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Spotlight on 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 5 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 SAR Dashboard 18 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 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 Colorectal Cancer Screening 24 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 25 Adenoma-Carcinoma Sequence • Majority of colorectal cancers arise from adenomatous polyps • Progression to invasive cancer takes 10 years on average 26 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 27 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 28 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 29 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% 30 ColonCancerCheck (CCC) Program Goals • Reduce mortality through an organized screening program • Improve capacity of primary care to participate in comprehensive colorectal cancer screening 31 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 32 CCC Program Features Patient correspondence includes: • FOBT result letters • Recall/reminder letters • Invitation letters to people aged 50 to 74 33 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 34 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 35 Overdue for CRC Screening 100 90 80 Overdue (%) 70 60 50 40 30 20 10 0 2008 2009 Year 2010 2011 36 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 37 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 38 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 39 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? 40 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? 41 CCC Resources For more information: www.cancercare.on.ca/pcresources 42 Call to Action! Screen Your Patients Screened Not Screened Breast 61% 39% Cervical 65% 35% Colorectal 30% 47% 43