Cancer
Screening
TriLHIN ICS Orientation Workshop
July 16, 2014
Dr. Jan Owen, MD, CCFP, FCFP
Regional Primary Care Lead, SWRCP
Learning Objectives
• To identify the goals and key features of Ontario’s
population-based cancer screening programs
(breast, cervical and colorectal)
• To explore and understand current evidence on
cancer screening
• To apply the evidence-based guidelines to relevant
cancer screening case studies
2
Agenda Outline
1. Benefits and Harms of Screening
2. Spotlight on Screening Programs
• Screening rate targets:
challenges/opportunities
• Latest evidence-based guidelines
• Current program performance
• Relevant case studies
3
Potential Benefits of Screening
• Reduced mortality and morbidity from the
disease, and in some cases reduced
incidence
• More treatment options when cancer
diagnosed early or at a pre-malignant
stage
• Improved quality of life
• Peace of mind
5
Possible Harms of Screening
• Anxiety about the test
• False-positive results
‾ Psychological harm
‾ Labeling due to negative association with disease
‾ Unnecessary follow-up tests
• False-negative results
‾ Delayed treatment
• Over-diagnosis and over-treatment
6
Screening Activity Report (SAR)
Purpose
Approach
Motivation: Enhance
physician motivation to
improve screening rates
Dashboard displays a comparison of a
physician’s screening rates relative to
peers in LHIN and province
Administration: Provide
support to foster improved
screening rates
Provides detailed lists of all eligible and
enrolled patients displaying their
screening-related history; clinic staff can be
appointed as delegates
Failsafe: Identify
participants who require
further action
Patients with abnormal results with no
known follow-up are clearly highlighted on
the reports
Performance: Improve
physician adherence to
guidelines and program
recommendations
Methodology based on the program’s
clinical guidelines and recommendations
for best practice
7
SAR Dashboard
8
Spotlight on
Breast Cancer Screening
9
Do I Need to be Screened for
Breast Cancer?
http://www.youtube.com/watch?v=PYTg3gcbuBo&index=34&list=
FLXu1tmVgO0Srr3vizeTiUUA
Sensitivity and Specificity
Cancer
Site
Breast
Test
Mammography
Sensitivity
77% to 95%
Specificity
94% to 97%
Less sensitive in
younger women
and those with
dense breasts
Breast
MRI
71% to 100%
81% to 97%
Studies
conducted in
populations of
women at high
risk for breast
cancer
Studies
conducted in
populations of
women at high
risk for breast
cancer
11
Effectiveness of Screening
Cancer
Site
Breast
Effectiveness of
Screening
With mammography:
21% reduction in
mortality with regular
screening in 50 to 69year-olds
Type of
Studies
Randomized
controlled
trials
12
Burden of Disease
• 1 in 9 Canadian women will develop
breast cancer in their lifetime
• In Ontario, an estimated 9,300
women will be diagnosed and 1,950
will die of breast cancer in 2013
• Most frequently diagnosed cancer in
women
13
Burden of Disease
• Breast cancer occurs primarily in women
aged 50 to 74 (57% of cases); 8 in every
10 breast cancers are found in women
aged 50+
• More deaths occur in women aged 80+
than in any other age group
• Reflects benefits of screening/treatment in
prolonging life for middle-aged women
14
Screening Rates
61% of eligible Ontario women age
50 to 74 years were screened for
breast cancer in 2010–2011
• 71% screened in OBSP,
• 29% outside of OBSP
• The national target is to increase
screening rates to ≥ 70% of the
eligible population
15
Challenges
• Screening rates have slowed; lowest in 70 to
74 year (53%) followed by 50 to 54 year age
groups (58%)
• Recruitment of under- and never-screened
women (e.g., marginalized groups)
• Increasing awareness of and referrals to the
high risk program among public and providers
• Controversy around screening women at
average risk in the 40 to 49 age group
16
Screening Recommendations
Screening
Modality
Mammography
Canadian Task Force on
Preventive Health Care (2011)
•
•
•
•
MRI
•
•
Women 40 to 49: Recommend not routinely
screening
Women 50 to 69: Recommend routinely screening
Women 70 to 74: Recommend routinely screening
Women aged 50 to 74: suggest screening every 2 to
3 years
Women aged 40 to 74 who are not at high risk for
breast cancer: Recommend not routinely screening
with MRI
Women at high risk aged 30 to 69: Recommend
annual screening with MRI (in addition to
mammography)
17
Screening Recommendations
Screening
Modality
Breast self
examination
(BSE)
Canadian Task Force on
Preventive Health Care (2011)
Recommend not advising women
to routinely practice BSE
Clinical breast Recommend not routinely
examination
performing CBE alone or in
(CBE)
conjunction with mammography
Breast Cancer Screening Participation
Rate, by LHIN
100
90
80
National target: ≥ 70%
70
60
50
40
30
20
10
0
OBSP
Non OBSP
Breast Cancer Screening Participation
Rate, by LHIN
100
90
80
70
60
50
40
30
20
10
0
National target: ≥ 70%
2004-2005
2006-2007
2008-2009
2010-2011
Ontario Breast Screening Program
(OBSP)
• Province-wide organized breast cancer
screening program since 1990
• Ensures Ontario women at average risk aged
50 to 74 receive benefits of regular
mammography screening
• Expansion of OBSP (July 2011) extended
benefits of organized screening to women at
high risk aged 30 to 69 (to be screened annually
with mammography and MRI)
21
OBSP Eligibility Criteria
Average-risk screening:
• Women aged 50 to 74 years
• Asymptomatic
• No personal history of breast cancer
• No current breast implants
22
OBSP Eligibility Criteria
High risk screening:
• Women aged 30 to 69 years
• Asymptomatic
• May have personal history of breast cancer
• May have current breast implants
• Confirmed to be at high risk for breast cancer
23
Heard About BRCA1, BRCA2,
Lately?
24
OBSP High Risk Eligibility Criteria
Four Assessment Categories:
1)
Confirmed carrier of gene mutation
2)
First-degree relative of mutation carrier and
refused genetic testing
3)
≥ 25% personal lifetime risk (IBIS, BOADICEA
tools
4)
Radiation therapy to chest more than 8 years
ago and before age 30
25
OBSP Screening Intervals
Average risk: biennial recall (every 2 years)
Increased risk: annual (ongoing) recall
• High-risk pathology lesions
• Family history
Increased risk: one-year (temporary) recall.,
• Breast density ≥ 75%
• Radiologist, referring MD, recommendation
• Client request
High risk: annual recall
26
OBSP Features – Average Risk
• Two-view mammography
• Automatic client recall
• Physician and client notification of results
• Quality assurance for all components
• Monitoring follow-up/outcomes
• Program evaluation
• Comprehensive information system
27
OBSP Features – High Risk
• Referral needed
• https://www.cancercare.on.ca/common/pages/UserFile
.aspx?fileId=285487
• Patient navigator
• If appropriate, referral to genetic assessment
• Screening breast MRI and mammogram
• Screening breast ultrasound if MRI
contraindicated
28
Mammography Accreditation
Program
Canadian Association
of Radiologists (CAR)
set standards for:
• Equipment
• Image quality
• Radiology staff skills and
qualifications
100% of OBSP affiliated
sites are CAR accredited.
29
30
Diagnostic Assessment Program
• Single point of access for diagnostic
services
• Coordinate patient care
• Help family physicians
gain access to
diagnostic tests and
results in a timely
manner
31
DAP Characteristics
• Patient-centered
 Improve access
 Provide support
 Timely diagnosis
• Coordinated referral and follow up
• Established and monitored quality
indicators
32
Patient Navigator
• Individual who guides
each patient through
the healthcare system
• Help patients to overcome barriers within
the system
33
DAP Healthcare Benefits
• Improve coordination of care
• Decrease wait times
• Improve patient
experience
• Minimize disease
progression
34
Breast Health Centre DAP
 What is the role of a Breast Health Centre?
1. Provides navigation of abnormal follow up
2. Reduces wait times for diagnostic assessment
3. Responds to client requests for information
4. Coordinates services and provides support
5. All of the above
35
OBSP Resources
https://www.cancercare.on.ca/common/pages/UserFile.as
px?fileId=280490
https://www.cancercare.on.ca/pcs/screening/breastscreeni
ng/patient_education/
https://www.publications.serviceontario.ca/pubont/servlet/e
com/
36
Clinical Case Study 1
• 42-year-old asymptomatic woman asks to be
screened for breast cancer
• Her grandmother was diagnosed with breast
cancer at age 65
What is your response?
37
Clinical Case Study 2
• 39-year-old asymptomatic woman asks to
be screened for breast cancer
• Her mother was diagnosed with breast
cancer at age 37
What is your response?
38
Clinical Case Study 3
• Your 58-year-old average risk
asymptomatic patient in a small rural
community asks about breast screening
• She wonders if she should take the longer
trip to Community A where there is a new
digital mammography unit; go to
Community B, which is closer and has an
analogue unit; or wait for the OBSP coach
(with a digital unit) to come to town
What is your advice?
39
Questions?
Thank You