapies for cancer and other diseases, develop new technologies for diagnosing and treating cancer, determine the effects of diet and behaviour on cancer risks, and develop and test informatics tools for the large-scale analysis of patient populations. In 2012, our OCI researchers produced 937 publications and secured close to $150,000,000 in external funding.

research

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At the Princess Margaret Cancer Centre, we provide comprehensive and integrated education for undergraduate, graduate and postgraduate trainees in medicine, nursing, allied health and other healthcare specialties. Continuing education is provided across health professions. In 2012, we trained over 100 clinical fellows, over 100 nursing students and more than 150 residents. We also provided training for close to 180 other students, including trainees in disciplines such as physics and social work. Training is delivered across the clinical disciplines of pathology, imaging, surgical oncology, radiation medicine, oncology nursing, medical oncology, psychosocial oncology and palliative care, as well as survivorship and patient education.

education

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In order to plan for world class personalized cancer medicine, we need to be aware of major trends in cancer services and healthcare. Some of the key emerging trends include:

»» Patients as partners in their care »» New models of inter-professional care »» New targeted therapies »» International collaboration amongst cancer centres »» Cancer survivorship needs

Strategizing for a “Top Five” cancer centre requires focus, attention and integration across our core areas of clinical service, research, outreach and education, as outlined on the next page.

emerging trends in cancer care

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“As a top five comprehensive cancer care centre, the Princess Margaret will be a leading contributor to conquering cancer within our lifetime.” Clinical Practice Recognized for delivering world-leading patient outcomes through personalized cancer care

Research Continuously developing new and improved instruments and interventions that will benefit patients and their families

Outreach and Education Sharing our knowledge and expertise to create new generations of cancer care professionals, promote cancer risk-reducing lifestyles and support development of cancer care locally and globally

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Transform the delivery of patient care Augment correlative cancer biology Accelerate guided therapeutics Expand novel therapeutics Drive outreach and education

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The Princess Margaret Cancer Centre strategic themes support the personalized cancer medicine agenda and guide us towards our vision of a world top five cancer institution: This plan supports patient-centred, personalized cancer care and empowers patients as partners in their care. The plan gives patients promise of well documented, best possible outcomes, with the broader goal of conquering cancer. In addition to delivering excellent patient care and education, and continuing to lead in clinical research, our plan supports continuous quality improvement and innovation. To support our goals, we must secure continuous development and renewal of our infrastructure to faciltitate operations and delivery of excellent care, education and research. This includes attention to optimal space, information technology support, state of the art equipment, the best talent, modern clinical processes and robust quality and risk management programs.

achieving our vision: one strategy, five themes

14

World Class Personalized Cancer Medicine

The Princess Margaret Cancer Centre Strategy 2013-2018

15

transform patient care We will transform patient care by developing new models of inter-professional care, offering support through all the aspects of cancer care, personalizing cancer care and serving unique vulnerable populations, as well as empowering patients to become partners in their care.

Strategic Initiatives

A B C D E

Personalize and optimize clinic operations and enhance patients’ experience Support patients, families and caregivers throughout the cancer journey Empower patients to become partners in their care Develop new models of inter-professional care Address the specialized needs of adolescent/young adult and geriatric patients

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A

Personalize and optimize clinic operations and enhance patients’ experience

Rationale New models of care will strengthen inter-professional practice and the integration of patient care with research and education on an ongoing, operational basis, continually improving the patient experience. Operational and process efficiencies will improve access to our expertise, and support patient-centred, high quality care.

Initial Activities »» Ambulatory care strategy planning and implementation to support the highest quality patient-centred ambulatory care experience across integrated, efficient clinics and services »» Implement point-of-care patient education training to equip all staff and trainees to deliver personalized patient education

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B

Support patients, families and caregivers throughout the cancer journey

Rationale Comprehensive support for symptoms associated with cancer diagnosis and treatment to improve patients’ quality of life and increase their satisfaction. The broad range of clinical services in palliative and supportive care must be applied to all aspects of clinical encounters.

Initial Activities »» Implement standardized processes for responding to Distress Assessment and Response Tool (DART) results to address patient’s symptom management needs »» Integrate with cancer rehab services and primary care to support seamless, integrated care across the continuum of cancer services

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C

Empower patients to become partners in their care

Rationale The quality of clinical interactions will be strengthened through enhanced clinician communication skills, empowering patients to become active partners in their care; informed patients are engaged in their own care, improving treatment compliance and increasing the potential for improved outcomes and patient satisfaction.

Initial Activities »» Develop electronic platforms to provide patients with access to comprehensive and ‘user-friendly’ information on treatment progress, results and consultation summaries »» Expand our patient education service to support access to and engagement in point of care patient education

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D

Develop new models of inter-professional care

Rationale Innovative care practices and processes will improve the patient experience, maximize clinician time and skills, and increase our capacity to care for growing numbers of cancer survivors, who require follow-up care.

Initial Activities »» Pilot virtual/satellite clinic models to improve access to our services and offer care closer to home »» Implement advanced clinical documentation to improve integration across our information systems and facilitate access to the right information in the right place and at the right time

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E

 ddress the specialized needs of A adolescent/young adult and geriatric patients

Rationale Adolescents and young adults (AYA) and the frail elderly with cancer face unique medical and psychosocial needs and require personalized, appropriate psychosocial support, information, and services. Creating a holistic approach that identifies the unique characteristics and circumstances will help target our care to their specific needs.

Initial Activities »» Establish an adolescent and young adult oncology program to address the specialized needs of this patient population in a coordinated and patient-centred way »» Develop and implement a standardized approach to strengthen our ability to assess and tailor treatment plans that optimize outcomes in the frail elderly

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augment correlative cancer biology We will accelerate implementation of personalized cancer care based on a novel understanding of patient and tumour molecular characteristics, as well as their impact on treatment outcomes, through expanded correlative cancer biology programs.

augment correlative Acancer biology

Strategic Initiatives

Implement a fully operational and robust cancer bio-bank

B C

 stablish a functional relational clinical and bio-specimen E database with clinical outcomes Invest in leading technologies to facilitate translational research

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A

Implement a fully operational and robust cancer bio-bank

Rationale To accelerate implementation of personalized cancer care based on the understanding of tumour biology, patient-specific characteristics and treatment outcomes, a fully operational and robust cancer bio-bank is required. These resources are essential to understanding outcomes of novel therapeutics and assessing individual patients’ response to treatment, and are also crucial for the development of translational medicine.

Initial Activities »» Continue expansion of our bio-bank to support collection of full bio-specimen sets across disease sites »» Implement expanded systems-level specimen characterization of bio-banked specimens

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B

 stablish a functional relational E clinical and bio-specimen database with clinical outcomes

Rationale A functional, relational clinical and bio-specimen database contains medical descriptions of stored specimens, as well as their physical location, and is necessary for efficient bio-bank usage (e.g. easy retrieval, search and identification).

Initial Activities »» Develop and implement integrated databases to optimize bio-bank usage

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C

Invest in leading technologies to facilitate translational research

Rationale Translational medicine gives us an enhanced understanding of which therapies will work and which will not, at the individual patient level. Achieving this understanding requires creating linkages between basic and clinical research; new IT technologies can provide an efficient interface between these two domains.

Initial Activities »» Identify and implement potential IT solutions to support point of care, standardized data collection and allow real-time patient data sharing between physicians, clinical researchers and laboratory researchers

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28

29

accelerate guided therapeutics We will continue to innovate in guided therapeutics and lead implementation of new and powerful cancer diagnostics and treatments supported by a robust foundation of new informatics including pattern recognition and automation.

augment correlative Acancer biology

Strategic Initiatives

Expand a coordinated multi-disciplinary innovation environment through TECHNA

B C D E F

Create state-of-the-art molecular imaging infrastructure and research program Accelerate effective utilization of advanced robotics in surgery and interventions Strengthen our leadership position in image-guided intervention  uild an informatics-supported, user-friendly visualization B (“heads up display”) for high performance cancer intervention, discovery and evaluation Establish the leading hospital-based proton therapy program in Canada

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A

Expand a coordinated multi-disciplinary innovation environment through TECHNA

Rationale Accelerating advancement in guided therapeutics requires excellent research and development (R&D) infrastructure and a framework for innovation. The future of cancer intervention includes highly coordinated, multi-modal interventions and the creation of multidisciplinary research environments that enable these interventions to be explored will be transformative.

Initial Activities »» Build a multi-disciplinary faculty and a strong management team at TECHNA to stimulate collaboration and build global connections in support of innovation in developing sophisticated cancer treatment trajectories that fully utilize personal information to maximize the therapeutic ratio

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B

Create state-of-the-art molecular imaging infrastructure and research program

Rationale Molecular imaging promises to enable minimally-invasive characterization of the disease state within the human body to better design and direct intervention. State-of-the-art cancer interventions will be personalized based upon molecular signatures from tissue and imaging.

Initial Activities »» Operationalize cyclotron and fully implement MR/PET to effectively use MI agents to provide greater specificity of the disease and its response to therapy »» Establish a molecular imaging (MI) team to work with clinical and basic researchers and to support innovation and impact in MI

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C

 ccelerate effective utilization of A advanced robotics in surgery and interventions

Rationale The implementation of robotic surgery has the potential to improve patient outcomes by enhancing specificity in resection. Robotic systems promise to increase safety and quality and will eventually affect cost.

Initial Activities »» Expand robotic surgery capacity and build novel imageguided robotics systems to support precision medicine »» Modify and create training and education programs to integrate robotic surgery and robotic interventions into practice

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D

Strengthen our leadership position in image-guided intervention

Rationale Guided radiotherapy reduces treatment-associated damage to healthy tissues by more precisely targeting cancer cells, which impacts outcomes and has the potential to improve patients’ quality of life. This is an area of strength, but also of great importance; this program needs to be strengthened and supported by more faculty.

Initial Activities »» Establish a team to create common platforms for optimized and coordinated multi-disciplinary image guided cancer intervention, including drug-delivery

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E

 uild an informatics-supported, userB friendly visualization (“heads up display”) for high performance cancer intervention, discovery and evaluation

Rationale All cancer research and intervention must be based on robust data; a data-driven approach is needed to provide the best, high-performance intervention and to accelerate innovation. Technological advances are providing a wealth of new information (e.g. genomics) and a coordinated system is needed to manage access to this information (utilization and input).

Initial Activities »» Develop and implement a cancer informatics strategy to support comprehensive availability of data to drive and enable clinical practice, research and innovation »» Establish coordinated visualization of information and analyses to reduce complexity

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F

Establish the leading hospital-based proton therapy program in Canada

Rationale Radiation therapy is a highly potent form of cancer treatment. Proton beams are a more precise and less harmful form of radiation therapy, especially for young patients. Adoption by leading cancer programs throughout the world has demonstrated the capacity to reduce long-term side effects of the disease and treatment. There is a compelling case for establishing a proton therapy facility in downtown Toronto under the leadership of the Princess Margaret Cancer Centre in collaboration with The Hospital for Sick Children.

Initial Activities »» Engage stakeholders and establish a provincial plan for providing Canadian patients with appropriate access to a state-ofthe-art proton therapy facility »» Secure resources, partnerships, and infrastructure to implement the first comprehensive and hospital-based proton therapy program in Canada

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37

expand novel therapeutics We will provide patients with access to leading-edge treatment methods through research and implementation of novel systemic therapeutics, incorporating molecular imaging and genomic signatures and improving outcomes for cancer patients globally.

augment correlative Acancer biology

Strategic Initiatives

Expand the size and scope of our Drug Development Program

B C D E

Accelerate advancements in immune based therapies

Introduce innovations in cellular therapy

Develop novel combined modality approaches to therapy Molecular profiling of tumour and host as part of routine care

38

A

Expand the size and scope of our Drug Development Program

Rationale A robust program encompassing all phases of early stage Drug Development will ensure patients at the Princess Margaret have access to the newest drugs. A comprehensive Drug Development Program supports our world class research reputation, integrates our basic and clinical research programs, and will provide the evidence to improve outcomes for cancer patients globally.

Initial Activities »» Build informatics and database systems to support complex clinical trials »» Expand inpatient drug development facilities to support the use of novel therapies across the spectrum of cancer care

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B

Accelerate advancements in immune based therapies

Rationale Immune therapies improve the ability of patients’ own biological systems to fight cancer. The genetic diversity of cancer is such that resistance occurs to many current targeted drug therapies; activating the immune system to fight the cancer will limit the development of resistance and will be complementary to current treatments. Recent advances in understanding of the immune system make this an area of much greater promise.

Initial Activities »» Establish a team to support leading-edge immunotherapy research and translate discoveries to clinical care as efficiently as possible »» Establish a lab to provide routine immune monitoring for patients on treatment and create dedicated inpatient and ambulatory facilities for the immunotherapy program

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C

Introduce innovations in cellular therapy

Rationale High dose therapy followed by infusion of stem cells to restore the hematopoetic system is currently used to treat and cure a number of hematological malignancies; new approaches such as haplo or cord blood expand the pool of recipients for such approaches. With advances in stem cell research, infusion of other types of human stem cells to replace damaged tissues (e.g. after radiation), and facilitate tissue regeneration are being studied. Other potential uses of cellular therapy include adoptive immunotherapy with T-cells or NK cells and the use of dendritic cells for gene transfer.

Initial Activities »» Create a cord blood transplant program to support a comprehensive stem cell therapy service »» Expand our facility for cell and vector production to support enhanced cell therapy

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D

Develop novel combined modality approaches to therapy

Rationale Combining novel agents and approaches and integrating them with established local and systemic therapies will result in new treatment methods with better outcomes. Traditional pharmaceutical driven drug development to bring single drugs to market approval is a slow and inefficient process. The genetic heterogeneity of cancer is such that combined approaches will be required.

Initial Activities »» Enhance imaging capabilities for early detection of metastatic disease »» Develop a program to study combination of radiation with targeted agents

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E

 olecular profiling of tumour M and host as part of routine care

Rationale We have a much greater understanding of the molecular diversity of cancer; this diversity can be used to select therapy that will have a higher chance of therapeutic success. There have been major advances in technology such that we are now able to rapidly generate a molecular profile for both the cancer and the patient.

Initial Activities »» Conduct genomic profiling using multiplex technologies in a CLIA-certified laboratory and incorporate analysis and reporting of genomic profiles into the patient journey and patient chart »» Offer access to genomic profiling to patients and centres across the country

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44

45

drive outreach and education We will strengthen our impact and reputation, contribute to our communities, improve care and research, and exchange knowledge through global and local collaborations and partnerships, as well as education.

augment correlative A cancer biology

Strategic Initiatives

Foster collaborative programs across the full spectrum of cancer care

B C

Amplify outreach in research and education

Expand national and international collaboration in clinical and academic cancer programs

46

A

 oster collaborative programs F across the full spectrum of cancer care

Rationale Fostering local and regional collaboration and sharing expertise will support overall improvements in cancer service quality across our communities. Collaboration will strengthen the Princess Margaret Cancer Centre’s reputation as the leading Canadian centre for cancer treatment and research. Research cooperation at the local and regional levels will provide the Princess Margaret with a larger population of patients for clinical trials and research.

Initial Activities »» Establish communities of practice to support collaboration and knowledge sharing both within and across disciplines to improve outcomes locally, provincially and globally »» Implement virtual multi-disciplinary cancer conferences for a collaborative approach to treatment decision making and improve access to expertise across disease sites and treatment modalities

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B

Amplify outreach in research and education

Rationale Building a global partnership network and sharing Princess Margaret Cancer Centre expertise internationally will have a significant impact on strengthening our reputation as a leading world cancer research centre. Development and dissemination of innovative models of education and training will foster world class talent and will enhance our reputation as a leading centre for cancer research, education and treatment.

Initial Activities »» Develop, implement and communicate a multi-disciplinary training curriculum for oncology professionals »» Expand active research and development partnerships with global cancer treatment centres to build a worldwide network of partners

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C

 xpand national and international E collaboration in clinical and academic cancer programs

Rationale Collaborative and philanthropic activities aiming to provide support and exchange knowledge with other national and international cancer programs will not only build our reputation as a world leading cancer care institution, but will also support our continuous learning and development.

Initial Activities »» Enable an active alumni network to support partnerships with other cancer institutions and develop fellowship exchanges to strengthen international outreach and knowledge sharing »» Develop a philanthropic outreach program to share our expertise, foster international cancer control and improve cancer

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the path ahead

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This strategic plan lays out a comprehensive set of goals to increase the Princess Margaret Cancer Centre’s capacity to deliver on its vision of a world top five cancer institution. It will require continuous optimization of our resources and the engagement of every staff member in the organization to achieve the proposed activities. We will develop and implement these specific initiatives with benchmarks, timelines and metrics to monitor our progress against the goals listed for each theme. This cannot be achieved without maintaining excellence in the delivery of core activities and continuously improving and investing in our infrastructure. As with all plans, this strategy sets the overall direction and focus for the Princess Margaret; however, its success will depend on flexibility in its implementation. The comprehensive set of themes and priorities identified in the plan will be adapted according to our resources and talent. Our strategic plan will drive us toward our goal of accelerating personalized cancer medicine through world class cancer care, and conquering cancer in our lifetime.

52

This plan represents major contributions and input from staff and would not have been possible without significant participation from every level and department within the Cancer Centre and the members of the Princess Margaret Cancer Centre leadership.

Strategic Plan Steering Committee

Mary Gospodarowicz

Marnie Escaf

Roxana Sultan

Brian O’Sullivan

We would like to thank Stephen Bear, Mark Hanrahan, Adam Mazur and Benjamin Concessi from McKinsey and Company for their assistance.

acknowledgements