1. Dr. Praveen Bansal, MD, CCFP Regional Primary Care Lead, Central West, Cancer Care Ontario November 23, 2013 Annual Scientific Assembly Spotlight on Cancer Screening: Breast, Cervical, & ProstateCancer Screening

2. Faculty/Presenter Disclosure 2 Faculty: Dr. Praveen Bansal, MD and Regional Primary Care Lead, Cancer Care Ontario, Mississauga Halton/Central West Regional Cancer Program Relationship with Commercial Interests: Not applicable

3. Disclosure of Commercial Support 3 Relationship with Commercial Interests: The delivery of this Cancer Screening program is governed by an agreement with Cancer Care Ontario. No affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization

4. Mitigating Potential Bias 4 Not applicable

5. Outline 5 1)Cancer Screening Overview 2)Breast Cancer Screening Update 3)Cervical Cancer Screening Update 4)The Prostate Cancer Debate 5)Clinical Case Studies

6. What is Screening? 6 Application of a test, examination or other procedure to asymptomatic target population to distinguish between: Those who may have the disease and Those who probably do not

7. Types of Screening 7 Population-Based Screening Offered systematically to all individuals in defined target group within a framework of agreed policy, protocols, quality management, monitoring and evaluation Opportunistic Case-Finding Offered to an individual without symptoms of the disease when he/she presents to a healthcare provider for reasons unrelated to that disease

8. Spotlight on: Breast Cancer Screening 8

9. Screening Recommendations 9 Screening Modality Canadian Task Force on Preventive Health Care (2011) Mammography 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 MRI 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) Canadian Task Force on Preventative Health: 21% reduction in mortality of Br Ca with regular mammo screening in 50-69 year old females

10. Screening Recommendations 10 Screening ModalityCanadian Task Force on Preventive Health Care (2011) Breast self examination (BSE) Recommend not advising women to routinely practice BSE Clinical breast examination (CBE) Recommend not routinely performing CBE alone or in conjunction with mammography

11. Ontario Breast Screening Program (OBSP) 11 Province-wide organized breast cancer screening program Ensures Ontario women at average risk aged 50 to 74 receive benefits of regular mammography screening Women determined to be at high risk, aged 30 to 69 are screened annually with mammography and MRI

12. 12 Average risk: biennial recall (every 2 years) Increased risk: annual (ongoing) recall, e.g., High-risk pathology lesions Family history Increased risk: one-year (temporary) recall, e.g., Breast density ≥ 75% Radiologist, referring MD, recommendation Client request High risk: annual recall OBSP Screening Intervals

13. Breast Cancer Screening Participation Rate, by LHIN 13 National target: ≥ 70%

14. Spotlight on: Cervical Cancer Screening 14

15. Cervical Cancer Natural History 15

16. Comparison of 2005 and 2011Guidelines 16 Question2005 Guidelines2011 Guidelines Initiation Within 3 years of first vaginal sexual activity with cytology (Pap test) Age 21 Interval after Negative Test Annual until 3 consecutive negative cytology tests, then every 2 to 3 years Every 3 years Cessation Age 70 if adequate and negative screening history in previous 10 years (≥ 3 negative tests) No change Management guidelines for follow-up of abnormal cytology did not change Guidelines summary: www.cancercare.on.ca/screenforlife

17. Screening Initiation 17 Women, age 21 and older who are or have ever been sexually active o Postpone screening until sexually active o Cervical cancer rare < 25 years and extremely rare < 21 years o 10 to 15 years to develop cervical cancer Aligns with other jurisdictions

18. Harms of Screening Adolescents 18 90% will clear infection within 2 years High rates of low-grade mostly transient and clinically inconsequential abnormalities Unnecessary anxiety from detection, biopsies and treatment Treatment linked to possibility of adverse future pregnancy outcomes No protective effect with screening

19. Screening Interval 19 Cytology screening every 3 years unless immunocompromised or previously treated for dysplasia No incremental benefit of screening more frequently than every 3 years Aligns with other jurisdictions

20. Screening Cessation 20 Stop screening at age 70 if adequate and negative screening history o Low incidence of cancer in women who have been adequately screened o Potential discomfort of procedure o Difficulties visualizing squamocolumnar junction Aligns with other jurisdictions

21. Screening: Future State 21 Currently, incidence and mortality reduced by up to about 80% with regular Pap test screening Clear evidence for primary HPV screening Must be implemented within an organized program HPV test must be publicly funded Updated cytology guidelines to bridge transition

22. Cervical Screening Participation Rate, by LHIN 22 Ontario Cancer Plan target 2010: 85%

23. Spotlight on: Prostate Cancer Screening 23

24. Prostate Cancer Screening No organized population-based screening program in Ontario for prostate cancer Most international and national screening guidelines recommend against population-based prostate cancer screening Why? No conclusive evidence that screening non- symptomatic men reduces illness or death 24

25. Prostate Specific Antigen (PSA) Blood test that measures the amount of PSA in a patient’s blood An elevated PSA may indicate: Prostate infection Benign prostatic hyperplasia – BPH Prostate cancer PSA test for screening is not paid for by OHIP PSA test for suspicion of cancer because of man’s history and/or results of DRE, test is covered by OHIP 25

26. Accuracy of PSA For every 100 men over age 50, with no symptoms, who have the PSA test: 10/100 men will have higher (>3.5n g/L)than normal level of PSA 3/10 men will be diagnosed with prostate cancer 7/10 men will not have prostate cancer 90/100 men will have normal (<3.5 ng/L) PSA levels 88/90 will not have prostate cancer 1-2/90 men will have prostate cancer, with normal PSA levels Note: Normal PSA values are age-based 26

27. Expected Harms of Screening False-positive results : 100-120 of every 1000 men screened Most positive tests result in biopsy 1/3 of men that undergo biopsy = fever, infection, bleeding, urination problems, pan 1% will be hospitalized Overdiagnosis : In most cases, prostate cancer does not grow or cause symptoms. If it does grow, usually asymptomatic and does not cause any health problems during a man’s lifetime Cannot distinguish indolent from aggressive cancers Overtreatment : treatment may not be needed for indolent cancers 90% of men receive treatment that are diagnosed Harms: ED, UI, complications from surgery 27

28. Summary 28 CitationSummary Recommendations and Key Points U.S. Preventive Services Task Force, (USPSTF) 2012 The USPSTF recommends against PSA-based screening for prostate cancer in men in the general U.S. population, regardless of age Men are harmed as a result of prostate cancer screening and few, if any, benefit Canadian Partnership Against Cancer, 2009/2012 Concluded that expansion of PSA screening practices beyond the current ad hoc situation is not justified and may even cause harm American College of Physicians, 2013 Men between ages of 50-69 should be informed about limited potential benefits and substantial harms of screening Decision to screen using PSA test should be based on man’s risk for prostate cancer, discussion of benefits and harms, general health, personal preference Average-risk men 69 yoa, or with life expectancy of <10-15 yrs, should not be screened

29. Referral of Suspected Prostate Cancer by Family Physicians Patients with signs and symptoms of prostate cancer, including incidental PSA test results, should be referred to Diagnostic Assessment Programs Diagnostic Assessment Programs Ontario-wide programs that provide fast tracking diagnostic tests Multidisciplinary team of urologist, nurse navigator, radiation oncologist 29

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31. Summary Provincial, population-based screening programs Breast Cancer Screening Average risk women ages 50-74, mammogram, biennially High risk women ages 30-69, mammogram and MRI, annually Cervical Cancer Screening Sexually active women ages 21 and older, Pap test, triennially Currently, no screening guidelines for prostate cancer for average risk men 31

32. Clinical Case Studies 32

33. Clinical Case Study 1 A 17-year-old old female sees you to initiate birth control pill She started having unprotected intercourse 2 months ago Do you screen her for cervical cancer? 33

34. Clinical Case Study 2 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? 34

35. Clinical Case Study 3 A 69-year-old female had a normal Pap test when she was 59 years old, an abnormal test when she was 63 years old and a normal Pap test most recently when she was 66 At what age can she safely stop screening? 35

36. Clinical Case Study 4 A 35-year-old woman had an ASCUS result on her recent Pap test What is the appropriate next step? 36

37. Clinical Case Study 5 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? 37

38. Clinical Case Study 6 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? 38

39. Thank you 39 Dr. Praveen Bansal Praveen.Bansal@trilliumhealthpartners.ca mhcwrcp@trilliumhealthpartners.ca