COLORECTAL CANCER
SCREENING PROGRAMS AND
STRATEGIES IN CANADA
ENVIRONMENTAL SCAN
March 2013
Background

Quarterly, the Canadian Partnership Against Cancer
collects information from the provinces/territories on the
status of population-based colorectal cancer screening
programs and/or strategies.

The information is collected through provincial and
territorial leads represented on the National Colorectal
Cancer Screening Network supported by the Canadian
Partnership Against Cancer.
March 2013
National Colorectal Cancer Screening Network
The Colorectal Cancer Screening Network
serves as a national forum to discuss and take
action on matters of mutual interest or concern
related to the implementation of organized
colorectal screening programs.
March 2013
Presentation Outline








Current National Guidelines
Colorectal Cancer Screening Program
Status/Availability
Entry Level Tests
Program Recruitment
Colonoscopy
Increased Risk Population Strategies
Promotion/Education/Human Resources
Quality Assurance
March 2013
Canadian Task Force on Preventive Health Care
Guidelines


Canadian Task Force in Preventive Health, 2001:
For people at normal risk there is good evidence to
support the inclusion of annual or biennial fecal occult
blood testing (A recommendation) and fair evidence to
include flexible sigmoidoscopy (B recommendation) in
the periodic health examinations of asymptomatic
individuals over 50 years.
March 2013
Colorectal Cancer Screening Program Status
Date of Program
Announcement
Program Status
Program Name
Agency responsible for
Program Administration
NU
No organized
program
No organized program
No organized program
No organized program
NT
No organized
program
No organized program
No organized program
No organized program
YK
No organized
program
No organized program
No organized program
No organized program
BC
2009
Pilot in three areas
Colon Check
BC Cancer Agency
AB
March 2007
Program-wide phased
program components
Alberta Colorectal Cancer Screening
Program (ACRCSP)
Alberta Health Services
SK
January 20, 2009
Program-wide phased
program components
Screening Program for Colorectal Cancer
Saskatchewan Cancer Agency
MB
2007
Phased in, province wide
ColonCheck
CancerCare Manitoba
ON
January 2007
Full program province-wide
ColonCancerCheck
Cancer Care Ontario
March 2013
Colorectal Cancer Screening Program Status, cont’d
Date of Program
Announcement
Program Status
Program Name
Agency responsible for
Program Administration
QC
December 2010
Planning phase
Programme québécois de dépistage du
cancer colorectal (PQDCCR)
Ministry of Health and Social
Services
NB
2009
Planning phase
New Brunswick Colon Cancer Screening
Program
New Brunswick Cancer Network (NB
Ministry of Health)
NS
2009
Province wide program
completed March 2013
Colon Cancer Prevention Program
Cancer Care Nova Scotia
PE
2009
Conducting second pilot
PEI Colorectal Cancer Screening
Program*
Health PEI
NL
March 19, 2010
Program-wide phased
program components
Newfoundland and Labrador Colon
Cancer Screening Program
Eastern Health, Cancer Care
Program
Colorectal Cancer Screening Program Availability
Entry Level Test: Fecal Occult Blood Test (FOBT)
All programs use, or plan to use, a fecal test as primary screening
modality for average-risk individuals
Guaiac
FIT
N/A – No organized program
NU

NT
Not programmatic
N/A – No organized program
YK

BC
AB
Comments

OC Auto Micro 80, 2 samples, either sample ≥ 100 ng/ml =positive
Plans to launch FIT province wide 2013

SK
MB

ON

Hemoccult Sensa
QC

NB

NS

PE

Fecal Occult Blood Test (current use) ; moving to FIT in Sept.. 2011
NL

Completed a validation study comparing FIT to guaiac and
colonoscopy results in 2011
Moving to fit in 2013
March 2013
Entry Level Test: FOBT Follow-up
Screening Interval
Standard follow-up
diagnostic procedure for
abnormal test
Average time from abnormal result to follow-up
procedure or ‘Wait time target’
NU
No organized program
No organized program
No organized program
NT
No organized program
No organized program
No organized program
YK
No organized program
No organized program
No organized program
BC
2 years
Colonoscopy
Not available
AB
1 year or at least 2
years
Colonoscopy
Not available at this time and will vary by Zone
SK
2 years
Colonoscopy
Median time was 12 weeks in May 2011
MB
2 years
Colonoscopy
Not available
ON
2 years
Colonoscopy
Median time was 7 weeks in March 2009
QC
2 years
Colonoscopy
< 60 days (target)
NB
2 years
Colonoscopy
To be defined
NS
2 years
Colonoscopy
Target is 8 weeks
PE
2 years
Colonoscopy
Variable
NL
2 years
Colonoscopy
< 60 days, with 90th percentile within 180 days
March 2013
Summary of Key Program Activities Across Canada
As of July 2011 key activities in colorectal cancer
screening across Canada include program:
 Program
Expansion
 Evaluation of Entry Level tests
 Development of Quality Indicators
March 2013
FOBT: Recruitment Strategy/ Invitation Method
Physician
Self-referral
Self-referral through
pharmacy*
Mailed invitation
letter
Mailed fecal test
Other
NU
No organized
program
No organized
program
No organized program
No organized
program
No organized program
No organized program
NT
No organized
program
No organized
program
No organized program
No organized
program
No organized program
*CRC guidelines in place in March 2011
YK
No organized
program
No organized
program
No organized program
No organized
program
No organized program
No organized program
BC


AB

 ( future plan)
SK
MB

ON
 (primary
method)

 (by calling Call Centre to register to
participate)
 (primary method)
 (~ 1 month after letter)
 (by calling Program)
 (primary method)
 (3 weeks after letter or
on request)
( by calling or emailing Program, and
through Breast Check )
(media)

QC
 (by calling Telehealth ON)
 (planning for
2013-2014)
Pick-up kit at hospital or
community laboratory
 target: Letter sent every 2 years to the
target population
NB


Invitation by Program
Marketing & education campaign focused
on Physicians, Public and Health care
professionals
NS

 (2 weeks after letter)

Will mail fecal test on
request
Posters, other promotional material at
Family Health Centres and Medical Clinic
Kits mailed weekly to
participants
Public advertizing (radio/print/web)
Media and advertising
 Referral through breast screening centers

PE

NL



*pick-up kit at pharmacy
Process Following an Abnormal Result
Process following abnormal results
NU
No organized program
NT
No organized program
YK
No organized program
BC
Navigator contacts participant to discuss follow-up
AB
Province wide abnormal result letters, navigation planning underway
SK
Primary care practitioner notified
Participant advised to see their doctor/nurse practitioner to review result and discuss follow-up
Practitioner or Client Navigator (in 1 RHA) refers participant for diagnostic testing (e.g., colonoscopy)
MB
Primary care provider notified
Navigator contacts participant to discuss results and referral process
Brochure “Colonoscopy” mailed to participant
Program arranges follow up colonoscopy for majority of participants
ON
Primary care provider contacts participant to follow-up; unattached patients are referred to a family physician for follow-up (phone and
letter)
QC
Target: Participant will be contacted by letter. Pre-colonoscopy evaluation is done by a nurse
NB
Planning that participant is contacted by phone to discuss results and follow-up procedures. Pre-colonoscopy assessment is done by a Program
Nurse who refers appropriate participants for colonoscopy
NS
Letter sent to participant and primary care provider indicating that district screening nurse will follow-up to discuss diagnostic procedure,
followed by telephone call to participant by district screening nurse
PE
Program sends results letter to primary care provider and patient. Unattached patients are sent a results letter and referred to a family physician
for follow up
NL
Nurse Follow up Coordinator makes telephone contact with FIT positive participant to provide test results and discuss possible follow up
colonoscopy. Results letter sent to primary care provider and participant. Nurse Coordinator will help navigate FIT positive participant through to
colonoscopy
Re-screening Recommendations for
+FOBT and Negative* Colonoscopy
Recommendations
Years before recall
to program
NU
No organized program
NT
No organized program
YK
No organized program
BC
FIT re-screening in 2 years
2
AB
Return to FOBT screening every 1 to 2 years
10
SK
Physicians may indicate patient return to screening program if still meet eligibility requirements at 5 or 10
yrs after normal colonoscopy (under review)
5/10
MB
Recalled for FOBT in 5 years
5
ON
Recalled for FOBT in 10 years (under review)
10
QC
Invitation letter for FOBT screening after 2 years (FOBT - : recall every 2 years)
10 (if negative
colonoscopy)
NB
Recalled after 10 years
10
NS
FOBT offered in 2 years
2
PE
Recalled for FOBT in 5 or 10 years (under review)
5/10
NL
Recalled after 5 years
5
* No cancer or polyp found
March 2013
FOBT – No physician
Fecal Test – No Physician
NU
No organized program
NT
No organized program
YK
No organized program
BC
Program assistance in finding physician for patients with abnormal result
AB
Not applicable
Fecal test must be ordered by physician
SK
Program assistance in linking individual to health region to find a physician for patients with abnormal result. Client navigator program will
expand provincially and will complete referral and ensure follow-up is completed.
MB
Program assistance in finding physician for patients with abnormal result
ON
Kit available from community pharmacy or Telehealth; for abnormal results program refers participant to family physician for follow-up
QC
Target: If FOBT +, reference directly to colonoscopy. The procedure associates a physician only if needed.
NB
Program assistance in finding a physician for patients with out a primary care provider (Under review with DoH)
NS
District Health Authorities have local processes for attaching screening program participants
PE
The program has recruited a physician to take unattached patients
NL
Medical Director acts as the referring physician for the FIT analysis in the lab and for any follow up colonoscopy. Program will provide
information on provincial processes for finding a family physician
March 2013
Colonoscopy

Standard follow-up diagnostic procedure following abnormal
fecal test

Standard procedure for increased risk individuals

Performed by gastroenterologists; surgeons; internal
medicine-specialists; or, in some cases, general practitioners

In hospitals or external clinics
March 2013
Increased Risk* Population Strategies
Increased Risk*: A level of risk that is above that of the general population, where the individual is still eligible for screening (and
not diagnostic workup or surveillance)
Increased risk population:
Planning to advise high risk population to see their Primary Care Provider through invitation letter in NB

Identified by physician in AB, MB and ON

Self-identified by program participant in which case, participant is advised to see primary care provider in NS

Self-identified in BC and SK

Information is documented separately in BC, AB, SK-may change

Are evaluated based on Medical and Nursing Clinical Practice Standards for colonoscopy (algorithms for moderate, slightly or
moderately increased risk , with a personal history of polyps and with a personal history of colorectal cancer) in QC.
*Is also referred to as: above-average risk, elevated risk, moderate risk, high risk
March 2013
Increased Risk Screening Recommendations*
NU
NT
YK
BC
AB
SK
Definition of
increased risk
No organized
program
No organized
program
No organized
program
≥2 first-degree
relatives with CRC
diagnosed at any age
OR 1 first degree
relative diagnosed
under age 60
1) First-degree relative with
CRC diagnosed <60 OR ≥2
first-degree relatives with
CRC at any age
2) First-degree relative with
CRC diagnosed ≥ 60
1) First-degree
relative with CRC <60
2) First-degree
relative with CRC ≥60
Screening
recommendation
for increased risk
population
No organized
program
No organized
program
No organized
program
Referred to
Colonoscopy
1) Colonoscopy at age 40 or
10 year younger than earliest
case, whichever comes first
2) Same as average risk but
beginning at age 40
1) Colonoscopy
beginning at age 40
or 10 years younger
than the earliest case
in the family
2) Same as average
risk but beginning at
age 40
Increased risk
screening follow-up
recommendations
after normal
colonoscopy
No organized
program
1) Repeat colonoscopy every
5 years
2) Same as average risk
1) Repeat
colonoscopy every 5
years
2) Same as average
risk
(Offered voluntary
FOBT)
No organized
program
No organized
program
*Not all programs coordinate referrals of increased risk population
If 1 first degree
relative with CRC ≤
60 OR ≥2 firstdegree relatives at
any age: Repeat
colonoscopy in 5
years
Follow-up as per
CAG guidelines and
close monitoring by a
physician
Increased Risk Screening Recommendations* cont’d
MB
ON
QC
NB
Definition of
increased risk
1) First-degree
relative with CRC or
advanced
adenomatous polyps
<60
2) ≥2 first-degree
relatives with CRC or
advanced
adenomatous polyps
at any age
≥1 first-degree relative
with CRC
1) Slight or moderate increased risk :
relative(s) with CRC or advanced
adenomatous polyps at >60 years old
2) With a personal history of polyps :
3) With a personal history of colorectal
cancer
Detailed algorithms are available from QC
1) With personal history of :
- CRC (colorectal cancer)
-adenomatous polyps
-One 1st degree family history
of CRC >60 years
- 2 second degree relatives
with polyps or CRC
Detailed algorithm is available
from NBCN
Screening
recommendation for
increased risk
population
The Program
recommends
colonoscopy. Referral
is not coordinated by
the Program, it is the
responsibility of the
primary care provider
to coordinate
Colonoscopy at age 50
or 10 years younger
than earliest age of
diagnosis of relative,
whichever comes first
1) Same as average risk or starting at
age 40 if 2 relatives at riskcolonoscopy every 5 years at 40
2) Same as average risk, colonoscopy
every 5 or 10 years or every 3 years
for advanced adenomas
3) Colonoscopy 1 year after surgery or 3
years if exam is normal. Follow-up
every 5 years
Detailed algorithms are available from QC
The Program recommends
follow up with their Primary
Care Provider or regular
Endoscopist (if they have one)
to determine and coordinate
screening follow up.
Detailed algorithm is available
from NBCN
Increased risk
screening follow-up
recommendations
after normal
colonoscopy
Recommendations at
the discretion of the
endoscopist
Repeat colonoscopy
every 5 - 10 years
1) Same as average risk
2) Colonoscopy every 10 years or every 5
years if advanced adenomas
3) Colonoscopy every 3 years or every 5
years if results are normal
Detailed algorithms are available from QC
Recommendations to return to
Program or continue ‘high risk’
follow up at the discretion of
the Endoscopist
*Not all programs coordinate referrals of increased risk population
Increased Risk Screening Recommendations*
cont’d
NS (under revision)
PE
NL
Definition of
increased risk
1) 1 first-degree relative with CRC or
adenoma diagnosed <60 OR ≥2
second-degree relatives with CRC or
adenoma <60
2) 1 first-degree relative with CRC or
adenomatous polyp >60 OR ≥2 seconddegree relatives with CRC or adenoma
diagnoses in their 60s or 70s
First-degree relative with CRC
OR ≥2 second-degree relatives
with CRC
•One first degree relative with colorectal cancer
(CRC) or adenomatous polyps before age 60
•Two or more first degree relatives with polyps
or colorectal cancer at any age
•Two or more second degree relatives with CRC
or adenoma before age 60
•Personal history of extensive ulcerative colitis
or Crohn’s colitis
Screening
recommendation
for increased risk
population
1)Colonoscopy at 40 or 10 yrs younger
than the earliest case in the family,
whichever comes first
2)FOBT at age 40 or colonoscopy every
10 yrs10 yrs younger than the earliest
case in the family, whichever comes first
Promote CAG guidelines.
Recommendation is at discretion
of the physician.
(Referral is not coordinated by
the Program)
Promote CAG guidelines
Increased risk
screening followup
recommendations
after normal
colonoscopy
1)Repeat colonoscopy in 5 years
2) Repeat FOBT every 2 yr or
colonoscopy every 10 years
Recommendations at the
discretion of the endoscopist
Recommendations at the discretion of the
endoscopist
*Not all programs coordinate referrals of increased risk population
March 2013
Program Education/Promotion: Health Care
Community
Education/Promotion Initiatives
NU
No organized program
NT
No organized program
YK
No organized program
BC
Education sessions; Focus group testing; Healthcare professional fact sheet, and CME presentation developed
AB
Provincial program provides education/information (content) and disseminates province –wide and uses Zone representatives to disseminate locally
SK
Education sessions (in person, web conferences, etc.) - in future may offer CME credits; Resources: Practitioner Postcard and Information Package
(fact sheet, FAQ, CRC screening guidelines summary, sample kit, poster, forms); Newsletters, direct mail, website, magazine ads and articles
MB
Newsletters, direct mail, lunch and learn presentations, webpage, continuing education day (CME credits); Resources: fact sheet, FAQ,
recommendations summary
ON
Regional and Provincial education sessions including CME and provider incentives for screening; Mail-outs to providers at launch of program;
Participation in professional conferences and trade shows; Professional publications
QC
Target: letters send to participants every two years, web page, CME, mail-outs to providers .
NB
Involvement in multi-disciplinary advisory committees; plans for province-wide education sessions and workshops.
NS
CME events and lectures (no incentive); Articles in magazines, direct mail, resources; Colonoscopist apply to be “credentialed” by program in order
to perform abnormal FOBT follow-up procedure; Skills training workshop for credentialed colonoscopists
PE
CME presentation at medical society of PEI; PEI division of CCS developing “screening kits"; education materials for physicians
NL
Information packages sent regularly to family physicians in the target areas, includes posters, brochures, business cards and referral forms.
Continuing education sessions are offered to family physicians by the program Medical Director. There are general awareness presentations
available for health care professionals and the general public. The program also networks with community and provincial groups with information on
the screening program. Program runs various advertizing ads on radio, print and web to promote access to the program along with earned media
opportunities
Program Education/Promotion: Health care
Community cont’d
Avenues for Feedback
NU
No organized program
NT
No organized program
YK
No organized program
BC
Contact program directly; Physician surveys; Colonoscopist and navigator focus group
AB
Physicians invited to Working Groups/Committees; Physician Specialty Review Panels arranged; Province-wide surveys
SK
Education session (e.g., Telehealth and Webinars); contact program directly (email, phone, website); Participate in working groups,
committees, other special meetings, focus groups, key informant interviews, surveys, etc.
MB
Contact program directly in person, via phone, email, or website; Participation in committees
ON
Regional Primary Care Leads working with providers; Call centre or email
QC
Target: Evaluation of the participant satisfaction before, during and after the colonoscopy exam.
NB
Plan for direct Colon Screening Program telephone line.
NS
Contact program directly; Q&A and Rounds; Participation in advisory committees, surveys, facilitated feedback workshops, local
implementation committees
PE
NL
The screening program has a website with information and option to email the program for a home screening kit or provide feedback.
Participants can contact the program toll free to provide feedback ask questions or request a kit. Program to develop a participant
questionnaire to gauge satisfaction with the screening program
March 2013
Program Education/Promotion: Public
Promotion Initiatives
Education Initiatives
NU
No organized program
No organized program
NT
No organized program
No organized program
YK
No organized program
No organized program
BC
Brochures, website
Brochures, website
AB
Brochures, radio campaign, promotional materials, website, web
advertising, use of local health promotion practitioners and health
providers to promote program
Brochures, website, toll-free phone to answer questions, use of local health
promotion practitioners and health providers to educate on CRC screening
SK
Community events (e.g., Tradeshows & Fundraisers) ,
Brochures, TV campaign, radio campaign, promotional materials,
website, and newsletter
Events (e.g., Giant Colon), Brochures, website, personal counseling- Early
Detection Coordinator, Client Navigator
MB
Brochures, TV campaign, radio campaign, promotional materials,
website, newspaper ads, outdoor ads, e-flyer
Brochures, website, personal counseling, video
ON
Promotional materials, regional/local campaigns
Brochures, website
QC
Promotion is planed in a communication plan
Nurses and physician information kits (brochures), website, toll-free phone
to answer questions
NB
Marketing & Communications strategy in planning and
development phase – Media (print ads or announcements,),
Website, and promotional materials
Education Strategy in planning and development phase – brochures,
website, Colon Cancer Screening Program telephone service
NS
Brochures, radio & print campaign, promotional materials,
website, newsletters, posters, PR activities
Brochures, website, personal counseling, public lectures- Screening Project
Officer and District Screening Nurses
PE
Social Marketing of program via Health Fairs, radio, television,
and print ads
Toll-free phone to answer questions, posters, bookmarks distributed at all
family health centres and medical clinics
NL
Brochures, facts sheets, radio, web and print ads, awareness
posters, website
Program website, educational presentations
Human Resources:
Navigation/Consultation/Coordination
Position Title
NU
No organized program
NT
No organized program
YK
No organized program
BC
Colon Check
Navigator
AB
Precolonoscopy
consultation
Centralized
intake/triage
for booking
Tracking
patients*
Data
collection
Yes
No
Yes
Yes
Yes -Planning
Yes-Planning
Decentralized
Yes Planning
Yes Planning
SK
Early Detection
Coordinator
Client Navigator
No
Yes
No
Yes (1 RHA
so far)
Yes
Yes
MB
Follow-up
Coordinator
Yes (Nurse
Practitioner) in
some areas
Yes, in some
areas
Yes
Yes
Other
Assist with data quality review, identification of data
issues & resolution; Assist with education about
screening; Assist with program monitoring
* Tracking patients from abnormal screen to diagnosis/treatment
March 2013
Human Resources:
Navigation/Consultation/Coordination Cont’d
Position Title
Precolonoscopy
consultation
ON
Nurse Navigator
(CCO pilot program)
Yes
QC
Project coordinator
in each
demonstration site
(hospital)
Program regional
responsibilities
(coordinator and
director)
NB
Centralized
intake/triage
for booking
Tracking patients*
Data collection
Other
Yes (books
follow-up)
Yes
Yes
Note: Diagnostic Assessment
Programs not part of
ColonCancerCheck, but is a
related CCO initiative.3 of the 7
pilot sites focus on CRC -Roles
vary among sites
Yes (nurse)
Yes
(nurse)
Yes
(nurse, 30 days after
colonoscopy)
Yes
(Starting with the
eight
experimental
sites)
Planning - Program
Access
Coordinator(s)
Yes -Planning
Yes -Planning
Yes -Planning
Yes-Planning
Refer patients (Planning)
NS
District Screening
Nurse (DSN)
Yes (includes
patient education)
Yes (at DHA
level)
Yes
Yes
Refer to colonoscopy where
appropriate (7% of cases are also
referred to colonoscopist for
consultation); Patient education is
significant role of the DSN
PE
Provincial
Coordinator
Carried out with
primary provider
No
Yes
Yes
Refer to colonoscopy where
appropriate
NL
Nurse Follow up
Coordinator
Yes
Yes
Yes
Yes
* Tracking patients from abnormal screen to diagnosis/treatment
Refer to colonoscopy where
appropriate and offer avenues for
public education
Current Quality Assurance Activities Planned or
Underway
Examples of Quality Assurance Activities
Provinces
Patient Satisfaction Surveys/
Program Implementation Evaluations
BC,SK,NS,PE,AB, NL,
MB, NB
Endoscopy Standardized Reporting
MB, AB,SK, NS, NL, QC
Global Rating Scale (GRS) Tool Implementation
BC,AB,NS,SK,NL, QC
Follow up of Every Patient with Abnormal Result (Until
declared negative, diagnosis and treatment)
PE, NL, MB
Cancer audits/monitoring interval cancers
SK, NS, MB, NB
Follow-up QA – credentialing endoscopists
SK, AB, NS, NL, NB
Implement an information system to monitor the quality
indicators of the program
QC, AB, NL, MB, NB
Establish a Central Assurance Quality Committee to
monitor the Program
QC, AB, NL, NB
March 2013
Reference Slide

Please use the following reference when citing
information from this presentation:
Colorectal Cancer Screening in Canada: Programs and
Strategies. Cancer View Canada. Available at: [Enter
Link], Accessed: [Enter Date Accessed].
March 2013