Transcript 2013 Breast Cancer Screening Slide Deck

Spotlight on
Breast 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
3
Mitigating Potential Bias
Not applicable
4
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
13
RPCL
LHIN
14
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
Breast Cancer Screening
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Burden of Disease
• 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
• 1 in 9 Canadian women will develop breast cancer in their
lifetime
• 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
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Screening Rates
• 61% of eligible Ontario women aged
50 to 74 years were screened for breast
cancer in 2010–2011
• 71% in OBSP, 29% outside of OBSP
• The national target is to increase
screening rates to ≥ 70% of the
eligible population
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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
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Screening Recommendations
Screening
Modality
Mammography
Canadian Task Force on
Preventive Health Care (2011)
•
•
•
•
MRI
•
•
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
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)
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Screening Recommendations
Screening
Modality
Breast self
examination (BSE)
Canadian Task Force on Preventive
Health Care (2011)
Recommend not advising women to
routinely practice BSE
Clinical breast
examination (CBE)
Recommend not routinely
performing CBE alone or in
conjunction with mammography
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Ontario Breast Screening
Program (OBSP)
• Province-wide organized breast cancer screening
program
• 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)
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OBSP Eligibility Criteria
Average-risk screening:
• Women aged 50 to 74 years
• Asymptomatic
• No personal history of breast cancer
• No current breast implants
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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 (see next slide)
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OBSP Eligibility Criteria
High risk 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
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OBSP Screening Intervals
• Average risk: biennial recall (every 2 years)
• Increased risk: annual (ongoing) recall, e.g.,
• High-risk pathology lesions
• Family history
• Increased risk: one-year (temporary) recall, e.g.,
• Breast density ≥ 75%
• Radiologist, referring MD, recommendation
• Client request
• High risk: annual recall
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OBSP Features
• 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
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OBSP Features
For women at high risk:
• Patient navigator
• If appropriate, referral to genetic
assessment
• Screening breast MRI and
mammogram
• Screening breast ultrasound if MRI
contraindicated
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Mammography Accreditation
Program
Canadian Association of
Radiologists sets standards for:
• Equipment
• Image quality
• Radiology staff skills and
qualifications
100% of OBSP-affiliated sites are
accredited
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Digital Mammography
The Digital Mammographic Imaging Screening Trial
(DMIST) found digital mammography more accurate in:
• Women < 50 years
• Women with radiographically dense breasts
• Pre-menopausal and peri-menopausal women
A study using OBSP data found:
• Digital radiography (DR) and screen film
mammography (SFM) have similar cancer detection
rates
• Computed radiography (CR) had lower cancer
detection rates than SFM
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Breast Cancer Screening Participation
Rate, by LHIN
100
90
80
National target: ≥ 70%
70
60
50
40
30
20
10
0
OBSP
Non OBSP
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Breast Cancer Screening Participation
Rate, by LHIN
100
90
80
70
60
50
40
30
20
10
0
National target: ≥ 70%
2004-2005
2006-2007
2008-2009
2010-2011
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Breast Diagnostic Interval
National target: ≥ 90% for both categories
Diagnostic Interval (%)
100
80
60
40
20
0
2008
2009
2010
2011
Year
Without Biopsy Within 5 Weeks
With Biopsy Within 7 Weeks
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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?
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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?
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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?
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OBSP Resources
For more information:
www.cancercare.on.ca/obspresources
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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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