Spotlight on  Colorectal Cancer ScreeningMaximizing Benefits and Minimizing Harms

Faculty/Presenter Disclosure

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Faculty:[Your Name Here] MD and RPCL with CCO “Spotlight on Breast, Cervical and Colorectal Cancer Screening: Maximizing Benefits and Minimizing Harms”

Relationship with Commercial Interests: Not applicable

Disclosure of Commercial Support

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Relationship with Commercial Interests: The delivery of this Cancer Screening program is governed by an agreement with Cancer Care Ontario. No affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization

Mitigating Potential Bias

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Not applicable

Learning Objectives• To better understand the benefits and harms of

cancer screening• To identify the goals and key features of

Ontario’s population-based cancer screening programs (breast, cervical and colorectal)

• To explore and understand current evidence on cancer screening

• To apply the evidence-based guidelines to relevant cancer screening case studies

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Agenda Outline1. Provincial Goals for Cancer Screening

2. Role of Primary Care

3. Benefits and Harms of Screening

4. Spotlight on Screening Programs

• Screening rate targets: challenges/opportunities

• Latest evidence-based guidelines

• Current program performance

• Relevant case studies6

Cancer Care OntarioVision and Mission 2012–2018

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Our New VisionWorking together to create the best health systems in

the world

Our New MissionTogether, we will improve the

performance of our health systems by driving quality, accountability, innovation,

and value

Cancer Care Ontario (CCO)• Provincial government agency

• Supports and enables provincial strategies

• Directs and oversees > $800 million

• Three lines of business:

Cancer– CCO’s core

mandate since 1943 to improve prevention,

treatment and care

Chronic Kidney Disease – Ontario Renal Network

launched June 2009

Access to Care– Building on Ontario’s

Wait Times Strategy; provides information solutions that enable

improvements to access

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CCO’s Screening Goal VISION

Working together create the best cancer system in the world

GOALIncrease screening rates for breast, cervical and

colorectal cancers, and integrate into primary care

Increase patient participation in

screening

Increase primary care provider

performance in screening

Establish a high-quality, integrated screening program

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CS Strategic FrameworkGOAL

Accelerate reduction in cancer mortality by implementing a coordinated, organized cancer screening program across Ontario

STRATEGIC DIRECTIONS

Enhance coordination

and collaboration

Improve quality

Maximize resourcesand build capacity

Promote innovation

and flexibility

Advance clinical

engagement

Deliver patient-centred

care

What is Screening?The application of a test, examination or other procedure to asymptomatic target population to distinguish between: • Those who may have the disease and

• Those who probably do not

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Types of Screening

Population-Based Screening

Offered systematically to all individuals in defined target group within a framework of

agreed policy, protocols, quality management,

monitoring and evaluation

Opportunistic Case-Finding

Offered to an individual without symptoms of the

disease when he/she presents to a healthcare provider for

reasons unrelated to that disease

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Current State of Programs• 3 cancer screening programs:

ColonCancerCheck (CCC)Ontario Breast Screening Program

(OBSP)Ontario Cervical Screening Program

(OCSP)

• Different stages of development

• Different information systems 13

Ontario Cancer Statistics 2013

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Cancer Type # New Cases

# Deaths

Breast 9,300 (F) 1,950 (F)

Cervical 610 (F) 150 (F)

Colorectal 4,800 (M)3,900 (F)

1,850 (M)1,500(F)

CCO and Primary CareRPCL

LHIN 1

RPCL LHIN 2

RPCL LHIN 3

RPCL LHIN 4

RPCL LHIN 5

RPCL LHIN 6

RPCL LHIN 7

RPCL LHIN 8

RPCL LHIN 9

RPCL LHIN

10

RPCL LHIN

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RPCL LHIN

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RPCL LHIN

13

RPCL LHIN

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Primary Care Program

Provincial Lead

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Cancer Journey and Primary Care

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PRIMARY CARE

Primary Care and Cancer Screening

• The essential role family physicians play in screening intervention is widely recognized: Identify screen-eligible populations and

recommend appropriate screening based on guidelines and patient’s history

Manage follow-up of abnormal screen test results

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SAR Dashboard

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Screening Activity Report (SAR)Purpose Approach

Motivation: Enhance physician motivation to improve screening rates

Dashboard displays a comparison of a physician’s screening rates relative to peers in LHIN and province

Administration: Provide support to foster improved screening rates

Provides detailed lists of all eligible and enrolled patients displaying their screening-related history; clinic staff can be appointed as delegates

Failsafe: Identify participants who require further action

Patients with abnormal results with no known follow-up are clearly highlighted on the reports

Performance: Improve physician adherence to guidelines and program recommendations

Methodology based on the program’s clinical guidelines and recommendations for best practice

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Potential Benefits of Screening

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• Reduced mortality and morbidity from the disease, and in some cases reduced incidence

• More treatment options when cancer diagnosed early or at a pre-malignant stage

• Improved quality of life

• Peace of mind

Possible Harms of Screening

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• Anxiety about the test

• False-positive results

Psychological harm

Labeling due to negative association with disease

Unnecessary follow-up tests

• False-negative results

Delayed treatment

• Over-diagnosis and over-treatment

Sensitivity and Specificity

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Cancer Site Test Sensitivity Specificity

Breast Mammography 77% to 95%Less sensitive in younger women and those with dense breasts

94% to 97%

Breast MRI 71% to 100%Studies conducted in populations of women at high risk for breast cancer

81% to 97%Studies conducted in populations of women at high risk for breast cancer

Colorectal gFOBT (repeat testing)

51% to 73% 90% to 100%

Cervical Pap test 44% to 78% 91% to 96%

Cervical HPV test 88% to 93% *

* Sensitivityfor CIN II

86% to 93%

Effectiveness of Screening

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Cancer Site Effectiveness of Screening Type of Studies

Breast With mammography:21% reduction in mortality with regular screening in 50 to 69-year-olds

Randomized controlled trials

Cervical With Pap testing: Incidence and mortality reduced by up to about 80% with regular screening

Observational studies and Global incidence data

Colorectal With FOBT:15% reduction in mortality with biennial screening

Randomized controlled trials

Spotlight on

Colorectal Cancer Screening

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Burden of Disease • In Ontario, an estimated 8,700 new cases of colorectal

cancer will be diagnosed and 3,350 people will die from it

in 2013

• Incidence of colorectal cancer in Canada is similar to

other developed countries, and is among the highest in the

world

• Approximately 93% of cases are diagnosed in people

aged 50 years and older

• 5-year relative survival rate for colorectal cancer has

improved over the past decade in Canada

Adenoma-Carcinoma Sequence

• Majority of colorectal cancers arise from adenomatous polyps

• Progression to invasive cancer takes 10 years on average

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Colorectal Cancer Sub Site• Cancers arising in the left vs. right side

of colon have different epidemiological, histological and molecular features

• Higher proportion of right-sided colon cancers diagnosed in women

• Survival rates are poorer in those diagnosed with right colon cancer

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Recommended Screening

Average Risk: fecal occult blood test (FOBT)• Biennial (every 2 years), aged 50 to 74• Follow up abnormal FOBT with colonoscopyIncreased Risk: Colonoscopy • One or more first-degree relatives with a

history of colorectal cancer• Begin at age 50, or 10 years earlier than age

relative was diagnosed, whichever is first

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• Average risk patients who have had a negative/normal colonoscopy should not be screened for 10 years, following which screening should resume using either FOBT or colonoscopy

FOBT and Colonoscopy

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Evidence for Screening Using FOBT

A meta-analysis of 3 randomized clinical trials shows that regular screening with FOBT reduces colorectal cancer mortality by 15%

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ColonCancerCheck (CCC) Program Goals

• Reduce mortality through an organized screening program

• Improve capacity of primary care to participate in comprehensive colorectal cancer screening

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• Colonoscopy and FOBT quality standards

• Increased colonoscopy capacity across Ontario

• Primary care provider awareness

• Program-branded FOBT kits

• Financial incentives for family physicians

• Patient correspondence

• Initiatives to assist with follow-up of abnormal results

CCC Program Features

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Patient correspondence includes:

• FOBT result letters

• Recall/reminder letters

• Invitation letters to people aged 50 to 74

CCC Program Features

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Assessing Risk

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Assess for colorectal cancer (CRC) signs

and symptoms

Symptoms(high risk of

CRC)

Age 50 to74;no symptoms; no

affected 1st degree relatives

(average risk of CRC)

No symptoms; 1 or more 1st degree relatives with

CRC(increased risk of CRC)

Refer to colonoscopy;

FOBT not appropriate

Refer to colonoscopy;start at 50 years of age or 10 years before age of relative’s diagnosis

FOBT every 2 years

FOBT Screening Participation Rate, by LHIN

Ontario

Erie St. C

lair

South West

Wate

rloo W

ellington

Hamilto

n Niag

ara H

aldim

and B

rant

Centra

l West

Mississ

auga H

alton

Toronto Cen

tral

Centra

l

Centra

l East

South East

Champlai

n

North Sim

coe M

uskoka

North East

North W

est0

10

20

30

40

50

60

70

80

90

100

2004-2005 2006-2007 2008-2009 2010-2011

CCO program target 2010: 40%

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2008 2009 2010 20110

10

20

30

40

50

60

70

80

90

100

Year

Ove

rdue

(%

)

Overdue for CRC Screening

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FOBT Abnormal Rate

50–74 50–54 55–59 60–64 65–69 70–740

1

2

3

4

5

6 Male Female

Age group

Abn

orm

al F

OB

T r

esul

t (%

)

Follow-up Colonoscopy After +FOBT

2008 2009 2010 20110

10

20

30

40

50

60

70

80

90

100

Year

Col

onos

copy

wit

hin

6 m

onth

s (%

)

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Colonoscopy Wait Time Benchmarks

ColonCancerCheck’s program colonoscopy wait time benchmarks (adapted from the Canadian Association of Gastroenterology benchmarks) are:

• 8 weeks for those with a FOBT+ result

• 26 weeks for those with a family history39

Clinical Case Study 1

A 54-year-old asymptomatic male comes in for his periodic health visit

What screening test would you suggest for him?

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Clinical Case Study 2

• A 47-year-old woman inquires about colorectal cancer screening• Her mother was diagnosed at age

65 with colorectal cancer

What would you suggest?

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CCC ResourcesFor more information: www.cancercare.on.ca/pcresources

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Call to Action!Screen Your Patients

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Screened Not Screened

Breast 61% 39%

Cervical 65% 35%

Colorectal 30% 47%