spotlight on colorectal cancer screening maximizing benefits and minimizing harms
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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
4
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
12
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%
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