TriLHIN ICS Orientation Workshop July 16, 2014 Dr. Jan Owen, MD, CCFP, FCFP

1. Cancer Screening TriLHIN ICS Orientation Workshop July 16, 2014 Dr. Jan Owen, MD, CCFP, FCFP Regional Primary Care Lead, SWRCP

2. Learning Objectives • 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

3. Agenda Outline • Benefits and Harms of Screening • Spotlight on Screening Programs • Screening rate targets: challenges/opportunities • Latest evidence-based guidelines • Current program performance • Relevant case studies

4. 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

5. 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

6. Screening Activity Report (SAR)

7. SAR Dashboard

8. Spotlight on Breast Cancer Screening

9. Do I Need to be Screened for Breast Cancer? http://www.youtube.com/watch?v=PYTg3gcbuBo&index=34&list=FLXu1tmVgO0Srr3vizeTiUUA

10. Sensitivity and Specificity

11. Effectiveness of Screening

12. Burden of Disease • 1 in 9 Canadian women will develop breast cancer in their lifetime • 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

13. Burden of Disease • 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

14. Screening Rates 61% of eligible Ontario women age 50 to 74 years were screened for breast cancer in 2010–2011 • 71% screened in OBSP, • 29% outside of OBSP • The national target is to increase screening rates to ≥ 70% of the eligible population

15. 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

16. Screening Recommendations

17. Screening Recommendations

18. Breast Cancer Screening Participation Rate, by LHIN National target: ≥ 70%

19. Breast Cancer Screening Participation Rate, by LHIN National target: ≥ 70%

20. Ontario Breast Screening Program (OBSP) • Province-wide organized breast cancer screening program since 1990 • 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)

21. OBSP Eligibility Criteria Average-risk screening: • Women aged 50 to 74 years • Asymptomatic • No personal history of breast cancer • No current breast implants

22. 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

23. Heard About BRCA1, BRCA2, Lately?

24. OBSP High Risk Eligibility Criteria Four Assessment Categories: • Confirmed carrier of gene mutation • First-degree relative of mutation carrier and refused genetic testing • ≥ 25% personal lifetime risk (IBIS, BOADICEA tools • Radiation therapy to chest more than 8 years ago and before age 30

25. OBSP Screening Intervals Average risk: biennial recall (every 2 years) Increased risk: annual (ongoing) recall • High-risk pathology lesions • Family history Increased risk: one-year (temporary) recall., • Breast density ≥ 75% • Radiologist, referring MD, recommendation • Client request High risk: annual recall

26. OBSP Features – Average Risk • 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

27. OBSP Features – High Risk • Referral needed • https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=285487 • Patient navigator • If appropriate, referral to genetic assessment • Screening breast MRI and mammogram • Screening breast ultrasound if MRI contraindicated

28. Mammography Accreditation Program Canadian Association of Radiologists (CAR)set standards for: • Equipment • Image quality • Radiology staff skills and qualifications 100% of OBSP affiliated sites are CAR accredited.

30. Diagnostic Assessment Program • Single point of access for diagnostic services • Coordinate patient care • Help family physicians gain access to diagnostic tests and results in a timely manner

31. DAP Characteristics • Patient-centered • Improve access • Provide support • Timely diagnosis • Coordinated referral and follow up • Established and monitored quality indicators

32. Patient Navigator • Individual who guides each patient through the healthcare system • Help patients to overcome barriers within the system

33. DAP Healthcare Benefits • Improve coordination of care • Decrease wait times • Improve patient experience • Minimize disease progression

34. Breast Health Centre DAP • Provides navigation of abnormal follow up • Reduces wait times for diagnostic assessment • Responds to client requests for information • Coordinates services and provides support • All of the above • What is the role of a Breast Health Centre?

35. OBSP Resources https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=280490 https://www.cancercare.on.ca/pcs/screening/breastscreening/patient_education/ https://www.publications.serviceontario.ca/pubont/servlet/ecom/

36. 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?

37. 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?

38. 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?

39. Questions? Thank You