Transcript 2013 Colorectal Cancer Screening Slide Deck

Spotlight on
Colorectal Cancer Screening
Maximizing Benefits and Minimizing Harms
Faculty/Presenter Disclosure
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
2
Disclosure of Commercial
Support
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
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Mitigating Potential Bias
Not applicable
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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
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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
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Cancer Care Ontario
Vision and Mission 2012–2018
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
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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
Access to Care
– Building on Ontario’s
Wait Times Strategy;
provides information
solutions that enable
improvements to access
Chronic Kidney Disease
– Ontario Renal Network
launched June 2009
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CCO’s Screening Goal
VISION
Working together create the best cancer
system in the world
Increase patient
participation in
screening
Increase primary
care provider
performance in
screening
Establish a highquality, integrated
screening program
GOAL
Increase screening rates for breast, cervical and
colorectal cancers, and integrate into primary care
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CS Strategic Framework
GOAL
Accelerate reduction in cancer mortality by implementing a
coordinated, organized cancer screening program across Ontario
STRATEGIC DIRECTIONS
Deliver
patientcentred
care
Enhance
coordination
and
collaboration
Improve
quality
Maximize
resources
and build
capacity
Promote
innovation
and
flexibility
Advance
clinical
engagement
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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
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Types of Screening
Population-Based
Screening
Opportunistic
Case-Finding
Offered systematically to all
individuals in defined target
group within a framework of
agreed policy, protocols,
quality management,
monitoring and evaluation
Offered to an individual
without symptoms of the
disease when he/she presents
to a healthcare provider for
reasons unrelated to that
disease
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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
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Ontario Cancer Statistics 2013
Cancer Type # New Cases
Breast
Cervical
Colorectal
# Deaths
9,300 (F)
1,950 (F)
61014 (F)
150 (F)
4,800 (M)
3,900 (F)
1,850 (M)
1,500(F)
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CCO and Primary Care
RPCL
LHIN
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RPCL
LHIN
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RPCL
LHIN 1
RPCL
LHIN 2
RPCL
LHIN
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RPCL
LHIN 3
Primary Care
Program
RPCL
LHIN
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RPCL
LHIN 4
Provincial
Lead
RPCL
LHIN
10
RPCL
LHIN 5
RPCL
LHIN 9
RPCL
LHIN 6
RPCL
LHIN 8
RPCL
LHIN 7
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Cancer Journey and
Primary Care
PRIMARY CARE
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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
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SAR Dashboard
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Screening Activity Report (SAR)
Purpose
Approach
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 screeningrelated 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
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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
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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
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Sensitivity and Specificity
Cancer
Site
Breast
Test
Sensitivity
Mammography 77% to 95%
Specificity
94% to 97%
Less sensitive in younger
women and those with dense
breasts
Breast
71% to 100%
81% to 97%
Studies conducted in
populations of women at high
risk for breast cancer
Studies conducted in populations
of women at high risk for breast
cancer
51% to 73%
90% to 100%
Cervical
gFOBT (repeat
testing)
Pap test
44% to 78%
91% to 96%
Cervical
HPV test
88% to 93% *
86% to 93%
Colorectal
MRI
* Sensitivityfor CIN II
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Effectiveness of Screening
Cancer Site Effectiveness of Screening
Type of Studies
Breast
With mammography:
Randomized
21% reduction in mortality with
controlled trials
regular screening in 50 to 69-yearolds
Cervical
With Pap testing:
Incidence and mortality reduced
by up to about 80% with regular
screening
Observational studies
and Global incidence
data
Colorectal
With FOBT:
15% reduction in mortality with
biennial screening
Randomized
controlled trials
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Spotlight on
Colorectal Cancer Screening
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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
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Adenoma-Carcinoma Sequence
• Majority of colorectal cancers arise
from adenomatous polyps
• Progression to invasive cancer takes
10 years on average
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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
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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
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FOBT and Colonoscopy
• 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
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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%
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ColonCancerCheck (CCC)
Program Goals
• Reduce mortality through an organized
screening program
• Improve capacity of primary care to
participate in comprehensive colorectal
cancer screening
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CCC Program Features
• 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
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CCC Program Features
Patient correspondence includes:
• FOBT result letters
• Recall/reminder letters
• Invitation letters to people aged 50 to
74
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Assessing Risk
Assess for colorectal
cancer (CRC) signs
and symptoms
Symptoms
(high risk of CRC)
No symptoms; 1 or more
1st degree relatives with
CRC
(increased risk of CRC)
Age 50 to74;
no symptoms; no
affected 1st degree
relatives
(average 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
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FOBT Screening Participation Rate,
by LHIN
100
90
80
70
60
50
CCO program target 2010: 40%
40
30
20
10
0
2004-2005
2006-2007
2008-2009
2010-2011
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Overdue for CRC Screening
100
90
80
Overdue (%)
70
60
50
40
30
20
10
0
2008
2009
Year
2010
2011
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FOBT Abnormal Rate
Male
Abnormal FOBT result (%)
6
Female
5
4
3
2
1
0
50–74
50–54
55–59
60–64
65–69
70–74
Age group
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Colonoscopy within 6 months (%)
Follow-up Colonoscopy After +FOBT
100
90
80
70
60
50
40
30
20
10
0
2008
2009
2010
2011
Year
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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
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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?
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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?
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CCC Resources
For more information:
www.cancercare.on.ca/pcresources
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Call to Action!
Screen Your Patients
Screened
Not Screened
Breast
61%
39%
Cervical
65%
35%
Colorectal
30%
47%
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