1. Breast Cancer Screening Guidelines Across Canada Environmental Scan July 2015

2. Background Quarterly, the Canadian Partnership Against Cancer collects information from the provinces/territories and international organizations on the status of population-based breast cancer screening programs and/or strategies. This information compares current guidelines and evidence-based recommendations in order to identify leading practices. July 2015

3. Presentation Outline  Canadian Task Force on Preventive Health Care Guidelines  Provincial and Territorial Screening Guidelines  Breast Cancer Screening Programs in Canada  Recall Following a Normal Mammogram  High Breast Density Recommendations  High Risk Screening Guidelines (Breast MRI)  Quality Assurance Measures July 2015

4. Canadian Task Force on Preventive Health Care Guidelines The Canadian Task Force on Preventive Health Care (2011) recommends the following for breast cancer screening amongst average risk women: 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) July 2015

5. 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) For more information please visit: http://canadiantaskforce.ca/ http://canadiantaskforce.ca/ July 2015

6. Breast Cancer Screening Programs: Provincial and Territorial Clinical Practice Guidelines Start AgeIntervalStop Age Nunavut*Current guidelines under review Northwest TerritoriesBegin at age 50 (age 40 – 49 accepted by physician referral for initial screen but not actively recruited) For women aged 40-49 – annual recall For women aged 50-74 - biennial recall 75 YukonBegin at age 50 (age 40-49 accepted by self referral but not actively recruited) For women aged 50-69 - biennial recall For women aged 70-74 - biennial recall 75+ British ColumbiaBegin at age 50 (age 40-49 accepted by self referral but not actively recruited) For women aged 40-49 - biennial recall For women aged 50-69 - biennial recall For women aged 70-74 - biennial recall For higher than average risk women aged 40-74 – annual recall 74 (age 75+ accepted by self referral but not actively recruited or recalled) AlbertaBegin at age 50 (age 40-49 accepted with physician referral for the first screen) For women aged 40-49 - annual recall For women aged 50-74 - biennial recall** 75+ ** (Since September 2013) SaskatchewanBegin at age 50 (age 49 accepted on the mobile if turning 50 in same calendar year) For women aged 50-69 - biennial recall For women aged 70-74 - biennial recall (only if previously enrolled in the program) 75+ ManitobaBegin 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 74 (age 75+ accepted by self referral but not actively recruited or recalled) OntarioBegin 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** 74 (75+ only with a primary care provider referral) *No screening program available in Nunavut but guidelines are under review **Women who meet specific criteria that may put them at increased risk for breast cancer will be recalled annually For asymptomatic women at average risk:

7. Breast Cancer Screening Programs: Provincial and Territorial Clinical Practice Guidelines, cont’d Start AgeIntervalStop Age Québec Begin at age 50 (accept ages 35-49 only with physician referral, at a program designated screening or referral center) For women aged 50-69 - biennial recall 69 (age 70+ only with a physician referral, at a program designated screening or referral center) New BrunswickBegin at age 50 (age 40-49 accepted only with physician or nurse practitioner referral) For women aged 50-74- biennial recall74 (age 74+ only with a physician or nurse practitioner referral) (Since June 1, 2013) Nova ScotiaBegin at age 40For women aged 40-49 - annual recall For women aged 50-69 - biennial recall 70+ Prince Edward IslandBegin at age 40For women aged 40-49 - annual recall For women aged 50-69 - biennial recall For women aged 70-74 - biennial recall 74 Newfoundland & Labrador Begin at age 50 (age 40-49 accepted only with physician referral) For women aged 50-74 - biennial recall 74 (age 74+ only if previously enrolled in the program) For asymptomatic women at average risk:

8. Distribution of mammography and CBE among breast screening programs Ontario Quebec Manitoba Saskatchewan Alberta British Columbia Yukon Territory Northwest Territories Nunavut New Brunswick Nova Scotia Prince Edward Island Newfoundland & Labrador (1990) (1998) (1995) (1990) (1988) (2003) (1990) (1995) (1991) (1998) (1996) Province/Territory (Program Distribution) Mammography alone Clinical Breast Examination & Mammography No Organized Program

9. Breast Cancer Screening Programs in Canada Program Start DateProgram NameAgency Responsible for Program Administration Nunavut* Northwest Territories2003 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 Yukon1990Yukon Mammography ProgramGovernment of Yukon (Yukon Hospital Corporation) British Columbia1988Screening Mammography Program of British Columbia BC Cancer Agency Alberta1990Alberta Breast Cancer Screening ProgramAlberta Health Services Saskatchewan1990Screening Program for Breast CancerSaskatchewan Cancer Agency Manitoba1995BreastCheckCancerCare Manitoba Ontario1990Ontario Breast Screening ProgramCancer Care Ontario Québec1998 Programme québécois de dépistage du cancer du sein (PQDCS) Ministère de la Santé et des Services sociaux New Brunswick1995New Brunswick Breast Cancer Screening Services New Brunswick Cancer Network (NB Department of Health) Nova Scotia1991Nova Scotia Breast Screening ProgramGovernment of Nova Scotia Prince Edward Island1998PEI Breast Screening ProgramGovernment of Prince Edward Island Newfoundland and Labrador 1996Breast Screening Program for Newfoundland and Labrador Eastern Health, Cancer Care Program *No screening program available in Nunavut but guidelines are under review

10. 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 Nunavut* Northwest Territories  Regional Coordination Centres  40-74 Yukon  Screening centre40-74 British Columbia  Centralized management (Program or Agency)  40-74 Alberta  (AHS Screen Test only) Centralized management (Program or Agency)  40-74 Saskatchewan  Centralized management (Program or Agency)  50-74 Manitoba  Centralized management (Program or Agency)  50-74 Ontario  Centralized management (Program or Agency)  50-74** Québec  Regional coordination centres  50-69 New Brunswick  (not all regions) Screening centre  50-74 Nova Scotia  (postcard)Centralized management (Program or Agency)  40-69 Prince Edward Island  Screening centre  40-74 Newfoundland and Labrador  Screening centre  50-74 *No screening program available in Nunavut **includes ages 30-49 if part of the high risk screening program

11. 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 the country. Automatic annual recall based on breast density Value considered high breast density Recommendation for high breast density levels Northwest Territories  > 75%Annual recall Saskatchewan  >75%Annual recall Ontario  > 75%Annual recall Nova Scotia  >75%Annual recall Newfoundland and Labrador  >75%Annual recall July 2015

12. High Risk Screening: MRI Referral Guidelines Self-reported family history (>=2) of breast cancer (first degree relative) Self- reported 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 Bannayan-Riley- Ruvalcaba syndrome e-cadherin mutation British Columbia **   ** Alberta  Ontario   ***   ****  *****  Nova Scotia   ****  Newfoundland and Labrador  (>=3)  Currently there are five provinces (British Columbia, Alberta, Ontario, Nova Scotia, Newfoundland and Labrador) that have developed standard guidelines for MRI referral. Table: The criteria or evidence that MRI referral is based upon per province *British Columbia allows women with a 50% risk of BRCA mutation who have not yet received their BRCA testing ** British Columbia includes the following syndromes: Li Fraumeni Syndrome, Cowden’s Syndrome, HDGC (CDH-1), Peutz-Jegher’s Syndrome ***First degree relative, and have declined genetic testing themselves **** ≥25% using validated assessment tool ***** Chest irradiation before age 30 and at least 8 years prior to the screen ⱡ Upon confirmation of high risk status after genetic assessment

13. High Risk Screening: MRI Referral Guidelines, cont’d Ontario has implemented an MRI screening component to its organized screening program for women considered at high risk for breast cancer. British Columbia, Nova Scotia and Alberta have established guidelines for the use of MRI among women considered to be at high risk (i.e. in British Columbia the women considered are confirmed cases of BRCA1 and BRCA2 mutation only). For more information on MRI guidelines for Nova Scotia please visit http://breastscreening.nshealth.ca/guidelines.pdfhttp://breastscreening.nshealth.ca/guidelines.pdf Newfoundland and Labrador is exploring the appropriateness of using MRI among women considered to be at high risk July 2015

14. Quality Assurance: Client Satisfaction Surveys Northwest Territories, British Columbia, Alberta, Manitoba, Nova Scotia and Newfoundland and Labrador evaluate client satisfaction on an ongoing basis. Mammography examParticular Screening Centre Organized Screening Program Northwest Territories (STHA site)  British Columbia  Alberta  Manitoba  Nova Scotia  Newfoundland and Labrador  Table: Specific information collected when evaluating client satisfaction per province/territory July 2015

15. Quality Assurance: Evaluation of Radiologist Performance Most provinces and territories evaluate radiologists on their level of performance on an annual basis with the exceptions of Yukon and Prince Edward Island. New Brunswick 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 Specific volume requirements for radiologists Northwest Territories (STHA site) ᶲ  480 / year British Columbia  2,500 / year Alberta  480 / year* † Saskatchewan  1,000 / year Manitoba  1,000 / year** Ontario  1,000 / year* † Québec  750/ year New Brunswick***1,200/ year* Nova Scotia  2,000 / year Newfoundland and Labrador  2,000 / year *Includes diagnostic and screening mammograms **All radiologists greatly exceed this number *** New Brunswick program policies stipulate that the RHAs must have a system for the annual review of mammography screening outcome data with Radiologists † This figure is currently under review and will likely be changed to align with CAR MAP requirements. ᶲ For Northwest Territories, the level of performance is done on the program as a whole (not specific radiologist) due to small volume numbers.

16. Reference Slide Please use the following reference when citing information from this presentation: Cancerview.ca. Breast Cancer Screening Guidelines Across Canada: Environmental Scan. Toronto: Canadian Partnership Against Cancer; [enter date]. Available from: [enter URL link] July 2015