Download 2013 Cancer Screening full presentation

Spotlight on
Breast, Cervical and
Colorectal Cancer Screening
Maximizing Benefits and Minimizing Harms
Faculty/Presenter Disclosure
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
2
Disclosure of Commercial
Support
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
3
Mitigating Potential Bias
Not applicable
4
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
Agenda Outline
1. 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 studies
6
Cancer Care Ontario
Vision and Mission 2012–2018
Our New Vision
Working together to create
the best health systems in
the world
Our New Mission
Together, we will improve the
performance of our health
systems by driving quality,
accountability, innovation,
and value
7
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
Access to Care
– Building on Ontario’s
Wait Times Strategy;
provides information
solutions that enable
improvements to access
Chronic Kidney Disease
– Ontario Renal Network
launched June 2009
8
CCO’s Screening Goal
VISION
Working together create the best cancer
system in the world
Increase patient
participation in
screening
Increase primary
care provider
performance in
screening
Establish a highquality, integrated
screening program
GOAL
Increase screening rates for breast, cervical and
colorectal cancers, and integrate into primary care
9
CS Strategic Framework
GOAL
Accelerate reduction in cancer mortality by implementing a
coordinated, organized cancer screening program across Ontario
STRATEGIC DIRECTIONS
Deliver
patientcentred
care
Enhance
coordination
and
collaboration
Improve
quality
Maximize
resources
and build
capacity
Promote
innovation
and
flexibility
Advance
clinical
engagement
10
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
11
Types of Screening
Population-Based
Screening
Opportunistic
Case-Finding
Offered systematically to all
individuals in defined target
group within a framework of
agreed policy, protocols,
quality management,
monitoring and evaluation
Offered to an individual
without symptoms of the
disease when he/she presents
to a healthcare provider for
reasons unrelated to that
disease
12
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
Cancer Type # New Cases
Breast
Cervical
Colorectal
# Deaths
9,300 (F)
1,950 (F)
61014 (F)
150 (F)
4,800 (M)
3,900 (F)
1,850 (M)
1,500(F)
14
CCO and Primary Care
RPCL
LHIN
13
RPCL
LHIN
14
RPCL
LHIN 1
RPCL
LHIN 2
RPCL
LHIN
12
RPCL
LHIN 3
Primary Care
Program
RPCL
LHIN
11
RPCL
LHIN 4
Provincial
Lead
RPCL
LHIN
10
RPCL
LHIN 5
RPCL
LHIN 9
RPCL
LHIN 6
RPCL
LHIN 8
RPCL
LHIN 7
15
Cancer Journey and
Primary Care
PRIMARY CARE
16
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
17
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 screeningrelated 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
18
SAR Dashboard
19
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 mind
20
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-treatment
21
Sensitivity and Specificity
Cancer
Site
Breast
Test
Sensitivity
Mammography 77% to 95%
Specificity
94% to 97%
Less sensitive in younger
women and those with dense
breasts
Breast
71% to 100%
81% to 97%
Studies conducted in
populations of women at high
risk for breast cancer
Studies conducted in populations
of women at high risk for breast
cancer
51% to 73%
90% to 100%
Cervical
gFOBT (repeat
testing)
Pap test
44% to 78%
91% to 96%
Cervical
HPV test
88% to 93% *
86% to 93%
Colorectal
MRI
* Sensitivityfor CIN II
22
Effectiveness of Screening
Cancer Site Effectiveness of Screening
Type of Studies
Breast
With mammography:
Randomized
21% reduction in mortality with
controlled trials
regular screening in 50 to 69-yearolds
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
23
Spotlight on
Breast Cancer Screening
24
Burden of Disease
• 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
• 1 in 9 Canadian women will develop breast cancer in their
lifetime
• 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
25
Screening Rates
• 61% of eligible Ontario women aged
50 to 74 years were screened for breast
cancer in 2010–2011
• 71% in OBSP, 29% outside of OBSP
• The national target is to increase
screening rates to ≥ 70% of the
eligible population
26
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
27
Screening Recommendations
Screening
Modality
Mammography
Canadian Task Force on
Preventive Health Care (2011)
•
•
•
•
MRI
•
•
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
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)
28
Screening Recommendations
Screening
Modality
Breast self
examination (BSE)
Canadian Task Force on Preventive
Health Care (2011)
Recommend not advising women to
routinely practice BSE
Clinical breast
examination (CBE)
Recommend not routinely
performing CBE alone or in
conjunction with mammography
29
Ontario Breast Screening
Program (OBSP)
• Province-wide organized breast cancer screening
program
• 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)
30
OBSP Eligibility Criteria
Average-risk screening:
• Women aged 50 to 74 years
• Asymptomatic
• No personal history of breast cancer
• No current breast implants
31
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 (see next slide)
32
OBSP Eligibility Criteria
High risk 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
33
OBSP Screening Intervals
• Average risk: biennial recall (every 2 years)
• Increased risk: annual (ongoing) recall, e.g.,
• High-risk pathology lesions
• Family history
• Increased risk: one-year (temporary) recall, e.g.,
• Breast density ≥ 75%
• Radiologist, referring MD, recommendation
• Client request
• High risk: annual recall
34
OBSP Features
• 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
35
OBSP Features
For women at high risk:
• Patient navigator
• If appropriate, referral to genetic
assessment
• Screening breast MRI and
mammogram
• Screening breast ultrasound if MRI
contraindicated
36
Mammography Accreditation
Program
Canadian Association of
Radiologists sets standards for:
• Equipment
• Image quality
• Radiology staff skills and
qualifications
100% of OBSP-affiliated sites are
accredited
37
Digital Mammography
The Digital Mammographic Imaging Screening Trial
(DMIST) found digital mammography more accurate in:
• Women < 50 years
• Women with radiographically dense breasts
• Pre-menopausal and peri-menopausal women
A study using OBSP data found:
• Digital radiography (DR) and screen film
mammography (SFM) have similar cancer detection
rates
• Computed radiography (CR) had lower cancer
detection rates than SFM
38
Breast Cancer Screening Participation
Rate, by LHIN
100
90
80
National target: ≥ 70%
70
60
50
40
30
20
10
0
OBSP
Non OBSP
39
Breast Cancer Screening Participation
Rate, by LHIN
100
90
80
70
60
50
40
30
20
10
0
National target: ≥ 70%
2004-2005
2006-2007
2008-2009
2010-2011
40
Breast Diagnostic Interval
National target: ≥ 90% for both categories
Diagnostic Interval (%)
100
80
60
40
20
0
2008
2009
2010
2011
Year
Without Biopsy Within 5 Weeks
With Biopsy Within 7 Weeks
41
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?
42
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?
43
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?
44
OBSP Resources
For more information:
www.cancercare.on.ca/obspresources
45
Spotlight on
Cervical Cancer Screening
46
Burden of Disease in Ontario
• Estimated 610 women will be diagnosed
and 150 will die of cervical cancer in
2013
• Up to 80,000 abnormal Pap tests require
assessment each year
• 4th most common cancer among women
under age 50
47
Cervical Abnormalities
Cancer
(0.015%)
Atypical
Glandular
Cells (0.1%)
Atypical Squamous
Cells: HSIL Cannot
be Excluded (0.1%)
High-Grade Squamous
Intraepithelial Lesion
(HSIL) (0.3%)
Low-Grade Squamous
Intraepithelial Lesion (2.1%)
Pre-cancer lesions/
Pap abnormalities: 80,000
Atypical Squamous Cells of
Undetermined Significance (2.3%)
Negative for Intraepithelial Lesion or
Malignancy (95.0%)
Women (aged 20–69) Eligible for Cervical Cancer
Screening
48
Ontario Screening Data
• 65% of women aged 20 to 69 screened
(2009 to 2011)
• Ontario Cancer Plan provincial target is
85% participation for cervical screening
• Of the 454 women diagnosed with invasive
cervical cancer in 2008, 60% were under/never-screened and 40% were screened
49
Cervical Cancer Causes
• Persistent infection with high risk (oncogenic) types of HPV
(human papillomavirus)
• HPV is commonly found in sexually active men and women
and transmitted through any skin to skin sexual contact
• Most HPV infections are transient; about 90% will clear within
2 years
• Pap tests detect cervical cell changes that are a result of HPV
infections
• Some abnormal Pap tests are also a reflection of premalignant
change
• Other co-factors (like smoking), that are not well-understood,
50
are also involved in oncogenesis
Cervical Cancer Natural History
51
HPV Vaccine
• Two vaccines—bivalent (Cervarix®) and
quadrivalent (Gardasil®)—prevent 2 high risk
HPV types that cause 70% of cervical cancers
• Injected in 3 doses over 6 months
• Provides best protection if received prior to
HPV exposure
• Natural infection does not reliably result in
immunity
• Does not replace regular cervical cancer
screening
52
Ontario HPV Vaccination
Program
• Publicly funded school-based
immunization program for grade 8 girls
• New catch-up program since September
2012 for girls in grades 9-12
• 59% uptake in grade 8 girls (2009/2010)
• More vaccine program information at
www.hpvontario.ca
53
Current Guidelines
• Clear evidence for primary HPV screening
with cytology triage, starting at age 30,
every 5 years
• Must implement within organized program
• Must be publicly funded
• Follow cytology-based guidelines during
transition to funded HPV screening
54
Comparison of
2005 and 2011Guidelines
Question
Initiation
Interval after
Negative Test
Cessation
2005 Guidelines
2011 Guidelines
Within 3 years of first vaginal sexual
activity with cytology (Pap test)
Age 21
Annual until 3 consecutive negative
cytology tests, then every 2 to 3 years
Every 3 years
Age 70 if adequate and negative
screening history in previous 10 years (≥
3 negative tests)
No change
Management guidelines for follow-up of abnormal cytology did not change
Guidelines summary: www.cancercare.on.ca/screenforlife
55
Screening Initiation
• Start at age 21 in sexually active women
Cervical cancer rare < 25 years and
extremely rare < 21 years
10 to 15 years to develop cervical
cancer
• Aligns with other jurisdictions
56
Harms of Screening Adolescents
• 90% will clear infection within 2 years
• High rates of low-grade mostly transient and
clinically inconsequential abnormalities
• Unnecessary anxiety from detection,
biopsies and treatment
• Treatment linked to possibility of adverse
future pregnancy outcomes
• No protective effect with screening
57
Screening Interval
• Cytology screening every 3 years
unless immunocompromised or
previously treated for dysplasia
• No incremental benefit of screening
more frequently than every 3 years
• Aligns with other jurisdictions
58
Screening Cessation
• Stop screening at age 70 if adequate and
negative screening history
Low incidence of cancer in women who
have been adequately screened
Potential discomfort of procedure
Difficulties visualizing squamocolumnar
junction
• Aligns with other jurisdictions
59
Follow-Up of
Abnormal Cytology
• Management based on current
screening result and screening history
• Refer to the Ontario Cervical
Screening Cytology Guidelines
Summary
www.cancercare.on.ca/screenforlife
60
60
Cervical Screening Participation Rate
100
90
Ontario Cancer Plan target 2010: 85%
80
70
60
50
40
30
20
10
0
2000-2002
2003-2005
2006-2008
2009-2011
61
Cervical Screening Participation
Rate, by Age
100
Ontario Cancer Plan target 2010: 85%
90
80
70
60
50
40
30
20
10
0
20-29
30-39
2000-2002
40-49
2003-2005
2006-2008
50-59
60-69
2009-2011
62
Cervical Screening Participation Rate,
by LHIN
100
Ontario Cancer Plan target 2010: 85%
90
80
70
60
50
40
30
20
10
0
2000-2002
2003-2005
2006-2008
2009-2011
63
Colposcopy Rate Following a HighGrade Abnormal Pap Test at 6 Months
100
90
80
70
60
50
40
30
20
10
0
2008
2009
2010
2011
64
Challenges
• Cervical cancer screening often linked to periodic
health exam, hormonal contraception and
bimanual exam
• Longer screening interval does not align with
physician/provider incentives
• Difficult for physicians/providers to track 3-year
screening interval
• Roll-out of program correspondence in 2013
(phased approach)
65
CCO Initiatives Underway
• Phased correspondence to women
starting in August 2013
Privacy notification
Result (normal, abnormal,
unsatisfactory) letters
Followed by recalls and invitations
66
Opportunities
• Updated guidelines reflect new evidence
• Increase awareness of balance between
benefits and potential harms of screening
• Reduce interventions in young women whose
abnormal Pap tests are due to transient and
inconsequential HPV infections
• Increase screening rates for under-/neverscreened groups
67
Opportunities
• Improve appropriate follow-up after
abnormal Pap test result
• Continue to encourage primary
prevention through HPV immunization
• CCO and Public Health Ontario
evaluating impact of primary and
secondary prevention of HPV-related
disease
68
Screening: Future State
• Clear evidence for primary HPV
screening
• Must be implemented within an
organized program
• HPV test must be publicly funded
• Updated cytology guidelines to bridge
transition
69
Future Considerations
• CCO working with ministry regarding
implementation of primary HPV screening
Public funding of HPV test
Family physician/primary care provider
education/information
Laboratories
Organization of colposcopy services
70
Clinical Case Study 1
• A 17-year-old old female sees you to
initiate birth control pill
• She started having unprotected
intercourse 2 months ago
Do you screen her for
cervical cancer?
71
Clinical Case Study 2
• A 69-year-old female had a normal Pap
test when she was 59 years old, an
abnormal test when she was 63 years old
and a normal Pap test most recently
when she was 66
At what age can she safely
stop screening?
72
Clinical Case Study 3
• A 35-year-old woman had an ASCUS
result on her recent Pap test
What is the appropriate
next step?
73
OCSP Resources
For more information:
www.cancercare.on.ca/pcresources
74
New: Ontario Cervical Screening
Mobile App!
• Guidelines and recommendations for
follow-up of abnormal cytology available
for free
• iPhone: search “Ontario cancer
screening” in Apple App Store
• Blackberry, Android or Windows 7, visit
https://screening.cancercare.on.ca
75
Spotlight on
Colorectal Cancer Screening
76
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
77
Adenoma-Carcinoma Sequence
• Majority of colorectal cancers arise
from adenomatous polyps
• Progression to invasive cancer takes
10 years on average
78
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
79
Recommended Screening
Average Risk: fecal occult blood test (FOBT)
• Biennial (every 2 years), aged 50 to 74
• Follow up abnormal FOBT with
colonoscopy
Increased 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
80
FOBT and Colonoscopy
• 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
81
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%
82
ColonCancerCheck (CCC)
Program Goals
• Reduce mortality through an organized
screening program
• Improve capacity of primary care to
participate in comprehensive colorectal
cancer screening
83
CCC Program Features
• 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
84
CCC Program Features
Patient correspondence includes:
• FOBT result letters
• Recall/reminder letters
• Invitation letters to people aged 50 to
74
85
Assessing Risk
Assess for colorectal
cancer (CRC) signs
and symptoms
Symptoms
(high risk of CRC)
No symptoms; 1 or more
1st degree relatives with
CRC
(increased risk of CRC)
Age 50 to74;
no symptoms; no
affected 1st degree
relatives
(average 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
86
FOBT Screening Participation Rate,
by LHIN
100
90
80
70
60
50
CCO program target 2010: 40%
40
30
20
10
0
2004-2005
2006-2007
2008-2009
2010-2011
87
Overdue for CRC Screening
100
90
80
Overdue (%)
70
60
50
40
30
20
10
0
2008
2009
Year
2010
2011
88
FOBT Abnormal Rate
Male
Abnormal FOBT result (%)
6
Female
5
4
3
2
1
0
50–74
50–54
55–59
60–64
65–69
70–74
Age group
89
Colonoscopy within 6 months (%)
Follow-up Colonoscopy After +FOBT
100
90
80
70
60
50
40
30
20
10
0
2008
2009
2010
2011
Year
90
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 history
91
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?
92
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?
93
CCC Resources
For more information:
www.cancercare.on.ca/pcresources
94
Call to Action!
Screen Your Patients
Screened
Not Screened
Breast
61%
39%
Cervical
65%
35%
Colorectal
30%
47%
95