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Guidelines for breast, cervical, and colorectal cancer screening FOR PRIMARY CARE PROVIDERS 09/09 to Cancer, “ When anit Comes ounce of prevention and screening is worth more than a pound of cure. ” Prepared for the Waterloo Wellington Regional Cancer Program by Red Door Wordsmithing RedDoorWordsmithing.ca Adapted with permission from Cancer Care Ontario's Spotlight on: Breast, Cervical and Colorectal Screening presentation. February 3, 2011. First printing June 2011. Screening • Evaluating screening procedures.............................................. 09 • Screening for breast, cervical, and colorectal cancer............... 11 Spotlight on breast cancer screening • Risk of getting breast cancer..................................................... 15 • Breast cancer screening data................................................... 15 • Ontario Breast Screening Program........................................... 16 • Challenges and opportunities.................................................... 17 • Clinical case study one............................................................. 17 • Clinical case study two.............................................................. 18 • Breast cancer screening recommendations.............................. 18 Table of contents Introduction................................................................................. 05 Cancer Care Ontario.................................................................. 06 • The role of primary care............................................................ 07 Spotlight on cervical cancer screening • Risk of getting cervical cancer.................................................. 23 (i) General risk....................................................................... 23 (ii) The role of HPV as a necessary precursor........................ 23 (iii)HPV Vaccination................................................................ 24 • Cervical cancer screening data................................................. 25 • Ontario Cervical Screening Program........................................ 26 • Challenges and opportunities.................................................... 26 • Clinical case study one............................................................. 27 • Clinical case study two.............................................................. 28 • Clinical case study three........................................................... 28 • Cervical cancer screening recommendations........................... 29 Spotlight on colorectal cancer screening • Risk of getting colorectal cancer (i) General risk........................................................................ 35 (ii)Adenoma-carcinoma sequence......................................... 35 (iii)The significance of colorectal cancer location (subsite)..... 35 • Colorectal cancer screening data.............................................. 36 • ColonCancerCheck................................................................... 37 • Challenges and opportunities.................................................... 38 • Clinical case study one............................................................. 38 • Clinical case study two.............................................................. 39 • Colorectal cancer screening recommendations........................ 39 3 Introduction Introduction "To practice primary care well, we need to be experts in managing complexity.” I heard a colleague say this recently, and remarked on how true it is. Our patients come to us with many different issues, often with multifactorial causes. These issues need to be managed in the context of our patients' other illnesses, their world views on medicine and healing, and socioeconomic considerations such as whether they can afford or be motivated to consider a particular treatment. We have some help managing this complexity. For some time there have been excellent reference handbooks available on infectious disease protocols, immunization evidence, and multiple other areas of family medicine. At the Waterloo Wellington Regional Cancer Program, we decided it was time to add one further handbook. This one is an effort to assist you by reducing the complexity surrounding screening for cancer. We know that screening saves lives. We know that when some cancers are caught early in the disease process, the outcome is dramatically altered. Treatment is simpler, and more effective. Screening is an essential part of every primary care practice, and should be carried out in a systematic way. Nonetheless, cancer screening is not straightforward. It does not offer certainty. There are false positives, and false negatives. Evidence continues to accumulate and shift, regarding which screening method is most appropriate, for which age group, under which circumstances. This handbook is a best effort to collate and interpret the standards of care for cancer screening, as they now stand. There are clear standards for breast, cervical, and colorectal cancer nad so we're presenting those in this booklet. It is an evidence-based approach, taking latest statistics, research, and policy from Cancer Care Ontario and around the world. We hope it helps to make your job simpler, and helps to make you a more effective clinician. Sophie Wilson, MD, CCFP Regional Primary Care Lead Waterloo Wellington Regional Cancer Program 5 Cancer Care Ontario Cancer Care Ontario Cancer Care Ontario (CCO) is the provincial government’s cancer advisor. CCO is the agency responsible for continually improving services to ensure that patients receive the right care, at the right time, from the right person, in the right place, at every step of their journey with cancer. CCO’s Ontario Cancer Plan III outlines steps to provide Ontarians with the best cancer prevention, screening, and care. This plan is structured around six goals spanning the full range of cancer care: 1. Help Ontarians lessen their risk of developing cancer. 2. Reduce the impact of cancer through effective screening and earlier detection. 3. Ensure timely access to effective diagnosis and safe, high-quality care. 4. Improve the patient experience along every step of the cancer journey. 5. Improve the performance of Ontario’s cancer system. 6. Strengthen Ontario’s ability to improve cancer control through research. CCO developed its Integrated Cancer Screening (ICS) strategy to facilitate the delivery of consistent and coordinated screening to primary care givers and patients. The key elements of the ICS strategy are outlined below: 1. Increase patient participation in screening • patient invitations and reminders • patient supports and health-risk assessments • targeted community-based outreach programs 2. Increase primary care provider performance in screening • screening prompts and exception reports • feedback on screening performance and change management • change management tools and training 6 3. Establish a high-quality integrated screening strategy • information management and information technology infrastructure • system performance monitoring and evaluation • quality standards The role of primary care The pivotal role of primary care in reducing the incidence of cancer and improving cancer care across the cancer continuum is widely recognized.1,2 The role of primary care The CCO has three distinct screening programs: the Ontario Breast Screening Program, the Ontario Cervical Screening Program, and ColonCancerCheck. The ICS strategy, together with these three screening programs, reflects CCO’s commitment to reduce the impact of breast, cervical, and colorectal cancers by facilitating effective screening and earlier detection. CCO created the Primary Care and Cancer Engagement Strategy in 2008. Under this program, primary care leads are recruited from each of CCO’s regional cancer programs across the province. These leads give primary care providers a voice in the cancer care system and the cancer care system a closer connection to primary care providers. Reducing the impact of cancer through effective screening and earlier detection is one of CCO’s key goals. Primary care providers oversee and influence the health and well-being of a significant portion of Ontario’s population. They can play an important role in screening intervention by: •systematically conducting patient risk assessments and recommending appropriate screening based on evidence, guidelines, and patient history •managing the follow-up of abnormal screening test results Research shows that decisions to screen are strongly associated with recommendations from trusted primary care providers.3,4 7 The Role of Primary Care 8 Primary care references 1. Blackwell DL, Martinez ME, Gentleman JF. Women's compliance with public health guidelines for mammograms and Pap tests in Canada and the United States: an analysis of data from the Joint Canada/United States Survey of Health. Women's Health Issues. 2008 Mar;18(2):85-99. 2. Poole B, Black C, Gelmon K, Kan L. Is Canadian women's breast cancer screening behaviour associated with having a family doctor? Can Fam Physician. 2010 Apr;56(4):e150-7. 3. Zarychanski R, Chen Y, Bernstein CN, Hébert PC. Frequency of colorectal cancer screening and the impact of family physicians on screening behaviour. CMAJ. 2007 Sep 11;177(6):593-7. 4. Zajac IT, Whibley AH, Cole SR, Byrne D, Guy J, Morcom J, et al. Endorsement by the primary care practitioner consistently improves participation in screening for colorectal cancer: a longitudinal analysis. J Med Screen. 2010;17(1):19-24. Evaluating screening procedures Screening Screening “Screening” refers to the application of tests, examinations, or other procedures to asymptomatic target populations in order to distinguish between those who may have a disease and those who probably do not.1 In 1968, the World Health Organization published the following guidelines outlining the principles of screening: 1. The condition should be an important health problem. 2. There should be a treatment for the condition. 3. Facilities for diagnosis and treatment should be available. 4. There should be a latent stage of the disease. 5. There should be a test or examination for the condition. 6. The test should be acceptable to the population. 7. The natural history of the disease should be adequately understood. 8. There should be an agreed policy on whom to treat. 9. The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole. 10. Case-finding should be a continuous process, not just a "once and for all" project.2 Screening can be employed through either population-based methods or case-finding methods: •Population-based screening occurs when a test is offered systematically to all individuals in the defined target group within a framework of agreed upon policy, protocols, quality management, monitoring, and evaluation. •Case-finding screening is more opportunistic and occurs when a test is offered to individuals without symptoms of the disease who present to a primary care giver for reasons unrelated to that disease. It is important to assess the potential harms and benefits when determining whether to screen. Just finding disease is not enough. If finding disease earlier does not positively affect the ultimate outcome (mortality, morbidity, or quality of life) then screening may be more harmful than beneficial. Harmful out- 9 Screening comes include over-treatment, anxiety about screening tests, the occurrence of false positive and false negative test results, and complications from diagnostic investigation and treatment.3,4 The U.S. Preventive Services Task Force (USPSTF) uses the following grade definitions to assess the balance between the benefits and risks of treatment and screening5: Grade Suggestions to Practice A The USPSTF recommends the service. There is high certainty that the net benefit is substantial. Offer or provide this service. B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Offer or provide this service. C The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small. Offer or provide this service only if other considerations support offering or providing the service in an individual patient. D The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Discourage the use of this service. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Read the clinical considerations section of the USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms. I Statement 10 Definition •Sensitivity refers to the proportion of people with disease who have a positive test result as an outcome of the screening. •Specificity refers to the proportion of people without disease who have a negative test result as an outcome of the screening. Screening It is also important to examine the accuracy of screening tests to look at how well they perform. Screening tests must demonstrate acceptable levels of sensitivity and specificity: Test characteristics of sensitivity and specificity do not prove that a screening test is efficacious. This must be shown by a demonstrated reduction in the risk of dying from the cancer with screening. Assessing the benefit of a screening test is based on what the USPSTF considers the highest level of evidence — a randomized controlled trial. Submitting a screening test to rigorous randomized controlled trials is the best way to determine whether that test will make a positive contribution to a populations’ health. Screening for breast, cervical, and colorectal cancer The USPSTF and CCO’s Program in Evidence-Based Care (PEBC) have assessed the sensitivity and specificity of screening tests used in breast, cervical, and colorectal cancer screening: Test Mammography6 Sensitivity Specificity (Proportion of people with disease who have a positive test result as an outcome of the screening.) (Proportion of people without disease who have a negative test result as an outcome of the screening.) 77 to 95 per cent 94 to 97 per cent Less sensitive in younger women and those with dense breasts Clinical breast exam6 40 to 69 per cent 88 to 99 per cent Pap: Liquid-Based Cytology7 53 to 96 per cent 45 to 100 per cent Pap: Conventional Cytology7 35 to 94 per cent 17 to 100 per cent gFOBT8 51 to 97 per cent 90 to 100 per cent 11 Screening Note the similarity in sensitivity between the liquid-based cytology Pap and the FOBT. Yet there is much better uptake of liquid-based cytology Pap as a screening test. The following table highlights the burden of disease for breast, cervical, and colorectal cancer in Ontario in 20109: Cancer Type Number of new cases Number of deaths Breast 8,900 (F) 2,100 (F) Cervix 490 (F) 140 (F) Colorectal 4,500 (M) 3,800 (F) 1,850 (M) 1,550 (F) Cervical cancer historically had the highest mortality rate among these three cancers. This has changed dramatically in the developed world since the introduction of Pap tests. 12 Screening The Ontario Breast Screening Program, the Ontario Cervical Screening Program, and ColonCancerCheck are saving lives in Ontario. However, screening rates for breast and cervical cancer have stalled and, although screening rates for colorectal screening are gaining some momentum, they are not reaching provincial targets. New approaches are needed to increase the number of Ontarians participating in regular screening. Specific outreach approaches need to be developed to better engage under-screened populations. These include First Nation, Metis, Inuit, and other aboriginal populations; new immigrants; and low-income groups. The effectiveness and corresponding evidence of screening can be seen in the following chart: Cancer site Effectiveness of screening Breast Mammography: 25 per cent reduction in mortality with regular screening in 50 to 69 year olds Randomized controlled trials10 Pap + colposcopy for abnormal results: Incidence reduced by up to 80 per cent with regular screening Global incidence data11 FOBT + colonoscopy for positive results: 16 per cent reduction in mortality with regular screening and 20 per cent reduction in incidence with regular screening Randomized controlled trials12,13 Cervical Colorectal Type of studies providing evidence 13 Screening Screening references 1. Commission on Chronic Illness. Chronic illness in the United States. Vol I. Prevention of chronic illness. Cambridge (MA): Harvard University Press; 1957. 2. Wilson JM, Jungner G. Principles and practice of screening for disease. Geneva: World Health Organization; 1968. 3. Trevena L. Cancer screening - pros, cons, choice, and the patient. Aust Fam Physician. 2009 Apr;38(4):188-92. 4. Public Health Agency of Canada. Information on mammography for women aged 40 and older: a decision aid for breast cancer screening in Canada. Ottawa: Chronic Disease Management Division, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada; 2009. 5. US Preventive Services Task Force. Grade definitions [Internet]. Rockville (MD): USPSTF; 2008 [cited 2011 Mar 24]. Available from: http://www.uspreventiveservicestaskforce.org/uspstf/grades.htm 6. Nelson HD, Tyne K, Naik A, Bougatsos C, Chan BK, Humphrey L. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med. 2009 Nov 17;151(10):727-37, W237-42. 7. McLachlin C, Mai V, Murphy J, Fung Kee Fung M, Chambers A, and members of the Cervical Screening Guidelines Development Committee of the Ontario Cervical Screening Program and the Gynecology Cancer Disease Site Group of Cancer Care Ontario. Cervical screening: a clinical practice guideline [Internet]. Toronto: Program in Evidence-Based Care, Cancer Care Ontario; 2005 May 20 [cited 2011 Mar 25]. Available from: http://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=14278 8. Rabeneck L, Zwaal C, Goodman JH, Mai V, Zamkanei M. Cancer Care Ontario guaiac fecal occult blood test (FOBT) laboratory standards: evidentiary base and recommendations. Clin Biochem. 2008 Nov;41(16-17):1289-305. 9. Canadian Cancer Society’s Steering Committee. Canadian cancer statistics 2010 [Internet]. Toronto: Canadian Cancer Society; 2010 [cited 2011 Mar 24]. Available from: http://www.cancer.ca/Canada-wide/About%20cancer/ Cancer%20statistics/~/media/CCS/Canada%20wide/Files%20List/English%20files%20heading/pdf%20not%20in%20publications%20section/Canadian20Cancer20Statistics2020102020English.ashx 10. World Health Organization, International Agency for Research on Cancer. Breast cancer screening. IARC handbooks of cancer prevention, volume 7. Lyon, FR: IARC Press; 2002. 11. World Health Organization, International Agency for Research on Cancer. World cancer report 2008. Boyle P, Levin B, editors. Lyon, FR: IARC Press; 2008. 12. Hewitson P, Glasziou P, Watson E, Towler B, Irwig L. Cochrane systematic review of colorectal cancer screening using the fecal occult blood test (Hemoccult): an update. Am J Gastroenterol. 2008;103(6):1541-9. 14 13. Pignone M, Rich M, Teutsch SM, Berg AO, Lohr KN. Screening for colorectal cancer in adults at average risk: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002 Jul 16;137(2):132-41. Risk of getting breast cancer One in nine Canadian women will develop breast cancer in her lifetime.1 As women get older, their risk of getting breast cancer increases. In Canada, 80 per cent of breast cancers are found in women over age 50 and 50 per cent of breast cancers occur in women aged 50 to 69.1 Women with a first-degree relative (mother, sister, or daughter) who has had breast cancer are at a higher risk of developing the disease. Nearly four per cent of women who are free from breast cancer at age 20 and who have one first-degree relative with breast cancer will develop the disease by the age of 50 compared to two per cent of those with no such family history.2 It is important to put the family history risk into perspective. Most women who develop breast cancer do not have a family history of the disease. About three per cent of women who develop breast cancer have one or more first-degree relatives with breast cancer, while only one per cent have two or more first-degree relatives with the disease.1 Spotlight on breast cancer screening Spotlight on breast cancer screening Women aged 50 to 69 who have a breast density of 75 per cent or greater, documented pathology of a high-risk lesion, or personal history of ovarian cancer are also considered to be at a higher risk of developing breast cancer. Breast cancer screening data Approximately 66 per cent of Ontario women aged 50 to 69 years were screened for breast cancer in 2007/2008. The provincial target is to increase screening rates to 70 per cent of the target population by 2011/2012. In 2002, the International Agency for Research on Cancer reported that regular breast cancer screening with mammography in 50 to 69 year olds achieved an average mortality reduction of 25 per cent.3 15 Spotlight on breast cancer screening Ontario Breast Screening Program Two thirds of Ontario women screened for breast cancer in 2007/2008 were screened within the Ontario Breast Screening Program (OBSP). The OBSP is a province-wide organized screening program that ensures asymptomatic Ontario women aged 50 and over receive the benefits of regular mammography screening. This program is a significant contributor to earlier detection of cancer and better health outcomes. Women aged 50 to 69 with an average risk of breast cancer are screened biennially. Women aged 50 to 69 who have a breast density of 75 per cent or greater, documented pathology of a high-risk lesion, personal history of ovarian cancer, or significant family history of breast cancer are considered to be at higher risk and may be screened annually. OBSP features a variety of services, including: • two-view mammography • automatic client recall • quality assurance for all components • monitoring of follow-up and outcomes of clients • program evaluation • a comprehensive information system • primary care provider referral or self-referral • provision of result letters to women and their primary care provider, ensuring abnormal results go to the primary care provider first • automatic booking of required diagnostic tests with primary care provider authorization • generation of performance statistics for all practitioners — including radiologists, primary care providers, and affiliate sites The Canadian Association of Radiologists Mammogram Accreditation Program (CAR-MAP) has developed accreditation standards for mammography, including: equipment, image quality, and the skills and qualifications of radiology staff. In Ontario, there are approximately 300 mammography screening facilities. As of April 1, 2011, there were 152 OBSP sites. All OBSP sites are CAR-MAP accredited. 16 1.Recent data indicates that screening rates for breast cancer have stalled. Among the target population of women aged 50 to 69, screening rates were lowest in the 50 to 54 year age group. The provincial target is to increase screening rates to 70 per cent of the target population by 2011/2012. 2.It is necessary to better understand under-screened population groups and the needs of ethno-cultural groups. Different approaches may be required to engage these hard-to-reach groups. 3.There is controversy around screening women aged 40 to 49. CCO does not support population-based screening or widespread promotion of screening to women aged 40 to 49 for the following reasons: • The evidence of mortality benefit from routine mammography for women aged 40 to 49 is not as strong as for women aged 50 to 69.4 •The potential harms of screening mammography for women aged 40 to 49 may outweigh the benefits.5 Spotlight on breast cancer screening Challenges and opportunities CCO recommends that women aged 40 to 49 talk to their health care provider to make a personal decision about mammography. Clinical case study one A 42-year-old asymptomatic woman asks to be screened for breast cancer. Her grandmother was diagnosed with breast cancer at the age of 65. What is your response? Answer: Explain that evidence shows she is not at increased risk because a grandmother is not a first-degree relative. In addition, evidence shows that the harms of screening may outweigh the benefits for women in their forties. Explain the role of healthy lifestyle choices in the prevention of breast cancer and suggest the patient wait until she is aged 50 to begin screening. 17 Spotlight on breast cancer screening Clinical case study two A 58-year-old average-risk asymptomatic patient in Erin asks if she should go for breast screening. Her options include: • travelling to the Waterloo Wellington Breast Centre (Grand River Hospital Freeport Site) to a new digital mammography unit • travelling to Guelph, which is closer, to a regular mammography unit What is your response? Answer: Overall, the diagnostic accuracy of digital and film mammography as a means of screening for breast cancer is similar.6 Explain the role of healthy lifestyle choices in the prevention of breast cancer and advise the patient to get screening at the most convenient location for her. Breast cancer screening recommendations There are four well-known screening methods for breast cancer: 18 1. B reast self-examination (BSE): BSE has recently been shown to cause many false alarms and does not make a significant difference in health outcomes. Recent evidence-based reviews do not recommend BSE.7,8 It is recommended that women of all ages learn what is normal for their breasts and immediately report any changes to their health care provider. 2. C linical breast examination (CBE): Overall, there is insufficient evidence of the effectiveness of CBE, with or without mammography, in reducing mortality from breast cancer. CBE has higher falsepositive results and low positive predictive value compared to mammography. This may lead to unnecessary visits, imaging, biopsies, and increased patient anxiety. A study by Chiarelli et al (2009) found that among OBSP centres offering both CBE and mammography, cancer detection rates and sensitivity were higher, as were referral rates and false-positive rates, compared to centres offering only mammography. Among centres offering both CBE and mammography, for each additional cancer detected by CBE per 10,000 women screened, there were an additional 55 false-positive results. 7,9-15 M ammography: Evidence has found that mammography screening reduces mortality by 25 per cent. For this reason, mammography is the best way to find breast cancer early in women aged 50 and older. Mammography is the only imaging modality that has been licensed by Health Canada for breast cancer screening of the general population. Overall, the diagnostic accuracy of digital and regular film mammography as a means of screening for breast cancer is similar. Digital mammography is more effective for women who are under the age of 50; who are premenopausal or perimenopausal; or who have radiographically dense breasts.8 Digital mammography also offers the added benefits of electronic data storage and ease of transmission. 4. M RI: MRI in addition to mammography has been shown to be effective for very high-risk women.16 Spotlight on breast cancer screening 3. 19 Spotlight on breast cancer screening 20 Patient characteristics Mammography screening recommendations Average-risk women under 40 Screening not recommended. Average-risk women aged 40 to 49 Current evidence does not support including or excluding mammography for average-risk women aged 40 to 49. On reaching the age of 40, averagerisk women should be informed of the potential benefits and risks of screening mammography to make a personal decision on when to initiate screening. When screening does take place, digital mammography may be most effective for women under the age of 50. Average-risk women aged 50 to 69 There is good evidence for screening average-risk women aged 50 to 69 with mammography. The best available data support screening every two years. Average-risk women aged 75 + Clinicians should help patients assess and understand the low benefit of mammography in this age group. Ultimately the decision to screen will be a personal decision for each woman. Women with radiographically dense breasts, premenopausal, and perimenopausal women Digital mammography is more effective than regular mammography for women with these characteristics. Very high-risk women, such as women with a BRCA1 or BRCA2 gene Consider MRI screening in addition to mammography. Further guidelines are pending to clarify who qualifies and with what frequency. For more information visit: http://www.cancercare.on.ca/pcs/screening/breastscreening/resources/ Spotlight on breast cancer screening Further information Breast cancer references 1.Canadian Cancer Society’s Steering Committee. Canadian cancer statistics 2009 [Internet]. Toronto: Canadian Cancer Society; 2009 [cited 2011 Mar 24]. Available from: http://www.cancer.ca/Canada-wide/About%20 cancer/Cancer%20statistics/~/media/CCS/Canada%20wide/Files%20List/ English%20files%20heading/pdf%20not%20in%20publications%20section/ Stats%202009E%20Cdn%20Cancer.ashx 2.Cancer Care Ontario. Influence of family history and genetics on breast cancer risk. Ontario cancer facts [Internet]. Toronto: Cancer Care Ontario; 2008 May [cited 2011 Mar 25]. Available from: http://www.cancercare.on.ca/ common/pages/UserFile.aspx?fileId=11116 3.World Health Organization, International Agency for Research on Cancer. Breast cancer screening. IARC handbooks of cancer prevention, volume 7. Lyon, FR: IARC Press; 2002. 4. Medical Advisory Secretariat. Screening mammography for women aged 40 to 49 years at average risk for breast cancer: an evidence-based analysis. Ontario Health Technology Assessment Series [Internet]. Toronto: Ministry of Health and Long-Term Care; 2007 Jan [cited 2011 Mar 24]. Available from: http://www.health.gov.on.ca/english/providers/program/mas/tech/reviews/pdf/ rev_mammo_010107.pdf 21 Spotlight on breast cancer screening 5.Armstrong K, Moye E, Williams S, Berlin JA, Reynolds EE. Screening mammography in women 40 to 49 years of age: a systematic review for the American College of Physicians. Ann Intern Med. 2007 Apr 3;146(7):516-26. 6.Pisano ED, Gatsonis C, Hendrick E, Yaffe M, Baum JK, Acharyya S, et al. Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med. 2005 Oct 27;353(17):1773-83. 7.Nelson HD, Tyne K, Naik A, Bougatsos C, Chan BK, Humphrey L. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med. 2009 Nov 17;151(10):727-37, W237-42. 8.Baxter N, Canadian Task Force on Preventive Health Care. Preventive health care, 2001 update: should women be routinely taught breast self-examination to screen for breast cancer? CMAJ. 2001 Jun 26;164(13):1837-46. 9.Miller AB, To T, Baines CJ, Wall C. Canadian National Breast Screening Study-2: 13-year results of a randomized trial in women aged 50-59 years. J Natl Cancer Inst. 2000;92:1490-9. 10.Smith, R, Saslow D, Sawyer K, et al. American Cancer Society Guidelines for Breast Cancer Screening: Update 2003. A Cancer Journal for Clinicians. 2003;53:141-169. 11.International Agency for Research on Cancer, World Health Organization. IARC Handbooks of Cancer Prevention: Breast Cancer Screening. IARC Press; 2002. 12.Oestreicher N, Lehman C, Seger D, Buist D, White E. The incremental contribution of clinical breast examination to invasive cancer detection in a mammography screening program. American J Roentgenol. 2005;184(2):428-432. 13.Bancej C, Decker K, Chiarelli A, Harrison M, Turner D, Brisson J. Contribution of clinical breast examination to mammography screening in the early detection of breast cancer. J Med Screen. 2003;10(1):16-21. 14.Kösters JP, Gøtzsche PC. Regular self-examination or clinical examination for early detection of breast cancer. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD003373. DOI: 10.1002/14651858. CD003373. 15.Chiarelli AM, Majpruz V, Brown P, Thériault M, Shumak R, Mai V. The Contribution of Clinical Breast Examination to the Accuracy of Breast Screening. J Natl Cancer Inst. 2009 Sep 16;101:1236–1243. 16.Warner E, Messersmith H, Causer P, Eisen A, Shumak R, Plewes D. Magenetic resonance imaging screening of women at high risk for breast cancer: a clinical practice guideline [Internet]. Toronto: Program in Evidence-Based Care, Cancer Care Ontario; 2007 Apr 12 [cited 2011 Mar 25]. Available from: http://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=37147 22 Risk of getting cervical cancer i) General risk: Each year in Ontario, there are up to 90,000 abnormal Pap tests and approximately 500 women are diagnosed with cancer of the cervix. Approximately 150 women in Ontario die from this disease every year.1 Approximately 37 per cent of invasive cervical cancers occur in women who have never been screened.2 The median age at diagnosis is 47 years and the median age at death is 60 years.3 The incidence of cervical cancer is low for women under 25 years of age.4,5 (ii) The role of HPV as a necessary precursor Human Papillomavirus (HPV) is an extremely common virus usually spread through sexual activity. There are over 120 types of HPV.6 Infection with certain types of HPV is a necessary, although not sufficient, cause of cervical cancer.7,8 Spotlight on cervical cancer screening Spotlight on cervical cancer screening There are more than 15,000 new cases of HPV infection in Ontario each year on average7. HPV is found in both men and women. The infection usually goes away on its own, but women are less likely to clear HPV infections as they get older.9 There is minimal risk of significant lesions within three to five years of first HPV contact and abnormalities in young women usually regress.10 Up to 80 per cent of women will acquire an HPV infection in their lifetime.10-12 The risk of oncogenic HPV infection is high after the first sexual encounter (i.e., with or without intercourse involving skin-to-skin contact), and continues throughout a woman’s sexually active lifetime.13 Three years after her first sexual encounter, a woman with one sexual partner faces a 46 per cent risk of acquiring a cervical HPV infection.13 Cervical cancer and its precursors are caused by persistent infection with high-risk forms of HPV, especially type 16 and 18. A number of behaviours or exposures act as co-factors among women infected with high-risk HPV, increasing the likelihood that cervical cancer will develop. These include smoking, high parity, long-term use of hormonal contraception, and exposure to other sexually transmitted diseases, including 23 Spotlight on cervical cancer screening herpes simplex virus type 2 [HSV-2], Chlamydia trachomatis, or human immunodeficiency virus (HIV).14-17 (iii) HPV Vaccination Health Canada has authorized two types of HPV vaccines that can block HPV infections before they occur: • G ardasil® is a quadrivalent vaccine that protects against infection from high-risk HPV types 16 and 18 (which cause approximately 70 per cent of cervical cancers18), and low-risk types 6 and 11 (which cause approximately 90 per cent of ano-genital warts7). In Canada it has been approved for use with females and males aged nine to 26. • C ervarix® is a bivalent vaccine that protects against high-risk HPV types 16 and 18 only. In Canada it has been approved for use with females aged 10 to 25. The vaccines are given as intramuscular injections in the arm in three doses (at 0, 2, and 6 months for Gardasil® and at 0, 1, and 6 months for Cervarix®). The duration of protection is unknown (evidence suggests protection for up to six years).6 Both vaccines also appear to be very effective in preventing changes in the cells of the cervix related to their targeted HPV types.19,20 Studies have found both Gardasil® and Cervarix® to be safe. These vaccines contain only particles from the HPV virus and do not contain antibiotics or preservatives such as thimerosal and mercury. Other than some soreness around the injection site, there have been few side effects reported. The National Advisory Committee on Immunization (NACI) recommends the use of Gardasil® for: 24 • females, prior to sexual intercourse, between nine and 13 years of age • females, even after they are sexually active, who have had previous Pap abnormalities, or have had a previous HPV infection, between the ages of 14 and 26 years of age Ontario’s HPV vaccination program recognizes that vaccination offers the best protection against cervical cancer if it is received prior to HPV exposure. Since 2007, the government has provided publicly-funded voluntary school-based immunization programs for Grade 8 girls. It is important to note that these vaccines do not protect against all cancer-causing HPV strains and should not replace regular cervical cancer screening with Pap tests. More information on Ontario’s HPV program can be found at www.hpvontario.ca. Cervical cancer screening data Between 2006 and 2008, 72 per cent of Ontario women aged 20-69 were screened. Spotlight on cervical cancer screening The NACI does not recommend Gardasil® for females under the age of nine, pregnant women, or males. These recommendations are currently under review. The provincial target is to increase screening rates to 85 per cent by 2011/2012. In 2008, the World Cancer Report stated that regular cervical screening has been shown to reduce cervical cancer incidence by up to 80 per cent.21 25 Spotlight on cervical cancer screening Ontario Cervical Screening Program Pap test screening is well integrated into primary care. CCO, in partnership with the Ministry of Health and Long-Term Care, is building on existing services and enhancing information systems to ensure a coordinated approach to: • education and communication • recruitment • provincial cervical screening information systems • recall and follow-up • quality assurance and improvement • evaluation and research The 2005 Ontario cervical screening guidelines recommend that cervical cancer screening should be initiated within three years of first vaginal sexual activity.22 After three consecutive annual normal Pap tests, screening should continue every two to three years. Screening may be discontinued after the age of 70 if there is an adequate negative screening history in the previous 10 years (i.e., three or more negative tests). The OCSP targets women aged 20 to 69 to participate in regular screening, but younger and older women are also screened, where appropriate, and in alignment with Ontario’s cervical screening guidelines. Aggressive follow-up of young women with abnormal screening results is not encouraged and may be harmful. Research shows 90 per cent of young women will clear an HPV infection within 24 months.23-27 Challenges and opportunities 26 1.Recent data indicates that screening rates for cervical cancer have stalled. The provincial target is to increase screening rates to 85 per cent by 2011/2012. 2.Some women are never, or rarely, screened for cervical cancer. Under-screened women include women over 50 years old and women who have low literacy levels; low income levels; belong to First Nations, Metis, Inuit, and other aboriginal groups; or are newcomers to Canada.28,29 3.There is a need for better Pap test follow-up. A 2010 study found that 26 per cent of women with serious cervical lesions did not receive any follow-up management Paps.30 4.HPV testing is not currently funded, but evidence increasingly recommends its use. 5.It is important to note that HPV vaccination is not a substitute for cervical cancer screening. Even if vaccinated, women still need regular screening tests because the vaccine does not protect against all cancer-causing HPV strains. 6.It is not known how vaccination programs will affect screening programs. 7.With regular Pap tests and the HPV vaccine, it is possible to prevent cervical cancer. Spotlight on cervical cancer screening Clinical case study one A 17-year-old girl sees you to initiate the birth control pill. She started having unprotected intercourse two months ago. Do you do a Pap test? Answer: You may want to confirm when she became sexually active (i.e., with or without intercourse involving skin-to-skin contact). You do not need to do a Pap test at this time if the length of potential exposure to HPV is short. A Pap test should be done within three years of initiation of sexual activity according to the current clinical guidelines. Explain the role of healthy lifestyle choices in the prevention of cervical cancer. 27 Spotlight on cervical cancer screening Clinical case study two A 35-year-old woman has had two normal annual Pap tests. What would your advice be to her regarding future cervical screening? Answer: Explain to the patient that the current guidelines call for three consecutive normal annual Pap tests. Thereafter, screening can be done every two to three years. Explain the role of healthy lifestyle choices in the prevention of cervical cancer. Clinical case study three A 47-year-old woman is seen for her annual physical. She had a total hysterectomy two years ago for benign uterine fibroids. Do you do a Pap test? Answer: As long as you know her cervix was removed, there is no need to do a Pap test. Guidelines advise to discontinue cervical screening in women who have undergone a total hysterectomy for benign causes. 28 All women who are or have ever been sexually active should be screened. Screening should be initiated within three years of first vaginal sexual activity. Aggressive follow-up of young women with abnormal screening results may be harmful. Research shows 90 per cent of young women will clear an HPV infection within 24 months. Thus, it may be unnecessary to treat these young women aggressively when most will be able to clear the HPV infection on their own if given enough time (i.e., abnormal cervical cells may change back to normal).23-27 In addition, there is evidence that screening young women and then treating those with cervical dysplasia is linked to adverse future pregnancy outcomes (e.g., preterm delivery, low birth weight). Thus, high colposcopy rates in this age cohort may be associated with future harm. The risk of developing and dying of cervical cancer increases with age. The colposcopy follow-up rates for older women need to dramatically increase in order for older women to optimally benefit from cervical cancer screening.23-27 Spotlight on cervical cancer screening Cervical cancer screening recommendations 29 Spotlight on cervical cancer screening It is recommended that women of average risk be screened annually until there are three consecutive negative Pap tests and then continue to be screened every two to three years. The following chart outlines Pap screening recommendations for cervical cancer: Patient characteristics Pap screening recommendations Average-risk women with no previous abnormal Pap including women with subtotal hysterectomy (with an intact cervix), pregnant women, and women who have sex with women Screen annually until three consecutive negative Paps and then continue to screen every two to three years. Women who are immunocompromised (e.g., have received transplants, HIV positive) Screen annually. Women who have undergone total hysterectomy for benign causes with no history of cervical dysplasia Discontinue screening. Women over age 70 Discontinue screening if there has been an adequate negative screening history in the previous 10 years (i.e., three or more consecutive negative tests). Further information For more information visit: http://www.cancercare.on.ca/pcs/screening/cervscreening/hcpresources/ 30 1.Canadian Cancer Society’s Steering Committee. Canadian cancer statistics 2010 [Internet]. Toronto: Canadian Cancer Society; 2010 [cited 2011 Mar 24]. Available from: http://www.cancer.ca/Canada-wide/About%20cancer/ Cancer%20statistics/~/media/CCS/Canada%20wide/Files%20List/English%20files%20heading/pdf%20not%20in%20publications%20section/ Canadian20Cancer20Statistics2020102020English.ashx 2.Spence AR, Goggin P, Franco EL. Process of care failures in invasive cervical cancer: systematic review and meta-analysis. Prev Med. 2007 Sep;45(2-3):93-106. 3.Cancer Care Ontario. Insight on cancer: news and information on cervical cancer. Toronto: Canadian Cancer Society (Ontario Division); 2005. 4.Screening for squamous cervical cancer: duration of low risk after negative results of cervical cytology and its implication for screening policies. IARC Working Group on evaluation of cervical cancer screening programmes. Br Med J (Clin Res Ed). 1986 Sep 13;293(6548):659-664. 5.Sasieni P, Castanon A, Cuzick J. Effectiveness of cervical screening with age: population based case-control study of prospectively recorded data. BMJ. 2009;339:b2968. Spotlight on cervical cancer screening Cervical cancer references 6.Cancer Care Ontario. Perspectives on infectious agents and cancer. Toronto: Cancer Care Ontario; 2010. 7.Ontario Agency for Health Protection and Promotion. Ontario burden of infectious disease study. Toronto: OAHPP/ICES; 2010. 8.Walboomers JM, Jacobs MV, Manos MM, Bosch FX, Kummer JA, Shah KV, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol. 1999;189(1):12-9. 9.Castle PE, Schiffman M, Herrero R, Hildesheim A, Rodriguez AC, Bratti MC, et al. A prospective study of age trends in cervical human papillomavirus acquisition and persistence in Guanacaste, Costa Rica. J Infect Dis. 2005 Jun 1;191(11):1808-1816. 10.Brown DR, Shew ML, Qadadri B, Neptune N, Vargas M, Tu W, et al. A longitudinal study of genital human papillomavirus infection in a cohort of closely followed adolescent women. J Infect Dis. 2005;191(2):182-192. 11.Koutsky L. Epidemiology of genital human papillomavirus infection. Am J Med. 1997 May 5;102(5A):3-8. 12.Bosch FX, de Sanjosé S. Chapter 1: Human papillomavirus and cervical cancer--burden and assessment of causality. J Natl Cancer Inst Monographs. 2003;(31):3-13. 13.Collins S, Mazloomzadeh S, Winter H, Blomfield P, Bailey A, Young LS, et al. High incidence of cervical human papillomavirus infection in women during their first sexual relationship. BJOG. 2002;109(1):96-98. 31 Spotlight on cervical cancer screening 14.Ontario Agency for Health Protection and Promotion and the Institute for Clinical Evaluative Sciences. Ontario Burden of Infectious Disease (OBOID) Study. December 2010. 15.Bosch FX, Lorincz A, Muñoz N, Meijer CJ, Shah KV. The causal relation between human papillomavirus and cervical cancer. J Clin Pathol. 2002;55(4):244-65. 16.Bosch FX, de Sanjosé S. The epidemiology of human papillomavirus infection and cervical cancer. Dis Markers. 2007;23(4):213-27. 17.International Collaboration of Epidemiological Studies of Cervical Cancer, Appleby P, Beral V, Berrington de González A, Colin D, Franceschi S, et al. Carcinoma of the cervix and tobacco smoking: collaborative reanalysis of individual data on 13,541 women with carcinoma of the cervix and 23,017 women without carcinoma of the cervix from 23 epidemiological studies. Int J Cancer. 2006;118(6):1481-95. 18.Smith JS, Lindsay L, Hoots B, Keys J, Franceschi S, Winer R, et al. Human papillomavirus type distribution in invasive cervical cancer and highgrade cervical lesions: a meta-analysis update. Int J Cancer. 2007 Aug 1;121(3):621-632. 19.Paavonen J, Naud P, Salmerón J, Wheeler CM, Chow S-N, Apter D, et al. Efficacy of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine against cervical infection and precancer caused by oncogenic HPV types (PATRICIA): final analysis of a double-blind, randomised study in young women. Lancet. 2009 Jul 25;374(9686):301-314. 20.Dillner J, Kjaer SK, Wheeler CM, Sigurdsson K, Iversen O-E, HernandezAvila M, et al. Four year efficacy of prophylactic human papillomavirus quadrivalent vaccine against low grade cervical, vulvar, and vaginal intraepithelial neoplasia and anogenital warts: randomised controlled trial. BMJ. 2010;341:c3493. 21.Boyle P, International Agency for Research on Cancer. World cancer report 2008. Lyon: IARC Press; 2008. 22.McLachlin C, Mai V, Murphy J, Fung Kee Fung M, Chambers A, and members of the Cervical Screening Guidelines Development Committee of the Ontario Cervical Screening Program and the Gynecology Cancer Disease Site Group of Cancer Care Ontario. Cervical screening: a clinical practice guideline. Toronto: Program in Evidence-Based Care, Cancer Care Ontario; 2005. 23.American College of Obstetricians and Gynecologists. Committee opinion number 463. Committee on Adolescent Health Care. Cervical cancer in adolescents: screening, evaluation and management. Obstet Gynecol. 2010;116(2):469-72. 32 24.Sasieni P, Castanon A, Cuzick J. The impact of cervical screening on young women: a critical review of the literature 2002-2009. National Health Service Cancer Screening Programmes (NHSCSP) Publication No 31. Sheffield: NHS Cancer Screening Programmes; 2010 Feb. 26.Bruinsma F, Lumley J, Tan J, Quinn M. Precancerous changes in the cervix and risk of subsequent preterm birth. BJOG. 2007;114:70–80. 27.Kyrgiou M, Koliopoulos G, Martin-Hirsch P, Arbyn M, Prendiville W, Paraskevaidis E. Obstetric outcomes after conservative treatment for intraepithelial or early invasive cervical lesions: systematic review and meta-analysis. Lancet. 2006;367:489–98. 28.Marrett LD, Chaudhry M. Cancer incidence and mortality in Ontario First Nations, 1968-1991 (Canada). Cancer Causes Control. 2003 Apr;14(3): 259-268. 29.Ng E, Wilkins R, Fung MFK, Berthelot J-M. Cervical cancer mortality by neighbourhood income in urban Canada from 1971 to 1996. CMAJ. 2004 May 11;170(10):1545-1549. 30.Kupets R, Paszat L. Physician and patient factors associated with follow up of high grade dysplasias of the cervix: a population-based study. Gynecol. Oncol. 2011;120(1):63-67. Spotlight on cervical cancer screening 25.Arbyn M, Kyrgiou M, Simoens C, Raifu AO, Koliopoulos G, Martin-Hirsch P, et al. Perinatal mortality and other severe adverse pregnancy outcomes associated with treatment of cervical intraepithelial neoplasia: meta-analysis. BMJ. 2008;337:a1284. 33 34 Risk of getting colorectal cancer (i) General risk: In Ontario, colorectal cancer is the third most common cancer diagnosed and the second leading cause of cancer deaths. In 2010, an estimated 8,300 new cases were diagnosed and approximately 3,400 people died.1 Approximately 93 per cent of cases are diagnosed in people aged 50 or older.1 Despite having a higher incidence of colorectal cancer, mortality rates tend to be lower in Canada than in regions of Europe for both men and women.2 The five-year survival rate for colorectal cancer has improved over the past decade in Canada.3 Individuals with a first-degree relative (parent, sibling, or child) who has been diagnosed with colorectal cancer are at an increased risk for the disease. People who have conditions such as Crohn’s disease, polyps, or colitis also have a higher risk of developing colorectal cancer.4 Spotlight on colorectal cancer screening Spotlight on colorectal cancer screening (ii) Adenoma-carcinoma sequence Over 95 per cent of colorectal cancers arise from adenomatous polyps. The progression to invasive cancer takes an average of 10 years.5 Approximately two-thirds of polyps are adenomas.6 One third are hyperplastic with no to minimal malignancy risk. Approximately one to five per cent of adenomatous polyps will progress to invasive cancer. This is more likely if the polyps have high-grade dysplasia or villous features and if they are greater than one cm.7 (iii) The significance of colorectal cancer location (subsite) Cancers arising from the left versus the right side of the colon have different epidemiological, histological, and molecular features. Tumours that are flat in appearance are more commonly located in the right colon whereas polypoid-type tumours are more common in the left colon. The flatter tumours on the right side are harder to detect and remove. Therefore, survival rates are lower with right versus left-sided colon cancer. A higher proportion of right-sided colon cancers are diagnosed in 35 Spotlight on colorectal cancer screening 36 women.8 The incidence and mortality of left-sided colon cancer, but not right-sided colon cancer, is reduced through the use of flexible sigmoidoscopy and colonoscopy respectively as screening measures.8 Colorectal cancer screening data Fecal occult blood test (FOBT) screening rates across Ontario are currently 30 per cent. Rates vary by region with some as high as 36 per cent. The rate for Waterloo Wellington in 2009/2010 was 32 per cent. The provincial target is to increase participation in biennial FOBT screening to 40 per cent of Ontarians between the ages of 50 and 74 by the year 2011/12. Each year, more women are screened than men. In 2007/2008, 28 per cent of men and 31 per cent of women were screened by FOBT. A Cochrane review reported a 16 per cent reduction in colorectal cancer mortality with regular screening using FOBT — combined with a colonoscopy for those with a positive FOBT. In 2002, the U.S. Preventive Services Task Force reported a 20 per cent reduction in colorectal cancer incidence with regular screening. In three randomized controlled trials, FOBT has been shown to reduce colorectal cancer mortality by 15 to 33 per cent. The five-year relative survival of patients diagnosed at an early stage is 90 per cent compared to only 11 per cent for those diagnosed at an advanced stage.9 ColonCancerCheck (CCC) is the first province-wide colorectal screening program in Canada. The CCC program goals are to: • reduce mortality from colorectal cancer through an organized screening program • improve the capacity of primary care to participate in comprehensive colorectal cancer screening Primary care providers play a central role in promoting CCC and distributing FOBT kits. The provincial target is to screen 40 per cent of eligible Ontarians by 2011/2012. Key features of the CCC program include: • colonoscopy and FOBT quality standards • increased colonoscopy capacity across province • primary care provider awareness • program branded FOBT kits • financial incentives for primary care providers • patient correspondence Spotlight on colorectal cancer screening ColonCancerCheck CCC patient correspondence as of 2010: • Recall letters are sent to past participants who are due for repeat biennial FOBT screening. Four months after the recall letter, a reminder letter is sent to any participant who has not completed screening. • FOBT result letters are sent to all participants (FOBT normal, indeterminate, and positive). FOBT positive letters are sent to advise participants to contact their primary care providers to discuss their test results. • Invitation letters are sent to Ontarians turning 50 to invite them to discuss colorectal cancer screening with their primary care provider. Invitation letters are not sent to those who have had FOBT activity within the past five years or a colonoscopy within the past 10 years. Going forward, if 50 per cent of the eligible population participates in ColonCancerCheck, it is estimated that 1,500 lives will be saved by 2020 and 5,500 lives will be saved by 2030.10 37 Spotlight on colorectal cancer screening Challenges and opportunities 1. Screening rates need to be increased. The provincial target is to increase participation in biennial FOBT screening to 40 per cent of Ontarians between the ages of 50 and 74 by 2011/2012. 2. Many patients do not complete their FOBT kit. This indicates an issue with program compliance. 3. Approximately 30 per cent of patients with positive FOBT results do not follow-up with colonoscopy. 4. There is an ongoing debate about whether FOBT or colonoscopy is the best tool for population-based screening.11 Clinical case study one A 54-year-old asymptomatic male comes in for his annual physical. What screening test would you suggest to him? Answer: Take his personal history to ensure he does not have a first-degree relative with colorectal cancer or another condition such as Crohn’s or colitis. You would also have to check that he is not symptomatic. Colorectal cancer symptoms include: • unexplained changes in bowel patterns • rectal bleeding • unexplained weight loss • urgent feeling to empty bowel • unexplained stool incontinence If there is a family history or concerning symptoms, you should refer him for a colonoscopy. Otherwise, explain the importance of screening for colorectal cancer and the use of the FOBT kit as a screening tool. Also explain to the patient the role of a healthy lifestyle in colorectal cancer prevention. 38 A 47-year-old woman inquires about colorectal cancer screening. On inquiry you find her only risk factor is that her mother was diagnosed at age 65 with colorectal cancer. What would you suggest? Answer: Explain to patient that since her mother was 65 when diagnosed, she can wait to be screened until 50 years of age. The recommendation is that individuals at increased risk because of a family history of colorectal cancer are screened using colonoscopy at age 4012, or 5013 ,or 10 years earlier than the age of diagnosis of their first-degree relative. Tell the patient that she may reduce her risk of getting colorectal cancer by leading a healthy lifestyle. Colorectal cancer screening recommendations There are three main screening methods for colorectal cancer: FOBT, flexible sigmoidoscopy, and colonoscopy. More evidence is evolving on CT colonoscopy and DNA testing. Spotlight on colorectal cancer screening Clinical case study two It is recommended that people at average risk from ages 50 to 74 have an FOBT every two years. A positive FOBT does not necessarily mean that a person has cancer, but does indicate that a follow-up colonoscopy is needed. Individuals at increased risk for the disease due to a first-degree relative with colorectal cancer should undergo an initial colonoscopy at age 4012 or 5013, or 10 years earlier than the age of any first-degree relatives at the time of their colorectal cancer diagnosis. The CCC has adopted Canadian Association of Gastroenterology benchmarks for colonoscopy wait times: • eight weeks after a positive FOBT result • twenty-six weeks for people with a family history of colorectal cancer14 CCO collects data on colonoscopies carried out at participating hospitals. Regular performance reports are sent out to these hospitals. 39 Benefits may outweigh the potential risks. Clinicians should discuss the service with eligible patients. FOBT screening should be carried out every two years. Not recommended. Average-risk aged 50 to 74 Increased risk (colorectal cancer history, a first-degree family history of colorectal cancer) People at increased risk should be screened using colonoscopy starting at age 4012 or 5013, or 10 years earlier than the age of any first-degree relatives at the time of their colorectal cancer diagnosis. Screening not recommended. Screening not recommended. Under age 50 The incidence and mortality of left-sided colon cancer, but not right-sided colon cancer, is reduced through the use of flexible sigmoidoscopy and colonoscopy respectively as screening measures. There is fair evidence to include flexible sigmoidoscopy in the periodic health examination of people with a history of familial adenomatous polyposis. There is insufficient evidence to make recommendations about whether only FOBT or flexible sigmoidoscopy or both tests should be performed. The incidence and mortality of left-sided colon cancer, but not right-sided colon cancer, is reduced through the use of flexible sigmoidoscopy and colonoscopy respectively as screening measures. Flexible sigmoidoscopy screening recommendations FOBT screening recommendations There is insufficient evidence to recommend colonoscopy for people who have a family history of colorectal polyps or cancer but who do not meet the criteria for hereditary nonpolyposis colon cancer. The incidence and mortality of left-sided colon cancer, but not right-sided colon cancer, is reduced through the use of flexible sigmoidoscopy and colonoscopy respectively as screening measures. There is fair evidence to include colonoscopy screening in patients with a history of hereditary nonpolyposis colon cancer. People at increased risk should be referred directly for a colonoscopy. Issues with population-based screening via colonoscopy include poor compliance, quality of non-hospital scopes, available capacity, potential harms of screening, and potential costs. There is insufficient evidence to include or exclude colonoscopy as an initial screening test. Screening not recommended, except for some high-risk cases. Colonoscopy screening recommendations Spotlight on colorectal cancer screening Patient characteristics 40 For more information visit: http://health.gov.on.ca/en/ms/coloncancercheck/pro/resources.aspx www.ontario.ca/coloncancer.ca Colorectal cancer references 1.Canadian Cancer Society’s Steering Committee. Canadian cancer statistics 2010 [Internet]. Toronto: Canadian Cancer Society; 2010 [cited 2011 Mar 24]. Available from: http://www.cancer.ca/Canada-wide/ About%20cancer/Cancer%20statistics/~/media/CCS/Canada%20wide/ Files%20List/English%20files%20heading/pdf%20not%20in%20 publications%20section/Canadian20Cancer20Statistics2020102020 English.ashx 2.Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. GLOBOCAN 2008, Cancer incidence and mortality worldwide: IARC CancerBase No. 10 [Internet]. Lyon, France: International Agency for Research on Cancer; 2010. Available from: http://globocan.iarc.fr 3.Canadian Partnership Against Cancer. Cancer control snapshot #3: colorectal cancer staging and survival [Internet]. Toronto: Canadian Partnership Against Cancer; 2010 [cited 2011 Mar 24]. Available from: http://www.cancerview.ca/idc/groups/public/documents/webcontent/ rl_crc_snapshot_three_en.pdf Spotlight on colorectal cancer screening Further information 4.Canadian Task Force on Preventive Health Care. Colorectal cancer screening. Recommendation statement from the Canadian Task Force on Preventive Health Care. CMAJ. 2001 Jul 24;165(2):206-8. 5.Bond JH. Update on colorectal polyps: management and follow-up surveillance. Endoscopy. 2003 Aug;35(8):S35-40. 6.Levin B, Lieberman DA, McFarland B, Smith RA, Brooks D, Andrews KS, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin. 2008 Jun;58(3):130-60. 7.Bond JH. Update on colorectal polyps: management and follow-up surveillance. Endoscopy. 2003 Aug;35(8):S35-40. 8.Canadian Partnership Against Cancer. Cancer control snapshot #2: colorectal cancer incidence and mortality [Internet]. Toronto: Canadian Partnership Against Cancer; 2010 [cited 2011 Mar 24]. Available from: http://www.cancerview.ca/idc/groups/public/documents/webcontent/ rl_crc_snapshot_two_en.pdf 41 Spotlight on colorectal cancer screening 42 9.Altekruse S, Kosary C, Krapcho M, Neyman N, Aminou R, Waldron W, et al., editors. 5-year relative survival (percent) 1999-2006 by stage at diagnosis [Internet]. In: SEER cancer statistics review, 1975-2007. Bethesda (MD): National Cancer Institute; 2009 [cited 2011 Mar 25]. Available from: http://seer.cancer.gov/csr/1975_2007/browse_csr. php?section=6&page=sect_06_table.12.html#table5 10.Erasmus University, Cancer Care Ontario. Colorectal cancer screening program: total number of lives saved, MISCAN model. Unpublished data 2008 Jan. 11.Towler B, Irwig L, Glasziou P, Kewenter J, Weller D, Silagy C. A systematic review of the effects of screening for colorectal cancer using the faecal occult blood test, hemoccult. BMJ. 1998 Aug 29;317(7158):55965. 12.Canadian Task Force on Preventive Health Care. Colorectal cancer screening. CMAJ. 2001 July 24;165(2):206. Available from: http://www. cmaj.ca/cgi/reprint/165/2/206 13. Cancer Care Ontario. About colorectal cancer screening [Internet]. 2011 May [cited 2011 Jun 20]. Available from http://www.cancercare.on.ca/ cms/One.aspx?portalId=1377&pageId=9858 14.Paterson WG, Depew WT, Paré P, Petrunia D, Switzer C, Veldhuyzen van Zanten SJ, et al. Canadian consensus on medically acceptable wait times for digestive health care. Can J Gastroenterol. 2006 Jun;20(6):411-23. For more information, Contact: 519-749-4370 ext. 2671 June 2011