trilhin ics orientation workshop july 16, 2014 dr. jan owen, md, ccfp, fcfp
DESCRIPTION
Cancer. Screening. TriLHIN ICS Orientation Workshop July 16, 2014 Dr. Jan Owen, MD, CCFP, FCFP Regional Primary Care Lead, SWRCP. Learning Objectives. To identify the goals and key features of Ontario’s population-based cancer screening programs (breast, cervical and colorectal) - PowerPoint PPT PresentationTRANSCRIPT
TriLHIN ICS Orientation WorkshopJuly 16, 2014
Dr. Jan Owen, MD, CCFP, FCFP Regional Primary Care Lead, SWRCP
ScreeningCancer
Learning Objectives
• 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 Outline
1. Benefits and Harms of Screening
2. Spotlight on Screening Programs
• Screening rate targets: challenges/opportunities
• Latest evidence-based guidelines
• Current program performance
• Relevant case studies 3
Potential Benefits of Screening
• 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 mind5
Possible Harms of Screening
• 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-treatment6
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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SAR Dashboard
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Spotlight on Breast Cancer Screening
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Do I Need to be Screened for Breast Cancer?
http://www.youtube.com/watch?v=PYTg3gcbuBo&index=34&list=FLXu1tmVgO0Srr3vizeTiUUA
Sensitivity and SpecificityCancer Site Test Sensitivity Specificit
yBreast 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
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Effectiveness of Screening
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
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Burden of Disease
• 1 in 9 Canadian women will develop breast cancer in their lifetime
• In Ontario, an estimated 9,300 women will be diagnosed and 1,950 will die of breast cancer in 2013
• Most frequently diagnosed cancer in women
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Burden of Disease
• Breast cancer occurs primarily in women aged 50 to 74 (57% of cases); 8 in every 10 breast cancers are found in women aged 50+
• More deaths occur in women aged 80+ than in any other age group
• Reflects benefits of screening/treatment in prolonging life for middle-aged women
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Screening Rates
61% of eligible Ontario women age 50 to 74 years were screened for breast cancer in 2010–2011
• 71% screened in OBSP,
• 29% outside of OBSP
• The national target is to increase screening rates to ≥ 70% of the eligible population
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Challenges• Screening rates have slowed; lowest in
70 to 74 year (53%) followed by 50 to 54 year age groups (58%)
• Recruitment of under- and never-screened women (e.g., marginalized groups)
• Increasing awareness of and referrals to the high risk program among public and providers
• Controversy around screening women at average risk in the 40 to 49 age group
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Screening Recommendations
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Screening Modality
Canadian Task Force on Preventive Health Care (2011)
Mammography
• Women 40 to 49: Recommend not routinely screening
• Women 50 to 69: Recommend routinely screening
• Women 70 to 74: Recommend routinely screening
• Women aged 50 to 74: suggest screening every 2 to 3 years
MRI • Women aged 40 to 74 who are not at high risk for breast cancer: Recommend not routinely screening with MRI
• Women at high risk aged 30 to 69: Recommend annual screening with MRI (in addition to mammography)
Screening Recommendations
Screening Modality
Canadian Task Force on Preventive Health Care
(2011)Breast self examination (BSE)
Recommend not advising women to routinely practice BSE
Clinical breast examination (CBE)
Recommend not routinely performing CBE alone or in conjunction with mammography
0
10
20
30
40
50
60
70
80
90
100
OBSP Non OBSP
Breast Cancer Screening Participation Rate, by LHIN
National target: ≥ 70%
Breast Cancer Screening Participation Rate, by LHIN
Ontario
Erie S
t. Clai
r
South W
est
Wate
rloo W
ellin
gton
Hamilt
on Niag
ara H
aldim
and B
rant
Centra
l Wes
t
Miss
issau
ga Halt
on
Toronto
Cen
tral
Centra
l
Centra
l Eas
t
South E
ast
Champlai
n
North S
imco
e Musk
oka
North E
ast
North W
est
0
20
40
60
80
100
2004-2005 2006-2007 2008-2009 2010-2011
National target: ≥ 70%
Ontario Breast Screening Program (OBSP)• Province-wide organized breast cancer
screening program since 1990
• Ensures Ontario women at average risk aged 50 to 74 receive benefits of regular mammography screening
• Expansion of OBSP (July 2011) extended benefits of organized screening to women at high risk aged 30 to 69 (to be screened annually with mammography and MRI) 21
OBSP Eligibility Criteria
Average-risk screening:
• Women aged 50 to 74 years
• Asymptomatic
• No personal history of breast cancer
• No current breast implants 22
OBSP Eligibility Criteria
High risk screening:
• Women aged 30 to 69 years
• Asymptomatic
• May have personal history of breast cancer
• May have current breast implants
• Confirmed to be at high risk for breast cancer
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Heard About BRCA1, BRCA2, Lately?
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OBSP High Risk Eligibility Criteria
Four Assessment Categories:
1) Confirmed carrier of gene mutation
2) First-degree relative of mutation carrier and refused genetic testing
3) ≥ 25% personal lifetime risk (IBIS, BOADICEA tools
4) Radiation therapy to chest more than 8 years ago and before age 30 25
Average risk: biennial recall (every 2 years)
Increased risk: annual (ongoing) recall
• High-risk pathology lesions
• Family history
Increased risk: one-year (temporary) recall.,
• Breast density ≥ 75%
• Radiologist, referring MD, recommendation
• Client request
High risk: annual recall
OBSP Screening Intervals
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• Two-view mammography
• Automatic client recall
• Physician and client notification of results
• Quality assurance for all components
• Monitoring follow-up/outcomes
• Program evaluation
• Comprehensive information system
OBSP Features – Average Risk
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OBSP Features – High Risk
• Referral needed
• https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=285487
• Patient navigator
• If appropriate, referral to genetic assessment
• Screening breast MRI and mammogram
• Screening breast ultrasound if MRI contraindicated
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Mammography Accreditation Program
Canadian Association of Radiologists (CAR)set standards for:• Equipment
• Image quality
• Radiology staff skills and qualifications
100% of OBSP affiliated sites are CAR accredited.
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Diagnostic Assessment Program
• Single point of access for diagnostic services
• Coordinate patient care
• Help family physicians gain access to diagnostic tests and results in a timely manner 31
DAP Characteristics
• Patient-centered Improve access Provide support Timely diagnosis
• Coordinated referral and follow up
• Established and monitored quality indicators 32
Patient Navigator
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• Individual who guides each patient through the healthcare system
• Help patients to overcome barriers within the system
DAP Healthcare Benefits
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• Improve coordination of care
• Decrease wait times
• Improve patient experience
• Minimize disease progression
Breast Health Centre DAP
1. Provides navigation of abnormal follow up
2. Reduces wait times for diagnostic
assessment
3. Responds to client requests for information
4. Coordinates services and provides support
5. All of the above
What is the role of a Breast Health Centre?
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OBSP Resourceshttps://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=280490
https://www.cancercare.on.ca/pcs/screening/breastscreening/patient_education/
https://www.publications.serviceontario.ca/pubont/servlet/ecom/
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Clinical Case Study 1
• 42-year-old asymptomatic woman asks to be screened for breast cancer
• Her grandmother was diagnosed with breast cancer at age 65
What is your response?
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Clinical Case Study 2
• 39-year-old asymptomatic woman asks to be screened for breast cancer
• Her mother was diagnosed with breast cancer at age 37
What is your response?
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Clinical Case Study 3• Your 58-year-old average risk
asymptomatic patient in a small rural community asks about breast screening
• She wonders if she should take the longer trip to Community A where there is a new digital mammography unit; go to Community B, which is closer and has an analogue unit; or wait for the OBSP coach (with a digital unit) to come to town
What is your advice?
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Questions?
Thank You