1. CERVICAL CANCER SCREENING PROGRAMS AND STRATEGIES IN CANADA ENVIRONMENTAL SCAN March 2013

2. Background Quarterly, the Canadian Partnership Against Cancer collects information from the provinces/territories on the status of population-based cervical cancer screening programs and/or strategies.  The information is collected through provincial and territorial leads represented on the Pan-Canadian Cervical Cancer Screening Initiative supported by the Canadian Partnership Against Cancer. March 2013

3. Presentation Outline  Canadian Task Force on Preventive Health Care Guidelines  Provincial and Territorial Guidelines  Cervical Cancer Screening Program Administration  HPV DNA Testing  HPV Immunization  Integration of Immunization and Screening/Information System Preparedness March 2013

4. Canadian Task Force on Preventive Health Care Guidelines The Canadian Task Force on Preventive Health Care (2012) recommends the following for cervical cancer screening:  For women aged <20, routine screening not recommended (Strong recommendation, high quality evidence)  For women aged 20 to 24, routine screening not recommended (Weak recommendation; moderate quality evidence)  For women aged 25 to 29, routine screening is recommended every 3 years. (Weak recommendation; moderate quality evidence)  For women aged 30 to 69, routine screening is recommended every 3 years. (Strong recommendation; high quality evidence)  For women aged ≥70 who have been adequately screened (i.e. 3 successive negative Pap tests in the last 10 years), routine screening may cease. For women aged 70+ who have not been adequately screened should continue screening until 3 negative test results have been obtained. (Weak recommendation; low quality evidence) March 2013

5. Cervical Cancer Screening Programs: Provincial and Territorial Guidelines Start AgeIntervalStop Age Nunavut Age 21 or 3 years post-first sexual contact Every 2 years after 3 consecutive annual negative tests Age 70 with 3 negative tests in previous 10 years Northwest Territories Age 21 or 3 years post first sexual contact Every 2 years after 3 consecutive annual negative tests Age 69 with 3 negative tests in previous 10 years Yukon BCCA guidelines British Columbia Age 21 or 3 years post first sexual contact, whichever occurs first Every 2 years after 3 consecutive annual negative tests Age 69 with 3 negative tests in previous 10 years or 3 annual negative tests (for women inadequately screened) Alberta Age 21 or 3 years post first sexual contact, whichever occurs later Within 5 years, with 3 negative tests at least 12 months apart and then continue every 3 years Age 69 with 3 negative tests in previous10 years or 3 annual negative tests (for women with no screening history) Saskatchewan Age 21 or 3 years post first sexual contact, whichever occurs later Ever y 2 years until 3 consecutive negative tests than every 3 years Age 69 with 3 negative tests in previous10 years or 3 annual negative tests (for women with no screening history) Manitoba Age 21 for all women who have ever been sexually active Every 2 yearsAge 70 with 3 negative tests in previous 10 years

6. Cervical Cancer Screening Programs: Provincial and Territorial Guidelines Start AgeIntervalStop Age Ontario Age 21Every 3 yearsAge 69 with 3 negative tests in previous 10 years Québec Age 21Every 2-3 yearsAge 65 with 2 negative tests in previous 10 years New Brunswick Age 21 or 3 years post first sexual contact, whichever occurs later Every 2 -3 years after 3 consecutive annual negative tests Age 69 with history of adequate negative tests in previous 10 years or 3 annual negative tests (for women with little/no screening history) Nova Scotia* Age 21 or 3 years post first sexual contact whichever occurs first Every 2 years after 3 consecutive annual negative tests Age 75 with adequate negative screening history in the previous 10 yrs (i.e. 3 or more negative tests) Prince Edward Island Age 18 or as soon as becoming sexually active Every 2 yearsAge 75 Newfoundland & Labrador Age 20Every 3 years after 3 consecutive annual negative tests Age 70 with 3 negative tests in previous 10 years or 3 consecutive negative tests (for women with little/no screening history) * NS currently under revision (Feb 2013) March 2013

7. Population-Based Cervical Cancer Screening Program Administration Program Start DateProgram NameAgency Responsible for Program Administration Nunavut N/AProgram not available Government of Nunavut Northwest Territories N/AProgram not available Department of Health & Social Services Yukon Government of Yukon British Columbia 1960Cervical Cancer Screening ProgramBC Cancer Agency Alberta 2003Alberta Cervical Cancer Screening Program Alberta Health Services Saskatchewan 2003Prevention Program for Cervical Cancer Saskatchewan Cancer Agency Manitoba 2000CervixCheckCancer Care Manitoba Ontario 2000Ontario Cervical Screening ProgramCancer Care Ontario Québec N/AProgram not available Ministère de la santé et des services sociaux du Québec New Brunswick 2013-2014New Brunswick Cervical Cancer Prevention and Screening Program New Brunswick Cancer Network (NB Ministry of Health) Nova Scotia 1991Cervical Cancer Prevention ProgramCancer Care Nova Scotia Prince Edward Island 2001PEI Pap Screening ProgramGovernment of Prince Edward Island Newfoundland and Labrador 2003Cervical Screening Initiatives Program Western Health, Department of Health and Community Services March 2013

8. Cervical Cancer Screening Practices  How are eligible individuals identified? NunavutNorthwest TerritoriesYukonBritish ColumbiaAlberta Health centre nurses ; and patients self refer for Pap smear screening Variable by health centre rosters in small communities, well woman checks, and individual recall in regional communities and capital. Information currently not available Self and health care provider Population based Screening registry with linkages with Alberta Health, cytology labs and cancer registry Program Invitations SaskatchewanManitobaOntarioQuebecNew Brunswick Population based screening registry with imports from Ministry of Health for demographic information Program Invitations Population based Screening registry and health care provider Primary health care providers. Opportunistic (especially in practices and local health and community centres – Centres locaux de santé et de servies sociaux) iEHR Client registry & Cervical Cancer Prevention and Screening Repository (CCPSR) Nova ScotiaPrince Edward IslandNewfoundland/Labrador Population based registry and health care provider Population based registry from Medical Affairs division of Health PEI Program Invitations Small media (flyers, brochures, pamphlets, etc.) Cervical Cytology Registry and health care provider

9. Cervical Cancer Screening Practices  Does the screening program send recall letters? NunavutNorthwest TerritoriesYukonBritish ColumbiaAlberta Information currently not available NoInformation currently not available Yes Recall letters sent to care providers only Yes Recall letters sent to women only SaskatchewanManitobaOntarioQuebecNew Brunswick Yes Recall letters sent to women only Phasing in (2013)No Recall letters to women planned to begin 2013/2014 Nova ScotiaPrince Edward IslandNewfoundland/Labrad or NoYes Via health care providers March 2013

10. Cervical Cancer Screening Practices  Who receives normal/abnormal cervical cancer screening test results? NunavutNorthwest TerritoriesYukonBritish ColumbiaAlberta Referring physician or community health nurse Nursing staff in health centres in small and some regional communities and individual physician or NP practitioners in regional/capital communities 1. GP, primary care, or referring physician 1. Woman and GP, primary care, or referring physician Nursing staff in health centres in small and some regional communities and individual physician or NP practitioners in regional/capital communities 2.GP, primary care or referring physician notified by mail 2. Woman and GP, primary care, or referring physician SaskatchewanManitobaOntarioQuebecNew Brunswick 1. Woman and GP, primary care, or referring physician 1. Smear taker1. Ordering provider1. GP, primary care, or referring physician 1. GP, primary care providers or referring physician from Lab 2. Woman and GP, primary care, or referring physician notified by mail 2. Smear taker. Woman notified if follow up is incomplete. 2. Ordering provider2. GP, primary care, or referring physician 2.GP, primary care provider or referring physician notified by mail from Lab Nova ScotiaPrince Edward IslandNewfoundland/Labrador1.Normal result 2.Abnormal result 1. GP, primary care, or referring physician 2.GP, primary care, or referring physician 2. Woman and GP, primary care,or referring physician notified by mail 2. GP, primary care, or referring physician

11. Cervical Cancer Screening Practices  Does the screening program send reminders for follow up after abnormal Pap test results? NunavutNorthwest TerritoriesYukonBritish ColumbiaAlberta 4. No4. YesInformation currently not available 1. Yes to care providers only 1. Yes to care providers and/or women Cytology lab sends follow-up letters to clinicians for abnormal smears on which they have not received a follow-up smear within a specific time frame. SaskatchewanManitobaOntarioQuebecNew Brunswick 1. Yes to care providers only 3. Yes, to women and care providers 4. No Letters sent to providers and women where recommended follow up has not been performed Abnormal Results correspondence to primary care providers and women planned to begin 2013/2014 Nova ScotiaPrince Edward IslandNewfoundland/LabradorOptions 1.Yes, to care providers only 2.Yes, to women only 3.Yes, to women and care providers 4.No 1. Yes, to care providers only 3. Yes, to women and care providers 1. Yes to health care providers, then women Reminder letters are sent to the health care provider who performed the pap test

12. Cervical Cancer Screening Practices  Detection methods in routine use in cervical cancer screening programs NunavutNorthwest TerritoriesYukonBritish ColumbiaAlberta LBC Conventional cytologyLBC Reflex HPV testing for ASCUS in women >30 years old HPV triage for certain Pap test abnormalities HPV triage for certain Pap test abnormalities** SaskatchewanManitobaOntarioQuebecNew Brunswick Conventional cytology LBCConventional cytology LBC (available but no public funding) LBC and conventional cytology HPV triage for certain Pap test abnormalities* (not an insured service) HPV triage for certain Pap test abnormalities (public funding in 2013) HPV triage for certain Pap test abnormalities** Nova ScotiaPrince Edward IslandNewfoundland/Labrador*triage in case of ASC-US/borderline dyskaryosis only **triage in case of ASC-US/ borderline dyskaryosis or LSIL/ mild dyskaryosis Conventional cytology and one district who is piloting LBC testing Conventional cytologyLBC HPV triage for certain Pap test abnormalities*

13. Cervical Cancer Screening Practices  When is a woman sent for a referral to colposcopy in your cervical cancer screening program? Colposcopy Result NUNT*YKBCABSKMBONQCNBNSPENL ASC-US/boderline dyskaryosis (1 st result) No LSIL/mild dyskaryosis (1 st result) LSIL Age >30 ASC-US and HPV+ result (for women >/= 30) Age >30 & 2 nd result 21-30* (for women >/= 30 yrs) Repeated ASC- US/LSIL after previous ASC- US/LSIL Age dependent * AGC yes HSIL+ yes Other: * Refer to Territorial Guideline persistent ASC- US/LSIL for 2 years women >/=50 years - LSIL and HPV + result, Persistent Unsat results due to inflammatio n or obscuring blood women > 50 years with LSIL and HPV + result

14. HPV DNA Testing  Is the use of HPV DNA testing a standard of practice in your province or territory?  If yes, in what capacity is it being used? NunavutNorthwest TerritoriesYukonBritish ColumbiaAlberta Aids triage in women >30 with ASCUS on Pap 3. Pilot trials/ Research 4. Follow up for treatment Information currently not available 3. Pilot trials/Research 4. Follow up for treatment 4. Follow up treatment SaskatchewanManitobaOntarioQuebecNew Brunswick 2. Personal request (only) 3. Pilot trials/Research 4. Follow up treatment (not an insured service) 3. Pilot trials/ Research 5. Not currently a provincial standard of practice Nova ScotiaPrince Edward IslandNewfoundland/LabradorOptions 1. Routine primary screening 2. Personal request (only) 3. Pilot trials/Research 4. Follow up for treatment 5.Other (specify) 3. Pilot trials/ResearchNot used but currently being considered 4. ASCUS Triage for women over 30 years of age March 2013

15. HPV Immunization  Immunization program details ( Check all those that apply) Province or Territory Are adverse effects reported? Are vaccines available outside program? Is there a catch-up strategy? Is there a school- based strategy? Is there a committee in place? NU Grade 6 girls only NT A general NWT Advisory Committee on Immunization YU BC AB SK MB ON QC NB (only for Public Health ‘s school aged based program) NS PEI NL

16. HPV Immunization  Date and age first cohort immunized NunavutNorthwest TerritoriesYukonBritish ColumbiaAlberta Date 2010Fall 2009November 2009December 2008 Age Grade 6 or >/= 9 yrs oldGrade 4, 5 or 6Grade 6 with Grades 7 and 8 Catch-up. Grade 6, 9Grade 5 SaskatchewanManitobaOntarioQuebecNew Brunswick Date December 2008 December 2007December 2008 Age Grade 6 Grade 84th year (age 9-10) of primary and 3 rd year (age14-15) of Secondary school or Grade 9, and girls under 18 in the general population (+ immunosuppressed woman up to 26 years of age) Grade 7 Nova ScotiaPrince Edward IslandNewfoundland/Labrador Date 2007 December 2007 Age Grade 7Grade 6All girls born since 1994 have been offered the vaccine, offered to grade 6 females. 2008- 2009 offered to grade 9 females as a catch up program

17. HPV Immunization  Size of population and number to receive first dose (or estimate) NunavutNorthwest TerritoriesYukonBritish ColumbiaAlberta Size of population 2008-2009 Information currently not available Variable due to regional program implementation at different cohorts. Grade 4, 5 6 would represent ~1200 females Information currently not available GR 6&9 girls, 2008/09 yr. Total target pop. was 47,153. This school year (10/11) is the third and last of the GR 9 program and the first of the two dose GR 6 program, ongoing. Information may be obtained from Population and Public Health of Alberta Health Services Number to receive first dose (or estimate) 2008-2009 Information currently not available Estimate – 71%Information currently not available GR 6: 14,378/22,234=64.7% GR 9: 16,537/24,919=66.4%. This is higher now 2010-2011 Grade 5: receiving series of 3 doses of HPV is 60.2%, Grade 9: receiving series of 3 doses of HPV is 60.1% SaskatchewanManitobaOntarioQuebecNew Brunswick Size of population 2008-2009 Information currently not available eligible HPV vaccine cohort size in 2008- 2009: 7,684 Grade 887,561 (36,741 registered for the second dose in the fourth primary and 50,820 enrolled for the third dose in Secondary 3) for the school population. Estimate 100,000 girls outside of school eligible girls in grade 7 and 8 in public school Number to receive first dose (or estimate) 2008-2009 73% grade 6 girls received at least 1 dose 4, 024 (52.4%) received first dose in 2008-2009 54.9% (3 dose coverage for 1 st year with extended eligibility from grade 8 to 9) 31,673 girls in grade 4 and 45,076 girls in Secondary 3; For the first dose, 84% in grade 4, 91% in Secondary 3 GR 7: 71.9% received 3 doses (+6.6% received 1 or 2 doses); GR 8: 73.8% received 3 doses (+6.5% received 1 or 2 doses) – 2008-2009 Nova ScotiaPrince Edward IslandNewfoundland/ Labrador Size of population 2008-2009 Grade 7 – only no catch up approximately 6000 Grade 62500 grade 6 girls Number to receive first dose (or estimate) 2008-2009 First dose– 84% All 3 doses- 73% Estimate – 80%First dose-87% grade 6; 84% coverage grade 9,

18. HPV Immunization  Does you cervical cancer screening program collect information for the following: Registry/ Database NUNTYKBCABSKMBONQCNBNSPENL HPV vaccination status In process (will collect by 2014) * * ** HPV vaccine type (quadrivalent/ bivalent) Number of doses Age at vaccination Age at each dose Participation rates by HPV vaccination staus (planning phase) (will collect by 2016) (Under evaluati on) (will collect by 2015) (will collect by 2014) * Through self-report data & school-based immunization program/ HPV School based registry (Public Health) **Through medical record data March 2013

19. Screening and Immunization/ Information System Integration  Registries and Databases currently available in your Province or Territory Registry Database NUNTYKBCABSKMBONQCNBNSPENL Population Cancer Cervical Screening (CS) CS Follow up Immunization HPV Immunization * * School aged HPV Immunization by Public Health only March 2013

20. Screening and Immunization/ Information System Integration  If yes to Registry, what is current location? NunavutNorthwest TerritoriesYukonBritish ColumbiaAlberta NA1,2,3,5,6 Health and Social Services NA1 BC MOH 2,3,4,BC Cancer Agency 5,6 Centre for Disease Control 1 Alberta Health 2,3,4,5,6 Alberta Health Services SaskatchewanManitobaOntarioQuebecNew Brunswick 1 SK Health 2,3,4, SK Cancer Agency 5. SK Immunization Management System (SIMS) 6.NA 1,5, 6 Manitoba Health 2, Cancer Care Manitoba 3,4,Manitoba Cervical Cancer Screening Program 1,2,3 Cancer Care Ontario 6 Local public health units 1,2 Provincial 3,4 NA 5,6 Local et régional 1,2,3,5,6,NB Dept of Health (DH) 4 Will be in DH by 2013/2014 Nova ScotiaPrince Edward IslandNewfoundland/LabradorRegistries 1.Population 2.Cancer 3.Cervical Screening 4. Cervical Screening Follow up 5. Immunization 6.HPV Immunization 1,2,3,4 Cancer Care Nova Scotia 5,6 NS Department of Health and Wellness 1.MOH 2.PEI Cancer Treatment Centre 3,4 Cerner Database Cytology Lab,Charlottetown 5.Chief Health Office 6. Public Health 1 Centre for Health Information 2,3,4, Eastern Health 5,6,Regional Health Authorities

21. Screening and Immunization/ Information System Integration  If yes to Registry, what are the personal identifiers? Personal IdentifiersNunavutNorthwest TerritoriesYukonBritish ColumbiaAlberta Name Health Number DOB Address Lab Agency ID NA 1,2,3,5,6 1,2,3,5,6 (community only) 1,2,3,5,6 NA1,2,3,4 1 3,4 2 5,6 1, 2,3,4,5,6 1,2,3,4 3 3, 4, 5, 6 SaskatchewanManitobaOntarioQuebecNew Brunswick Name Health Number DOB Address Lab Agency ID NA 1,2,3,4,5 6 1,2,3,4,5,6 3,4 2,3,4 1,2,3,4,5,6 1,2,5,6 5,6 1,2,5,6 (& gender) 5,6 1,2 (postal code) 5,6 3,4 1,2,3,4,5,6 3 Nova ScotiaPrince Edward IslandNewfoundland/ Labrador Registries 1.Population 2.Cancer 3.Cervical Screening 4. Cervical Screening Follow up 5. Immunization 6.HPV Immunization Name Health Number DOB Address NA 1,2,3,4 1,2,3,4( postal code) 5,6 1,2,3,4,5,6 1,2,3,4 5,6

22. Screening and Immunization/ Information System Integration  Can the Screening Registry be linked to: Registry Database NUNTYKBCABSKMBONQCNBNSPENL Population Cancer Cervical Screening Follow up By 2013/ 2014 HPV Immunization March 2013

23. Reference Slide  Please use the following reference when citing information from this presentation: Cervical Cancer Screening in Canada: Programs and Strategies. Cancer View Canada. Available at: [Enter Link], Accessed: [Enter Date Accessed]. March 2013