BREAST 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 breast cancer screening programs and/or
strategies.

The information is collected through provincial and territorial
leads represented on the National Committee of Canadian
Breast Cancer Screening Initiative supported by the Canadian
Partnership Against Cancer.
March 2013
Presentation Outline

Canadian Task Force on Preventive Health Care
Guidelines


Provincial and Territorial Guidelines
Breast Cancer Screening Program Distribution and
Administration

Recruitment and Recall

Quality Assurance

Breast Cancer Data Reported
Breast MRI (High Risk Screening Guidelines)

March 2013
Canadian Task Force on Preventive
Health Care Guidelines

The Canadian Task Force on Preventive Health Care (2011)
recommends the following for breast cancer screening:
Mammography

For women aged 40-49, routine screening not recommended (Weak
recommendation; moderate quality evidence)

For women aged 50-69, routine screening every 2 to 3 years (Weak
recommendation; moderate quality evidence)

For women aged 70-74, routine screening every 2 to 3 years (Weak
recommendation; low quality evidence)
Magnetic Resonance Imaging

Routine screening not recommended (Weak recommendation; no
evidence)
March 2013
Canadian Task Force on Preventive
Health Care Guidelines (Cont’d)
Clinical Breast Exam

Routine screening for breast cancer is not recommended when
performing clinical breast exam alone or in conjunction with
mammography (Weak recommendation; low quality evidence)
Breast Self Exam

Routine practice of breast self exam is not advised by the Task Force
(Weak recommendation; moderate quality evidence)
March 2013
Breast Cancer Screening Programs:
Provincial and Territorial Guidelines
Start Age
Interval
Stop Age
Nunavut
Northwest Territories
Yukon
British Columbia
Alberta
Saskatchewan
Begin at age 50 (age 40 – 49 accepted
by physician referral and self –referral
but not actively recruited)
For women aged 40-49 - annual recall
For women aged 50-69 - biennial recall
For women aged 70+ - biennial recall
79
Begin at age 40
For women aged 50-69 - biennial recall
For women aged 70+ - biennial recall
70+
Begin at age 40 (<40 accepted with
physician referral)
For women aged 40-49 - annual recall
For women aged 50-69 - biennial recall
For women aged 70-79 - biennial recall
79 (age 80+ only with physician
referral)
Begin at age 50 (age 40-49 accepted
with physician referral for the first
screen)
For women aged 40-49 - annual recall
For women aged 50-69 - biennial recall
70+
For women aged 50-69 - biennial recall
For women aged 70-74 - biennial recall
(only if previously enrolled in the program)
75+
Begin at age 50 (age 49 accepted on the
mobile if turning 50 in same calendar
year)
Manitoba
Begin at 50 (ages 40-49 accepted to
mobile unit only with physician referral)
For women aged 40-49 - biennial recall
For women aged 50-69 - biennial recall
For women aged 70-74 - biennial recall
75+
Ontario
Begin at age 50 (ages 30-49 accepted if
high risk and referred by physician)
For high risk women aged 30-49 - annual
recall
For high risk women aged 50-69 – annual
recall
For women aged 50-69 - biennial recall
For women aged 70-74 - biennial recall
75+
Breast Cancer Screening Programs:
Provincial and Territorial Guidelines (Cont’d)
Start Age
Québec
New Brunswick
Nova Scotia
Prince Edward Island
Newfoundland &
Labrador
Begin at age 50 (accept ages 35-49 only
with physician referral if done at a
program screening centre)
Interval
For women aged 50-69 - biennial recall
Stop Age
69 (age 70+ only with a
physician referral at a program
screening centre)
Begin at age 50 (age 40-49 accepted
only with physician referral)
For women aged 50-69 - biennial recall
69 (age 70+ only with a
physician referral)
Capacity to increase to age 74
Begin at age 40
For women aged 40-49 - annual recall
For women aged 50-69 - biennial recall
70+
Begin at age 40 (ages 30-39 accepted if
high risk and referred by physician)
For women aged 30-39 - annual recall
For women aged 40-49 - annual recall
For women aged 50-69 - biennial recall
For women aged 70-74 - biennial recall
74
Begin at age 50 (age 40-49 accepted
only with physician referral)
For women aged 50-69 - biennial recall
69 (age 70+ only if previously
enrolled in the program)
March 2013
Distribution of mammography and CBE among
breast screening programs
Province/Territory
(Program Disribution)
Mammography alone
Yukon
Territory
Clinical Breast Examination
& Mammography
(1990)
Northwest
Territories
(2003)
British
Columbia
(1988)
No Organized Program
Nunavut
Newfoundland
& Labrador
(1996)
Alberta
(1990)
Saskatchewan
Manitoba
(1990)
(1995)
Quebec
(1998)
Ontario
(1990)
Prince Edward Island
(1998)
New Brunswick
(1995)
Nova Scotia
(1991)
Breast Cancer Screening Program
Administration
Program Start Date
Program Name
Agency Responsible for Program
Administration
Nunavut
Northwest Territories
2003
2008
Breast Screening Program, Stanton
Territorial Health Authority
Breast Screening Program, Hay River
Health and Social Services Authority
Stanton Territorial Health Authority
Hay River Health and Social Services Authority
Yukon
1990
Yukon Mammography Program
Government of Yukon
British Columbia
1988
Screening Mammography Program of
British Columbia
BC Cancer Agency
Alberta
1990
Alberta Breast Cancer Screening Program
Alberta Health Services
Saskatchewan
1990
Screening Program for Breast Cancer
Saskatchewan Cancer Agency
Manitoba
1995
BreastCheck
Cancer Care Manitoba
Ontario
1990
Ontario Breast Screening Program
Cancer Care Ontario
Québec
1998
Québec Breast Screening Program
Ministère de la Santé et des Services sociaux
New Brunswick
1995
New Brunswick Breast Cancer Screening
Services
New Brunswick Cancer Network (NB Ministry
of Health)
Nova Scotia
1991
Nova Scotia Breast Screening Program
Government of Nova Scotia
Prince Edward Island
1998
PEI Breast Screening Program
Government of Prince Edward Island
Newfoundland and
Labrador
1996
Breast Screening Program for
Newfoundland and Labrador
Eastern Health, Cancer Care Program
Participant Recruitment
Doctor referral
Self-referral
Initial letter of
invitation
Age group to which
letter is sent
Nunavut
Northwest Territories


Yukon


British Columbia



50-69
Alberta



50-69

50-70+

50-69

50-69
 (not all regions)
50-69
Saskatchewan
Manitoba


Ontario


Québec

New Brunswick


Nova Scotia*


Prince Edward Island


Newfoundland and Labrador


* NS initially started sending out letters of invitation; however, they have since stopped due to capacity issues.
March 2013
Recall Following a Normal
Mammogram
Send out
recall letters
Coordination of recall for women following a
normal screening episode performed by
Any additional follow-up to
first recall letter after no
reply
Age group
for recall

40-79
Nunavut
Northwest Territories

Centralized management (Program or Agency)
Yukon

Screening centre
British Columbia

Centralized management (Program or Agency)

40-79
(AHS Screen
Test only)
Centralized management (Program or Agency)

40-69
Saskatchewan

Centralized management (Program or Agency)

50-70+
Manitoba

Centralized management (Program or Agency)

50-74
Ontario

Regional coordination centres/ Screening centre

50-74
Québec

Regional coordination centres

50-69
 (not all
regions)
Screening centre

50-69
 (postcard)
Centralized management (Program or Agency)

40-69
Prince Edward Island

Screening centre

40-74
Newfoundland and
Labrador

Screening centre

50-74
Alberta
New Brunswick
Nova Scotia
40-79
March 2013
High Breast Density Recall and
Recommendations
Five provinces and territories recall women based on high breast density
Recommendations following a high breast density reading varies across P/Ts
Automatic annual
recall based on breast
density
Value considered high
breast density
Recommendation for high breast
density levels
> 75%
Annual recall
>75%
Annual recall

>75%
Annual recall
Nova Scotia

>75%
Annual recall
Newfoundland and Labrador

>75%
Annual recall
Northwest Territories

Alberta
Ontario
March 2013
Association of Screening Program/Centre
with Diagnostic Follow-Up
Assessment of
abnormal results
(radiological or
histopathological)
occurs within the
screening program
Screening centre
books diagnostic
assessments
Medical prescription
needed for each
diagnostic assessment
Radiological/
pathological
assessment teams
have access to
screening reports
Nunavut
Northwest
Territories


Yukon



Facilitates diagnostic
referral

British Columbia

 (Varies by site)
 (Varies by site)
Saskatchewan



Manitoba



Ontario
 (Varies by site)


Québec

 (Varies by site)
 (Varies by site)


Nova Scotia



Prince Edward
Island


Newfoundland and
Labrador


Alberta
New Brunswick



 (On request)


Quality Assurance: General
Conduct a review of
screening films/digital
images of interval
cancers*
Conduct a review
of missed at
assessment
cancers
Require a
‘double read’
of a portion of
all screens
Have a
questionnaire to
evaluate client
satisfaction
Conduct analyses to
estimate the effect of
organized breast screening
on mortality
Nunavut
Northwest
Territories


Yukon
British Columbia




Alberta**





Saskatchewan



Manitoba




Ontario


 (Done at individual
centres)



Québec
New Brunswick
Nova Scotia


(Provincial Cancer Report)
***


 (periodically)





 (in the process)
Prince Edward
Island
Newfoundland and
Labrador
*Classify cancer as either true interval or missed at screening
**Alberta Health Services Screen Test sites only
***NS review of all interval cases 1991 to 2004 and CD of various cases are sent to all screening radiologists. Now with full field digital this will be competed electronically.
Quality Assurance:
Client Satisfaction Surveys
NWT, BC, AB, MB, NS and NL evaluate client satisfaction on an ongoing
basis
Table: Specific information collected when evaluating client satisfaction per province/territory
Mammography
exam
Particular
Screening Centre
Organized
Screening
Program
Northwest Territories



British Columbia



Alberta


Manitoba



Nova Scotia



Newfoundland and Labrador



March 2013
Quality Assurance:
Evaluation of Radiologist Performance

Most P/Ts evaluate radiologists on their level of performance on an annual basis with the exceptions of YK and PEI. NB
collects this data but does not report on it
Table: Specific information collected when evaluating radiologist performance per province/territory
Positive
Predictive
Value (PPV)
Abnormal call
rate
Cancer
detection rate
Interval
cancers
Northwest Territories



British Columbia



Alberta



Saskatchewan




Manitoba








Québec



Nova Scotia



Newfoundland and
Labrador



Ontario
General
performance
reviews
Other (specified)


Sensitivity/ Specificity
Sensitivity/ Specificity
Sensitivity/ Specificity and
One year recall rate


Sensitivity/ Specificity
Table: Specific volume requirement for radiologists per province/territory
NL
NS
NB
QC
ON
MB
SK
AB
BC
NT
1,500 / year
480 / year**
2,500 / year
480 / year
2,500 / year
1200/ year**
*All radiologists greatly exceed this number
**Includes diagnostic and screening mammograms
500/ year
1,000 / year
1,000 / year*
3,000 / year
Quality Assurance:
Vital and Cancer Registry-Linkages with Provincial Registries
Collection of ‘Vital Status’
variable
Collection of ‘Date of
Death’ variable
Collection of cancer stage
(TNM or Collaborative stage)
or other cancer variables
Nunavut

Northwest Territories
**
**
British Columbia



Alberta
*
*

Saskatchewan



Manitoba



Ontario





***
Yukon
Québec
New Brunswick
Nova Scotia
Prince Edward Island
Newfoundland and
Labrador
*Through provincial client registry
**Decreased lists are provided to WGH monthly
***linkage for post-screen cancer information only


March 2013
Mammography Screening Program:
Vital and Cancer Registries – TNM or Collaborative Stage
For the provinces and territories that do not currently link
with provincial cancer registries to collect cancer stage
(TNM or Collaborative Stage) or other cancer variables, it
may still be possible:

For the collection of post-screen cancer information (BC, QC, NS*)

For the collection of cancer and stage information (BC, NS*)
 *Note: Both linkages are possible in NS; however, an agreement has
not yet been established
 For YK it is unknown if this is possible
March 2013
Breast MRI: High Risk Guidelines
Currently there are five provinces (BC, AB, ON, NS, NL) that have developed standard
guidelines for MRI referral
Table: The criteria or evidence that MRI referral is based upon per province
Self-reported
family history
(>=2) of breast
cancer (first
degree
relative)
British Columbia
Selfreported
family
history of
BRCA 1/2

Genetic
testing
BRCA 1
or 2
Risk of
breast cancer
>20% (scored
by validated
assessment
tools)
Chest
irradiation
between the
ages of 10
and 30
years


Li-Fraumeni
syndrome,
Cowden
syndrome, or
BannayanRileyRuvalcaba
syndrome
****
Alberta




Ontario
*

**
***

**






Nova Scotia
Newfoundland and
Labrador
Prince Edward
Island
>=3






* First degree relative
** >25% using validated assessment tool
*** Chest irradiation before age 30 and at least 8 years ago
**** BC includes the following syndromes: Li Fraumeni Syndrome, Cowden’s Syndrome, HDGC
(CDH-1), Peutz-Jegher’s Syndrome
March 2013
Future Implementation of MRI
Ontario has implemented an MRI screening component to its organized
screening program for women considered at high risk for breast cancer.
BC, NS and AB have established guidelines for the use of MRI among women
considered to be at elevated risk (i.e. in BC the women considered are
confirmed cases of BRCA1 and BRCA2 mutation only). For more information
on MRI guidelines for NS please visit www.breastscreening.ns.ca
NL is exploring the appropriateness of using MRI among women considered to
be at elevated risk
March 2013
Reference Slide

Please use the following reference when citing
information from this presentation:
Breast Cancer Screening in Canada: Programs and
Strategies. Cancer View Canada. Available at: [Enter
Link], Accessed: [Enter Date Accessed].
March 2013