Since 2013, Sunnybrook’s Family Navigation Project has helped thousands of youth and their families find the mental health care and addiction services they need. Now, Sunnybrook is sharing its knowledge by collaborating with Humber College on a unique graduate program.

For years, the health-care system was a frustrating maze to Cathy Walsh.

She first faced difficulties finding the right kind of help for her daughter who grew up with developmental challenges. Then, when her younger daughter began grappling with mental health problems, Cathy again struggled to find the right programs and care for her child.

“The mental health care system is really complex,” says Cathy, who lives in Ajax, Ont., with her husband and two children. “And with mental health, there needs to be the correct fit between client and service provider for treatment to be successful.”

The situation took a turn for the better about two years ago, when Cathy connected with the Family Navigation Project (FNP) team at Sunnybrook. Within days, a family navigator at FNP found a residential placement with services and programs that matched her daughter’s needs.

“We had exhausted all resources in our jurisdiction,” she recalls. “By using FNP’s navigation services, we were able to find this residential placement outside of our region. Their help made a huge difference.”

Since launching in September 2013, FNP has helped more than 2,500 youth and their families, like the Walshes, find the health-care providers and programs best suited to their needs.

Growing to meet demand

The idea of FNP began with a group of families committed to make it easier for other families to get help for their loved ones. Over the years, the program has grown from two navigators to a team of 20, including an intake coordinator, a parent advocate with lived experience and 10 navigators – all working with Sugy Kodeeswaran, the executive director, and Dr. Anthony Levitt, the medical director. Navigators at Sunnybrook have diverse educational backgrounds and work experience, from social work to psychology to child development.

“Our goal since the project’s inception has been to provide direction for patients and their families, and at the same time act as a beacon for education and the dissemination of health-care system information,” says Dr. Levitt.

“We have excellent health-care services in this province, and there is a great deal of information available, but often people don’t know how to access the services or what to do if things don’t work out – or what to do if the youth themselves are not motivated to receive care. Too frequently the youth and their families get lost trying to understand and find resources in the system,” he says.

Health-care navigation originated in New York in 1990 to help cancer patients, and in Canada programs have also largely focused on cancer care. However, at Sunnybrook, FNP was established to help families who have a youth dealing with mental health and addiction challenges.

As with any start-up, seed funding was essential to the early success of FNP. Sunnybrook was fortunate to partner with RBC to launch the program, and it has continued to provide critical support through the annual RBC Race for the Kids.

“There are so many reasons people don’t talk about mental health or addiction, so it is often even harder for them to know what to do and what particular services to seek,” Dr. Levitt says.

“That’s why it’s so important to have someone who can help ensure you’re going down the right care pathway.”

This means much more than just handing patients a list of health-care providers and asking them to sort out which to contact. Effective navigation requires in-depth knowledge of the health-care system and a dedication to understanding the unique needs of each client. It also requires empathy for families as they juggle the logistics of getting the proper care, while coping with the physical and psychological challenges of a serious illness, and their own health, family and financial issues.

“Navigation also involves ‘getting in the boat’ with families to make sure they really do connect with the services we provide as options,” Kodeeswaran explains.

Navigator education

FNP’s first wave of navigators trained with Dr. Levitt, a psychiatrist, and with therapeutic placement professionals in the United States. Today, FNP has the depth of family navigation knowledge and experience to provide its own in-house training for new team members.

“Family navigators come into FNP with varied experience in supporting clients and families finding their way through the system. Even with this background, it takes several months of on-the-job training to become a skilled family navigator,” Dr. Levitt says.

Their education doesn’t stop there, adds Kodeeswaran.

“Our navigators are constantly learning from each other, learning about and sharing new resources daily,” she says. “We have our finger on the pulse of the system, so our knowledge is real-time and not restricted only to a database. Our focus is being on the ground, finding out about programs and constantly sharing information with each other.”

Cathy Walsh (left) in class with Sunnybrook navigator and Humber College instructor Miriam Blond (right). (Photograph by Kevin Van Paassen)

Collaborating with Humber

This commitment to sharing systems navigation knowledge expanded even further last year, when Toronto’s Humber College reached out to FNP for help in developing a new Systems Navigator graduate certificate program.

Launched this past September with a cohort of 24 students, the one-year program – which combines in-class learning with 240 hours of field work – is designed to build skills for guiding patients and families through complex health-care and social care systems. Admission into the program requires a bachelor’s degree or diploma in health, social and community service or other health-related or human-services field.

“When our committee came together to design the program, one of the first things we asked was, ‘Does it have to be just health care? Or could it also address navigation needs in other systems, such as social, housing, Indigenous and criminal justice?’” says Colin MacRae, coordinator for Humber’s Systems Navigator program.

Students learn how to work with interdisciplinary teams in hospitals, medical centres, community services organizations, correctional facilities and other public and private entities, all while keeping the needs of patients, clients and their families front and centre.

With three representatives at the table, Sunnybrook’s family navigation team had a “large presence” on the Humber program development committee, MacRae notes. “After the committee was dissolved, we went back to Sunnybrook again and asked if any team members would be interested in helping us write the curriculum,” he says.

When the program was ready for launch, FNP clinical and research staff stepped up to teach six courses: systems theory, health literacy, professional self-care, professional communication, strength-based approaches to service and a field-based internship.

“We were thrilled when the folks at Sunnybrook agreed to help us draw up and teach the program,” MacRae says.

Teaching and learning

For Miriam Blond, one of two Sunnybrook navigators now teaching at Humber, the opportunity to share her knowledge with future system navigators was too good to pass up.

She teaches a strength-based approach to service course, which she explains is a relatively new approach in the field of health. “It focuses on resilience and a positive approach to concerns, rather than focusing on pathology,” says Blond. She came to family navigation from a background in social work and community mental health. “It’s looking at what people can bring to a solution and what’s working well for them that we can bring forward to achieve better outcomes.”

Like the other courses in the program, Blond’s teachings apply to systems beyond health care. But the students aren’t the only ones learning from the program, she says.

“I’m also able to bring the theories back to Sunnybrook, which helps to improve our practice,” she says. “My team has asked me to bring in academic material that we can use to review and evaluate our navigation model at Sunnybrook and potentially to translate into training material for our staff.”

Continued expansion

Patient navigation continues to expand, becoming part of the gold standard of care for chronic conditions such as cancer, diabetes, cardiovascular disease and mental illness – as evidenced by the creation of the Humber certificate program. Yet while the growing number of such programs means improved access to care for more patients, a lack of common standards for navigation itself could also lead to a fragmented navigation system in the future, says Dr. Levitt.

This is why Sunnybrook recently began speaking and working with stakeholders to explore building a system that ties together the disparate navigation services across the province.

“There’s a need to create a cohesive system of navigation,” Dr. Levitt says. “With our years of experience in family navigation, we’d like to contribute to this integration.”

Full circle

For Cathy, working with the FNP team at Sunnybrook has translated into a smoother journey through the health-care system and better solutions for her daughter. Cathy remembers how the navigator, having identified the right health-care facility, contacted the doctor in charge of the facility and explained her daughter’s medical and care history.

“By the time we talked to the doctor and the facility staff, they had a good background of what we were coming for,” says Cathy. “So it took away the stress of having to tell our story over and over again.”

For Dr. Levitt, “Cathy’s family journey is an example of how navigation is not simply about putting a bandage on a fragmented system, but rather that navigation is an integral part of an effective system. Navigation takes a family-focused approach to improve access to and transitions through the system, even when all the services are actually in existence. So there’s lots to teach our community and lots still to learn.”

For Cathy, her positive experience with FNP inspired her to pursue a new career.

After being out of the workforce for a decade, she had been thinking about rebooting her career but wasn’t sure what she wanted to do. Then, a navigator at Sunnybrook mentioned the new program at Humber.

“I said to my husband, ‘That’s the program I’ve been waiting for,’” says Cathy, who has a psychology degree and work experience in the insurance industry.

“I applied that same day.” 

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Violet had been born at 24 weeks, weighing under one pound, and she spent 133 days in Sunnybrook’s NICU.

“[The panic attack] was scary and forced me to acknowledge what a toll it was taking on me,” says Daphne, who booked an appointment with her family doctor immediately. “I felt like a worker bee in the NICU. I wanted to show I could pump all the milk Violet needed. I wanted to prove I was a good mom.”

When she was approached by hospital staff about a study called Coached, Coordinated, Enhanced Neonatal Transition, Daphne jumped at the opportunity. This neonatal follow-up model offers mindfulness-based support and coping resources for parents during the first year of their child’s life.

As part of the study, Daphne began attending Acceptance and Commitment Therapy coaching sessions at the hospital. It’s an approach that encourages families to focus on what’s important to them and to remember that while the experience of having a baby in the NICU can be very stressful, it’s temporary.

“You can live a life that is meaningful, even if there is pain and trauma,” says Kate Robson, project manager for Sunnybrook’s Neonatal Follow-Up Clinic. Kate has two children who were formerly in the NICU.

“The reality of the NICU can obscure what’s actually important to families, so we’re encouraging them to do things that hold meaning for them, whether it’s going for a walk outside or visiting a local coffee shop,” she says.

The coaching sessions helped Daphne better handle the stress of having a premature infant still in hospital. She has since returned to the gym to reconnect with her passion for powerlifting.

“I realized I didn’t need to carry the pain of having a baby in the NICU with me at all times,” she says. “I didn’t need to live in fear; I was going to be okay.”

Daphne Schibler and her daughter Violet enjoy some playtime at home. Photography by Kevin Van Paassen

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University of Toronto graduate students Peter Kuitenbrouwer (left) and Joanna Yu measure trees on Sunnybrook’s Bayview site (Photography by Kevin Van Paassen)

Sunnybrook is even greener than usual this spring, thanks to a pioneering program designed to nurture and protect its unique tree canopy.

In partnership with the University of Toronto’s Faculty of Forestry, Sunnybrook has embarked on an ambitious forest management plan.

Last summer, graduate students Joanna Yu and Peter Kuitenbrouwer began by assessing the woodlots and cataloguing the trees on Sunnybrook’s Bayview site.

Their inventory resulted in an impressive tally: more than 1,200 individual trees from 72 species, including two endangered butternuts. The team also checked the health of thousands of other trees in the hospital’s woodlots.

“With 42 hectares of beautiful landscape, Sunnybrook’s Bayview site is a natural healing environment and legacy property unique among hospitals in Canada,” says Kuitenbrouwer.

“It was a great summer job,” he adds, remembering crisp early mornings criss-crossing the hospital grounds in steel-toed boots.

Together with a team of forest conservation students, Kuitenbrouwer returned to plant 110 trees in early November, placing them according to each sapling’s specific needs. This effort contributed to Sunnybrook’s 2017 goal of planting 500 trees over five years.

Kuitenbrouwer and Yu are not the first researchers to take on the task of inventorying Sunnybrook’s ample woodlands.

Eighty years ago, botanist R.B. Thomson made the first major attempt to document the forest of maple, oak, elm, beech, hemlock, white pine, hickory, birch and catalpa that covers the area. He found 40 species of trees, a figure that has almost doubled in the intervening years.

One tree that made both Thomson’s list and last year’s survey is a 250-year-old sugar maple that’s older than Canada. Nearly a metre and a half wide, the massive maple is dwarfed only by another giant – a 34-metre pin oak that’s taller than the hospital’s main wing.

The benefits of such trees are more than aesthetic. Research suggests a link between healthy forests and healthy people: regular walks through greenery can strengthen immunity, lower blood pressure and reduce stress.

Considering these potential benefits, it’s encouraging to see the saplings taking root and spreading their branches wide.

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Dr. Jeannie Callum, blood transfusion specialist at Sunnybrook. (Photograph by Kevin Van Paassen)

Blood tests are crucial tools in diagnosing and treating illness. But when not medically necessary, too many blood tests can be too much of a good thing. These, and other medical tests, are being scrutinized at Sunnybrook in order to improve patient care and free up resources.

No one likes being pricked with a needle for a blood test – especially when it’s happening every day.

In September 2018, Stafan Williams was undergoing surgery at Sunnybrook to remove tumours caused by colon cancer. The 70-year-old Toronto resident spent four days in the hospital, and each day she had blood drawn.

“It didn’t seem necessary,” says Stafan of the daily tests. “Especially for a patient like me, who has low iron.”

Daily blood tests are a familiar routine for anyone who has spent a significant amount of time in any hospital for surgery or another medical procedure.

But Dr. Jeannie Callum, a blood transfusion specialist at Sunnybrook, says that in many cases, daily blood tests have become a habit for doctors everywhere. “We get our coffee, then we check everybody’s blood work results from that morning and then we go and see the patients,” says Dr. Callum, who is also an associate scientist at the Sunnybrook Research Institute.

It would make more sense, she says, to check on the patient first, then perform only blood tests that are required for the patient’s care.

Daily blood work is just one of the practices that are being scrutinized at Sunnybrook through an initiative called Choosing Wisely, a program that aims to improve patient care and free up resources. The premise is simple: Doctors should consider which tests and procedures are necessary to properly diagnose and care for a patient – and then make smarter choices about what’s done.

With a more judicious review of the benefits of a test or procedure, doctors can reduce tests that offer little or no value to specific patients.

Choosing Wisely was started in the United States by the American Board of Internal Medicine Foundation in 2012, and the movement made its way to Canada in 2014. Dr. Adina Weinerman, a general internist at Sunnybrook, is leading the charge to implement significant changes around the hospital.

“We grew up with a North American culture in medicine that ‘more was more,’ and, as technology advanced, we started using it,” says Dr. Weinerman, who also chairs the Choosing Wisely committee of the Canadian Society of Internal Medicine. “But now the pendulum has swung, where we’re sometimes using things because they’re available and not because they’re necessary.”

There can be a downside to unnecessary procedures for both patients and the hospital, Dr. Weinerman says.

Because phlebotomists (the clinicians who draw blood) have so many patients to attend to, in some cases they have to wake patients in the middle of the night or early in the morning to have their blood drawn. It’s a time- consuming process that can be uncomfortable for patients. Also, a surplus of routine blood tests can create a backlog in the lab where the blood is analyzed, delaying more urgent tests.

In some cases, too many blood tests can lead to patients developing anemia or requiring a blood transfusion. Transfusions can be risky procedures for any patient, and they can be problematic for patients like Stafan, a Jehovah’s Witness whose religion prohibits blood transfusions.

Beyond blood tests, the initiative at Sunnybrook is reviewing the routine administration of other procedures such as computerized tomography (CT) scans.

Like blood tests, CT scans are invaluable tools that aid in the diagnosis of illness and injury. They provide images that are much more detailed than ultrasounds or X-rays. But they shouldn’t be overused, Dr. Weinerman says. If a CT scan is administered unnecessarily, doctors may see something on the scan that appears abnormal, but never would have caused problems for that person.

“[Once] we see [those abnormalities], it leads to a snowball effect where we feel compelled to do more tests, like a biopsy,” she says.

Patients may need to take time off work for unnecessary tests that might have been avoided if an ultrasound had been done instead of a CT scan.

Reducing unnecessary CT scans also cuts down on wait times for those who really need them, Dr. Weinerman notes.

“There’s a finite number of resources and a finite number of hours in the day, and if we can reduce the number of medically unnecessary tests, that frees up those resources,” she says.

(Photograph by Kevin Van Paassen)

The initiative at Sunnybrook has already shown the positive impact of reducing unnecessary tests. In 2017, Dr. Callum decided to tackle two high-volume blood tests: one a measure of kidney function, the other a liver test. Both are not needed except in very specific cases, she says, but doctors routinely order them.

Dr. Callum first held widely publicized “grand rounds” with hospital staff, where she and her team outlined the tests they wanted to reduce and why. Then, she ensured that these tests were not automatically included in the
order sets for patients getting other kidney and liver tests done. After that, it was a matter of sending monthly emails to doctors who were still ordering these tests, unless their patients needed them.

Dr. Callum’s efforts paid off. “Between 2017 and 2018, we reduced the volume of [these two] tests by 75,000, which was a 75 per cent reduction,” she says.

In addition to reducing the total number of tests, Dr. Callum says they have decreased the amount of blood drawn for all blood tests.

“We switched the entire hospital to low-vacuum tubes for drawing blood,” she says.

With low-vacuum tubes, about half the amount of blood gets drawn per tube. There is also less pressure on the blood that’s drawn, leading to less of the sample becoming haemolyzed (when red blood cells become ruptured). Haemolyzed blood is unfit for testing, which subsequently leads to more blood having to be drawn.

“We’ve dramatically cut down on the amount of blood that we’re taking out of a patient, which helps keep them healthy and fit,” Dr. Callum says.

Efforts to improve the use of resources and patient care are ongoing, says Dr. Weinerman. So far, she has looked mostly at tests and procedures already identified by Choosing Wisely as most likely to be overused. But now she is turning to examples more specific to Sunnybrook, to see what changes can be made.

For her part, Dr. Callum has two new targets in mind: one is a routine heart muscle blood test that has been replaced by a newer and better test; the second is a blood test which assesses vitamin D levels.

In Canada, about half of all blood vitamin D measurements in healthy people are low, says Dr. Callum.

“In a healthy person without any serious diseases who eats a complete diet, there is no evidence that these low levels need any treatment – so why are we doing the measurement in the first place?”

Read more: Sunnybrook awarded Level 3 designation by Choosing Wisely Canada »

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Gord Mason supports cochlear implant research, so more patients can fully benefit from the device. (Photograph by Doug Nicholson)

After cochlear implants allowed Gord Mason to hear again, he wanted to give back. The Mason Scientific Discovery Fund will investigate how the brain turns sound into signals, to improve implant results for all patients.

Gord Mason, who has enjoyed a long and successful career as a homebuilder and businessman, loves to share how he regained the ability to hear.

Gord first noticed trouble with his hearing as a young man. It was the late 1950s, and he was training with the Royal Canadian Air Force. The training included being tested in a decompression chamber to simulate the thin atmosphere pilots encounter at 3,000 metres in the air.

“I thought my right ear was going to blow apart,” Gord remembers. “It was killing me. They told me it was routine, but I ended up not going into the Air Force.”

Gord’s hearing difficulties continued after he founded his Stouffville, Ont.-based house and condo-building business, Mason Homes, in 1961.

“I used to travel a lot for business. I’d get off a flight and I wouldn’t be able to hear until the next day,” he says.

Progressive hearing loss over the next few decades affected Gord professionally and emotionally.

“You lose your confidence when you can’t hear,” he says. “I remember sitting down with four people, two on either side of me. They had a cross-conversation going. I’m sitting in between and I’m not getting anything.”

Gord says he wouldn’t realize that he was talking too loudly because of his hearing loss. He said he felt that could sometimes give the impression to others that he was angry or hot-tempered.

By the time Gord reached his 70s, he had lost much of his ability to hear the people and the world around him.

“It’s hard, and it’s especially hard when you’re in business,” he says.

Today, Gord hears quite well, thanks to dual cochlear implants he received from Sunnybrook’s Cochlear Implant Program. He received his second implant last year, several years after the first ear.

Gord says for him, the ability to hear properly is life-changing.

“It gave me my confidence back. Now I can go to meetings and hear people at the other end of the table,” he says. “And when I drive, I put on the radio. I listen to music!”

Gord’s journey back to hearing – and greater happiness – meant so much to him that he decided to donate funds to establish the Mason Scientific Discovery Fund at Sunnybrook.

The fund’s researchers are working to advance the science of cochlear implants, studying how the brain “listens” to sound and investigating why some implants are more successful than others.

“The Mason Scientific Discovery Fund will allow us to create a hub and bring researchers from different areas of electrophysiology and auditory science to innovate and find novel solutions to improve outcomes,” says Dr. Joseph Chen, director of the Sunnybrook Otology-Skull Base Fellowship Program and provincial coordinator of the Ontario Cochlear Implant Program.

In cochlear implant surgery, which takes up to two hours, an electronic device is implanted into the patient’s skull and inner ear, and the patient wears an external piece of the device behind the ear.

The implanted device stimulates the hearing nerve directly, bypassing damaged parts of the inner ear and sending signals directly to nerves connected to the brain.

After the surgery, the device must be calibrated with a computer, and it takes up to four weeks for it to start working at full capacity.

“It’s a medical miracle that has actually outperformed our wildest dreams,” says Dr. Chen, who began performing cochlear implant surgery at Sunnybrook in 1992. The Sunnybrook program is the largest in Canada, performing 200 implants every year.

Now I can go to meetings and hear people at the other end of the table.
– Gord Mason

Dr. Chen, who performed Gord’s implant surgery, says that cochlear implants have traditionally been implanted in people who were completely deaf.

“Over time, we have learned that people with a bit of residual hearing can benefit the most,” he says.

Adults with normal language skills who lose hearing later in life are perhaps the best candidates for cochlear implants, says Dr. Chen. Within this group, patients who are younger may have physiological and cognitive advantages to perform better.

But after 30 years of implant surgery, “what we have realized is that everything else being equal, the biggest impact to performance is related to the intensity of rehabilitation immediately after activation in the first six to 12 months of use,” says Dr. Chen. “We are becoming more and more focused on this window.”

Andrew Dimitrijevic is research director for the Cochlear Implant Program at Sunnybrook. He says the Mason Fund will enable researchers to study the interaction between cochlear implants and the nerves that translate sound into signals to the brain.

“We look at the brain waves of people who are hard of hearing and also of people who hear normally to see how the brain responds to sounds, including specific sounds such as speech and noise,” says Dimitrijevic, who holds a PhD in neuroscience.

“It turns out that you need to reach the higher centres of the brain to understand and process speech,” he says. “We hear with our ears, but our brain is where the listening takes place.”

He explains that our brains store a “template” of sounds we have heard in the past that helps us understand what we’re hearing. Cochlear implant patients may not have heard these stored sounds for years, or ever, so they must build new connections between what the implants allow them to hear and how the brain listens to these sounds.

“We’re trying to understand these connections better, so we can improve how patients hear,” Dimitrijevic says.

The research is endlessly exciting to Gord.

“I’m funding an idea,” he says. “And when I talk to Andrew and hear his excitement, I’m convinced there’s something [big] coming.”

While hearing has made him more productive at work, Gord says the subtle joys are perhaps the most satisfying.

“Shortly after I had the second implant, I stayed late at the office. I came outside around 7 p.m., and I heard something strange,” he says.

It was a gentle noise that Gord could not recall ever hearing before.

“It was a soft rain,” he says. “It was such a pleasant sound.”

The post This new fund will help advance the science of cochlear implants appeared first on Your Health Matters.

(Photography by Kevin Van Paassen)

Hospital food has long had a bad reputation, but Sunnybrook is leading the charge to change that perception.

With a new production kitchen, customized menus, the guidance of nutrition experts and an executive chef at the helm, in-patients now have every reason to clean their plates.

Sunnybrook’s “Fresh Flex” menu is tailored to fit patients’ needs, within a wide range of culturally diverse dishes. Patients submit their food preferences, then meals are personalized in compliance with their medically prescribed diet. Most recipes are made from scratch on-site in a newly renovated kitchen.

Sunnybrook’s first executive chef, Serge Kostenko, and a team of experienced cooks manage every step of the process.

Fresh meal items and more choice may be welcome perks for patients, but there’s another important benefit: they can boost recovery. Research shows that providing quality nutrition can accelerate the healing process and can decrease a patient’s length of stay.

For overall health and happiness, good food matters!

1. The production kitchen
   Sunnybrook’s newly renovated space is brimming with fresh ingredients and cutting-edge equipment. Recipes for the dishes are formulated in an off-site test kitchen to ensure they can be replicated on a larger scale.
2. Meal selection
   Inpatients are offered a customized selection of dinner choices, which they preorder on iPads brought to their bedside.
3. The personalized ticket
   Each order generates a ticket, which tells kitchen staff exactly how to customize each meal. Approximately 3,000 meals are prepared daily.
4. Tray assembly
   Freshly cooked items are assembled on each patient’s tray one meal in advance.
5. Final preparation on the unit
   Meals are transported from the kitchen to each patient care unit, where specialized equipment reheats each tray to a specific preset temperature.
6. Distribution to patients
   Customized dinner items are delivered to each patient’s room.
7. Bon appétit
   Patients tuck into their meals at their bedsides. After dinner, patients are encouraged to provide feedback. This survey information will help inform future menu choices.

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Bill Temos was part of a trial that saw him receive just two doses of radiation. (Photograph by Kevin Van Paassen)

Radiation has long been a critical tool in the fight against prostate cancer. But sometimes, less is more. Doctors at Sunnybrook have pioneered a way to deliver fewer radiation treatments to tumours while ‘packing a greater punch.’

After Bill Temos’s good friend died from prostate cancer in 2017, he knew he had to look into his own PSA levels.

Bill’s PSA (prostate-specific antigen) tests, which examine blood for this protein, had been rising steadily for years. Higher levels of PSA can mean cancer is present.

Soon after returning from his friend’s funeral, Bill visited his doctor, who agreed to investigate further.

After some additional tests, a biopsy came back positive for prostate cancer.

“You know, you think the worst when someone says ‘cancer,’” Bill says. “Then there’s the CT scans, the bone scans and all the worry that comes with those, and the worries about what the treatments will be like.”

Bill’s doctor referred him to Dr. Andrew Loblaw, a radiation oncologist at Sunnybrook.

“My doctor explained that Dr. Loblaw was targeting tumours with radiation in more precise doses, for a fewer number of treatments,” Bill says.

Dr. Loblaw and his colleague Dr. Patrick Cheung have spent decades researching and perfecting SABR – stereotactic ablative body radiotherapy – a high-precision, external beam radiation treatment.

In 2018, Sunnybrook became the first hospital in Canada to change treatment protocols for most men with intermediate risk prostate cancer. Traditionally, radiation treatment plans involved visits to the cancer centre five days a week for eight weeks.

The Sunnybrook team targets prostate tumours using stereotactic ablative body radiotherapy (SABR), a high-precision radiation treatment. (Photograph by Doug Nicholson)

“With SABR, we’ve reduced that to once per week, for five weeks, and we are really proud of that change,” Dr. Loblaw says.

The SABR treatment involves implanting tiny markers made of gold into a prostate tumour and using image-guidance to precisely target the tumour with radiation from outside the body. It is done on a regular linear accelerator, which is the standard equipment used for external beam radiation. That means any cancer centre providing radiation treatment could adopt SABR, Dr. Loblaw says.

“Because of the precision, we are actually able to deliver less radiation into the body, which is better for patients too,” he says.

The new SABR treatment plans were years in the making.

“We were always taught that the best way to treat prostate cancer was with six to eight weeks of low-dose treatments. Then about 20 years ago, some scientists in the United States noticed that prostate cells were more easily killed with high dose per day radiation,” Dr. Loblaw explains. “So we used that theory to start developing this technique – delivering fewer radiation treatments to a tumour, but ultimately packing a greater punch.”

Because prostate cancer is often a slow-growing cancer, researchers had to watch and check in on patients for years to ensure the SABR was working effectively, Dr. Loblaw explains.

And, since the side effects of radiation treatments can take years to surface, it was important for the researchers to track patients over time to ensure the treatments were also safe. In fact, the first cohort of patients was followed for a minimum of 11 years.

“This kind of work takes a long time to fund and to complete,” Dr. Loblaw says. “But ultimately, we’ve found that SABR is highly effective for treating prostate cancer, it’s well tolerated by patients – meaning there are few side effects – and it’s very convenient for patients.”

Dr. Andrew Loblaw, radiation oncologist at Sunnybrook. (Photograph by Kevin Van Paassen)

Now, Dr. Loblaw and his team are going even further in their SABR research. 

“We are looking into whether we can effectively treat some prostate patients with just one dose of radiation,” he says.

Bill was a part of a trial that saw him receive just two doses of radiation, saving him dozens of trips from his Nobleton, Ont., home and allowing him to continue running his bakery equipment business, where he has worked for the past 40 years.

“If you have to undergo eight weeks of radiation because that’s best for your type of prostate cancer, then you should,” Bill says. “But for me, to have the option to undergo just two doses was amazing. It was the least invasive and disruptive option.”

Just shy of one year post-treatment, Bill says his PSA levels have dropped dramatically and he is in good health.

“I just got back from a business trip abroad and a vacation with the whole family, including the grandkids,” Bill says. “I’m very lucky.” 

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• One in 10 Sunnybrook trauma patients arrive by air ambulance. A team of eight or more highly trained staff then diagnose the patient and begin treatment as quickly as possible.
• Air ambulances also transport high-risk mothers and very premature babies in need of urgent care.
• The new 75-by-75-foot helipad will sit on the roof of the main wing of the hospital. A covered tunnel will protect patients arriving in poor weather, leading to a pair of dedicated elevators for quick access to the treatment areas.
• The project was made possible thanks to the generosity of donors, including the Gelato Cup and the Rudolph P. Bratty Family Foundation.
• Construction is expected to be completed by the fall of 2019.
• Sunnybrook’s Tory Trauma Program, the largest in Canada, treats more than 2,000 patients annually from across Ontario who need rapid, life-saving care following a car crash, fall or other catastrophic injury.

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It’s a role that requires more than a sense of direction and a good pair of shoes.

Transport staff often provide a sympathetic ear and a large measure of comfort for patients. They can be a source of reassurance in an unfamiliar environment.

Even if patients are anxious about the destination, Sunnybrook’s Patient Transport Team is there to make the journey as pleasant as possible.

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One-size-fits-all has no place in Sunnybrook’s personalized breast cancer program. Using imaging, innovative genomic approaches and high-tech cellular analysis, doctors and scientists are taking a bold new path to treat breast cancer with precision-based medicine.

Debbie Duclos had a gut feeling something was very wrong with her left breast. It was November 2014 and the 42-year-old registered nurse from Campbellville, Ont., noticed that its shape and feel had changed.

After a local hospital ordered a mammogram and an ultrasound, “a sizeable area of concern” was identified through imaging. Stricken, Debbie conferred with her family doctor and was referred to Sunnybrook for her biopsy, having worked at the hospital in the past. 

“Within 48 hours, I had my diagnosis. Stage 2 breast cancer,” she recalls. “The tumour was the size of a lemon.”

The news led to a lot of anxiety and fear.

“The uncertainty of a cancer diagnosis really rocks your boat,” says Debbie. “I was thinking, ‘Why me? Why did this happen?’”

Reeling from the news, Debbie was comforted by the support of her husband, parents and friends, and by the fact that she had an appointment with a team of oncologists at Sunnybrook by the end of the week.

During that first meeting, the team of doctors and radiologists provided Debbie with a detailed plan for her care. Within the next nine months, they were going to give her chemotherapy, surgery and radiation, while continuously tracking her tumour’s response to treatment.

She was also enrolled in several studies during her breast cancer journey, including a tumour-mapping study.

Debbie left the meeting understanding her diagnosis and with a personalized plan, giving her an enormous feeling of relief.

“I felt like they had taken me under their wing,” she says. “They had a clear direction for me. It’s what enabled me to really think I was going to be okay.”

Debbie Duclos, diagnosed with breast cancer in 2014, benefited from Sunnybrook’s innovative personalized treatment program. (Photograph by Kevin Van Paassen)

A personalized approach

Debbie had become part of Sunnybrook’s ongoing clinical research program that aims to provide a personalized approach to cancer care.

This approach focuses on obtaining as much information as possible about tumours through quantitative magnetic resonance imaging (MRI), digital pathology and genetic mapping, known as genomics. Using these advanced techniques, Sunnybrook oncologists and scientists work together to determine exactly how these tumours behave – and what treatments are best at eradicating them.

“We decided to form a core team of clinical and scientific experts here at Sunnybrook,” says Dr. William Tran, a radiation therapist and clinician-scientist at Sunnybrook and a vital part of the new precision medicine program. The team includes Dr. Katarzyna Jerzak, a medical oncologist at the Odette Cancer Centre and assistant professor in the Department of Medicine at the University of Toronto, pathologists and radiation oncologists at Sunnybrook and Dr. David Andrews, director and senior scientist in the Biological Sciences Platform at Sunnybrook Research Institute and professor of biochemistry at the University of Toronto.

“Now I can answer patients who ask, ‘How do you know if the chemo is working?’”

– Dr. Katarzyna Jerzak,
medical oncologist at the Odette Cancer Centre at Sunnybrook

They work holistically with patients at every stage of their care program to assess the responsiveness of the tumour to the treatment.

Traditionally, tumours aren’t viewed multiple times over an extended period during treatment, says Dr. Tran. The new, personalized approach tracks the cancer as it evolves in a patient’s body. In addition, the information gleaned from these patients will be tracked, recorded and stored in a databank, to be used for guidance on future cases at Sunnybrook and other Canadian hospitals.

Dr. Tran says there is a great interest in the medical and scientific community to improve treatments for breast cancer. “We’re trying to shake [things] up in this research program.”

‘A changing paradigm’

As part of the precision-treatment program, the team is trying to identify women who are at high-risk for developing metastasis (the spread of the disease beyond the primary site). Once a patient with high-risk breast cancer is identified by medical oncologists at Sunnybrook, they are followed by the team as part of a study.

At the onset of treatment, these patients receive chemotherapy to shrink their tumours. This approach can halt the cancer cells early and help prevent metastases, even prior to surgery.

“There’s a changing paradigm now,” says Dr. Jerzak. “Historically, women with early breast cancer were treated with surgery first, followed by chemotherapy. But increasingly, women with triple-negative or HER2 positive tumours are getting chemotherapy first, instead of surgery first.” 

For some women, the upfront chemo means the tumour shrinks entirely or enough that breast conserving surgery is possible, rather than a full mastectomy.

At select points in the chemotherapy regimen, quantitative imaging will be done to determine if the tumour is responding well to treatment, says Dr. Tran.

“We are exploring new ways to analyze tumours using quantitative MRI, ultrasound and digital pathology; we think these are our best shot right now,” he says. Unlike conventional MRI, quantitative MRI (and imaging) provides clinicians with measurable and consistent data of the biological and physiological properties of the tumour. 

More good news

In accordance with the Sunnybrook team’s personalized approach, Debbie underwent chemo immediately after her diagnosis. She watched as her tumour shrank dramatically.

“[The doctors] could see how the chemo was reducing the tumour size,” Debbie recalls. “And they were able to give me results.”

She later had a mastectomy of her left breast, 36 lymph nodes removed and 25 sessions of radiation.

Dr. Jerzak is happy that she now has more good news to share with patients like Debbie.

“Now I can answer patients who ask, ‘How do you know if the chemo is working?’” she says.

Dr. Jerzak says she’s currently working to recruit patients with triple-negative or HER2 positive breast cancer for a study that not only incorporates imaging, but also measures blood-based and genomic markers of response to
chemo-therapy. Later, she hopes to work with women with metastatic breast cancer as well.

Databank for the future

A biopsy of a tumour taken at the onset of treatment can provide scientists with vital information about its composition. Tumours are often made up of a variety of cancer cells – rather than just one type – meaning that each portion of a tumour can react differently to different medications.

That’s why after Dr. Andrews and his team remove a tumour sample, they culture the cancerous cells in the lab. Then, they effectively grow 3-D models of the tumours in order to determine their composition and their responsiveness to a variety of drugs. (See below.)

“We try to extract a lot of information from images of the cells,” says Dr. Andrews. “We’re trying to find out how they’ll respond to treatment, [and] within weeks, instead of months, we have an answer.”

The end game, says Dr. Andrews, is that the patient will be given targeted chemotherapy to treat the exact cancer – or cancers – they have, rather than being bombarded with drugs that wipe out not only cancer cells but healthy cells as well.

And the work done in the lab won’t just benefit each individual patient. All the information being gathered from patients is being stored, with the hopes of building a large databank in the future that doctors can access.

In essence, the databank will illustrate what worked – and what didn’t – for each patient and their particular type of tumour. This valuable information will be used to help oncologists plot the best treatment plans for future patients.

Giving back

Now 46, Debbie has been in remission since September 2015. She gets follow-up appointments every six months and is still undergoing active surveillance as part of the precision medicine studies. Last year, imaging caught some shadowing in her right breast, which could indicate a tumour. Luckily, the area hasn’t changed in subsequent scans, and Debbie is confident she’s being watched carefully by her team at Sunnybrook.

She is now the founder and CEO of a medical-device training company, having been inspired by some of the technology used during her care.

Debbie’s also been volunteering in her community, including participating in events supporting women’s cancer research. She says she’s happy to share her energy and enthusiasm, having received a new lease on life.

“I am just so grateful to my entire care team and want to show my appreciation by giving back,” she says. “I always say, ‘Is there a way you can pay it forward?’”

Solving complex cases

Dr. David Andrews in Sunnybrook’s High Content Screening Lab. (Photograph by Kevin Van Paassen)

In the High Content Screening Lab, at the Sunnybrook Research Institute, senior scientist Dr. David Andrews and his team are growing cancerous tumour cells sourced from breast biopsies into 3-D models called organoids. These models can provide key information about the cells within them – and give clues as to which medication combinations will prove successful.

“We’re trying to mimic what’s going on in the patient’s body,” explains Dr. Andrews.

Zeroing in on the ‘bad guys’

Some of his research looks at how cancer driver cells work. These cells, which are responsible for fuelling tumour growth, are notoriously tough to treat. (“They’re the real bad guys,” he says.) Dr. Andrews wants chemotherapy to be more precise, zeroing in on these types of cells that resist chemotherapy and often come back.

To that end, he and his team analyze how the cancer cells in his samples behave. These behaviours can offer clues as to how effective chemotherapy will be. “In response to chemotherapy drugs, we ask, ‘Are they stressed? Are they starving? Are they going to sit there and wait it out? Or are they going to die?’ Chemotherapy regimens can evoke those behaviours,” says Dr. Andrews.

Ultimately, scientists won’t just be analyzing cellular behaviour. Dr. Andrews says scientists may someday be able to activate a built-in self-destruct program in these tough-to-treat cancer cells, instructing them to die off.

Predicting the right treatment

To witness this kind of sophisticated cellular interplay, Dr. Andrews and his team use state-of-the-art technology. New, automated microscopes generate data sets containing millions of images. This data is then evaluated though a process called high content analysis – using microscopes and computers to employ complex algorithms that can identify and categorize cells.

Once the information on the cells is available, it is then stored in the lab’s servers. The information can then be accessed by radiologists and oncologists with the goal of helping them treat high-risk breast cancer patients.

“The goal is to be able to tell patients what drug combination they should be taking,” says Dr. Andrews. “We need a way to predict success upfront.” 

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