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

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OBSP Non OBSP

Breast Cancer Screening Participation Rate, by LHIN

National target: ≥ 70%

Breast Cancer Screening Participation Rate, by LHIN

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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