Spotlight on Colorectal Cancer Screening Maximizing Benefits and Minimizing Harms

Faculty/Presenter Disclosure 2 Faculty: [Your Name Here] MD and RPCL with CCO “Spotlight on Breast, Cervical and Colorectal Cancer Screening: Maximizing Benefits and Minimizing Harms” Relationship with Commercial Interests: Not applicable

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

Mitigating Potential Bias 4 Not applicable

Learning Objectives To better understand the benefits and harms of cancer screening 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 5

Agenda Outline 1.Provincial Goals for Cancer Screening 2.Role of Primary Care 3.Benefits and Harms of Screening 4.Spotlight on Screening Programs Screening rate targets: challenges/opportunities Latest evidence-based guidelines Current program performance Relevant case studies 6

Cancer Care Ontario Vision and Mission 2012 – Our New Vision Working together to create the best health systems in the world Our New Mission Together, we will improve the performance of our health systems by driving quality, accountability, innovation, and value

Cancer Care Ontario (CCO) Provincial government agency Supports and enables provincial strategies Directs and oversees > $800 million Three lines of business: Cancer – CCO’s core mandate since 1943 to improve prevention, treatment and care Chronic Kidney Disease – Ontario Renal Network launched June 2009 Access to Care – Building on Ontario’s Wait Times Strategy; provides information solutions that enable improvements to access 8

CCO’s Screening Goal VISION Working together create the best cancer system in the world VISION Working together create the best cancer system in the world GOAL Increase screening rates for breast, cervical and colorectal cancers, and integrate into primary care Increase patient participation in screening Increase primary care provider performance in screening Establish a high- quality, integrated screening program 9

10 CS Strategic Framework GOAL Accelerate reduction in cancer mortality by implementing a coordinated, organized cancer screening program across Ontario GOAL Accelerate reduction in cancer mortality by implementing a coordinated, organized cancer screening program across Ontario STRATEGIC DIRECTIONS Enhance coordination and collaboration Improve quality Maximize resources and build capacity Maximize resources and build capacity Promote innovation and flexibility Advance clinical engagement Deliver patient- centred care

What is Screening? The 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 11

Types of Screening 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 12

Current State of Programs 3 cancer screening programs:  ColonCancerCheck (CCC)  Ontario Breast Screening Program (OBSP)  Ontario Cervical Screening Program (OCSP) Different stages of development Different information systems 13

Ontario Cancer Statistics Cancer Type# New Cases# Deaths Breast9,300 (F)1,950 (F) Cervical 610 (F) 150 (F) Colorectal4,800 (M) 3,900 (F) 1,850 (M) 1,500(F)

CCO and Primary Care RPCL LHIN 1 RPCL LHIN 2 RPCL LHIN 3 RPCL LHIN 4 RPCL LHIN 5 RPCL LHIN 6 RPCL LHIN 7 RPCL LHIN 8 RPCL LHIN 9 RPCL LHIN 10 RPCL LHIN 11 RPCL LHIN 12 RPCL LHIN 13 RPCL LHIN 14 Primary Care Program Provincial Lead 15

Cancer Journey and Primary Care 16 PRIMARY CARE

Primary Care and Cancer Screening The essential role family physicians play in screening intervention is widely recognized:  Identify screen-eligible populations and recommend appropriate screening based on guidelines and patient’s history  Manage follow-up of abnormal screen test results 17

SAR Dashboard 18

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 19

Potential Benefits of Screening 20 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

Possible Harms of Screening 21 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

Sensitivity and Specificity 22 Cancer Site TestSensitivitySpecificity BreastMammography77% to 95% Less sensitive in younger women and those with dense breasts 94% to 97% BreastMRI71% 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 ColorectalgFOBT (repeat testing) 51% to 73%90% to 100% CervicalPap test44% to 78%91% to 96% CervicalHPV test88% to 93% * * Sensitivityfor CIN II 86% to 93%

Effectiveness of Screening 23 Cancer SiteEffectiveness of ScreeningType of Studies BreastWith mammography: 21% reduction in mortality with regular screening in 50 to 69-year- olds Randomized controlled trials CervicalWith Pap testing: Incidence and mortality reduced by up to about 80% with regular screening Observational studies and Global incidence data ColorectalWith FOBT: 15% reduction in mortality with biennial screening Randomized controlled trials

Spotlight on Colorectal Cancer Screening 24

25 Burden of Disease In Ontario, an estimated 8,700 new cases of colorectal cancer will be diagnosed and 3,350 people will die from it in 2013 Incidence of colorectal cancer in Canada is similar to other developed countries, and is among the highest in the world Approximately 93% of cases are diagnosed in people aged 50 years and older 5-year relative survival rate for colorectal cancer has improved over the past decade in Canada

Adenoma-Carcinoma Sequence Majority of colorectal cancers arise from adenomatous polyps Progression to invasive cancer takes 10 years on average 26

Colorectal Cancer Sub Site Cancers arising in the left vs. right side of colon have different epidemiological, histological and molecular features Higher proportion of right-sided colon cancers diagnosed in women Survival rates are poorer in those diagnosed with right colon cancer 27

Recommended Screening Average Risk: fecal occult blood test (FOBT) Biennial (every 2 years), aged 50 to 74 Follow up abnormal FOBT with colonoscopy Increased Risk: Colonoscopy One or more first-degree relatives with a history of colorectal cancer Begin at age 50, or 10 years earlier than age relative was diagnosed, whichever is first 28

Average risk patients who have had a negative/normal colonoscopy should not be screened for 10 years, following which screening should resume using either FOBT or colonoscopy FOBT and Colonoscopy 29

Evidence for Screening Using FOBT A meta-analysis of 3 randomized clinical trials shows that regular screening with FOBT reduces colorectal cancer mortality by 15% 30

ColonCancerCheck (CCC) Program Goals Reduce mortality through an organized screening program Improve capacity of primary care to participate in comprehensive colorectal cancer screening 31

Colonoscopy and FOBT quality standards Increased colonoscopy capacity across Ontario Primary care provider awareness Program-branded FOBT kits Financial incentives for family physicians Patient correspondence Initiatives to assist with follow-up of abnormal results CCC Program Features 32

Patient correspondence includes: FOBT result letters Recall/reminder letters Invitation letters to people aged 50 to 74 CCC Program Features 33

Assessing Risk 34 Assess for colorectal cancer (CRC) signs and symptoms Symptoms (high risk of CRC) Age 50 to74; no symptoms; no affected 1 st degree relatives (average risk of CRC) No symptoms; 1 or more 1 st degree relatives with CRC (increased risk of CRC) Refer to colonoscopy; FOBT not appropriate Refer to colonoscopy; start at 50 years of age or 10 years before age of relative’s diagnosis FOBT every 2 years

FOBT Screening Participation Rate, by LHIN CCO program target 2010: 40% 35

36 Overdue for CRC Screening

37 FOBT Abnormal Rate

Follow-up Colonoscopy After +FOBT 38

Colonoscopy Wait Time Benchmarks ColonCancerCheck’s program colonoscopy wait time benchmarks (adapted from the Canadian Association of Gastroenterology benchmarks) are: 8 weeks for those with a FOBT+ result 26 weeks for those with a family history 39

Clinical Case Study 1 A 54-year-old asymptomatic male comes in for his periodic health visit What screening test would you suggest for him? 40

Clinical Case Study 2 A 47-year-old woman inquires about colorectal cancer screening Her mother was diagnosed at age 65 with colorectal cancer What would you suggest? 41

CCC Resources For more information: 42

Call to Action! Screen Your Patients 43 ScreenedNot Screened Breast 61%39% Cervical 65%35% Colorectal 30%47%