1. TriLHIN ICS Orientation Workshop July 16, 2014 Dr. Jan Owen, MD, CCFP, FCFP Regional Primary Care Lead, SWRCP Screening Cancer

2. 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

3. 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

4. Cancer Journey & Primary Care PRIMARY CARE 4

5. 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

6. 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

7. Screening Activity Report (SAR) PurposeApproach 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

8. SAR Dashboard 8

9. Spotlight on Breast Cancer Screening 9

10. Do I Need to be Screened for Breast Cancer? http://www.youtube.com/watch?v=PYTg3gcbuBo&index=34&list= FLXu1tmVgO0Srr3vizeTiUUA

11. Sensitivity and Specificity Cancer Site TestSensitivitySpecificity Breast Mammography 77% to 95% Less sensitive in younger women and those with dense breasts 94% to 97% Breast MRI 71% to 100% Studies conducted in populations of women at high risk for breast cancer 81% to 97% Studies conducted in populations of women at high risk for breast cancer 11

12. Effectiveness of Screening Cancer Site Effectiveness of Screening Type of Studies BreastWith mammography: 21% reduction in mortality with regular screening in 50 to 69- year-olds Randomized controlled trials 12

13. 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

14. 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

15. 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

16. 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

17. Screening Recommendations 17 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)

18. Screening Recommendations Screening Modality Canadian 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

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

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

21. 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

22. OBSP Eligibility Criteria Average-risk screening: Women aged 50 to 74 years Asymptomatic No personal history of breast cancer No current breast implants 22

23. 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

24. Heard About BRCA1, BRCA2, Lately? 24

25. 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

26. 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 OBSP Screening Intervals 26

27. 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 OBSP Features – Average Risk 27

28. OBSP Features – High Risk Referral needed https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=285487 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

29. 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. 30

31. 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

32. DAP Characteristics Patient-centered Improve access Provide support Timely diagnosis Coordinated referral and follow up Established and monitored quality indicators 32

33. Patient Navigator 33 Individual who guides each patient through the healthcare system Help patients to overcome barriers within the system

34. DAP Healthcare Benefits 34 Improve coordination of care Decrease wait times Improve patient experience Minimize disease progression

35. Breast Health Centre DAP 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  What is the role of a Breast Health Centre? 35

36. 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

37. 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

38. 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

39. 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

40. Questions? Thank You