Breast Cancer Screening Guidelines Across Canada

Environmental Scan

July 2015July 2015

Background

• Quarterly, the Canadian Partnership Against Cancer collects information from the provinces/territories and international organizations on the status of population-based breast cancer screening programs and/or strategies.

• This information compares current guidelines and evidence-based recommendations in order to identify leading practices.

July 2015

Presentation Outline

Canadian Task Force on Preventive Health Care Guidelines

Provincial and Territorial Screening Guidelines Breast Cancer Screening Programs in Canada Recall Following a Normal Mammogram High Breast Density Recommendations High Risk Screening Guidelines (Breast MRI) Quality Assurance Measures

July 2015

Canadian Task Force on Preventive Health Care Guidelines

The Canadian Task Force on Preventive Health Care (2011) recommends the following for breast cancer screening amongst average risk women:

Mammography• For women aged 40-49, routine screening not recommended

(Weak recommendation; moderate quality evidence)• For women aged 50-69, routine screening every 2 to 3 years

(Weak recommendation; moderate quality evidence)• For women aged 70-74, routine screening every 2 to 3 years

(Weak recommendation; low quality evidence)

Magnetic Resonance Imaging• Routine screening not recommended (Weak recommendation;

no evidence)

July 2015

Canadian Task Force on Preventive Health Care Guidelines, cont’d

Clinical Breast Exam• Routine screening for breast cancer is not

recommended when performing clinical breast exam alone or in conjunction with mammography (Weak recommendation; low quality evidence)

Breast Self Exam• Routine practice of breast self exam is not advised by

the Task Force (Weak recommendation; moderate quality evidence)

For more information please visit: http://canadiantaskforce.ca/

July 2015

Breast Cancer Screening Programs: Provincial and Territorial Clinical Practice Guidelines

Start Age Interval Stop Age

Nunavut* Current guidelines under review

Northwest Territories Begin at age 50 (age 40 – 49 accepted by physician referral for

initial screen but not actively recruited)

For women aged 40-49 – annual recallFor women aged 50-74 - biennial recall

75

Yukon Begin at age 50 (age 40-49 accepted by self referral but not actively

recruited)

For women aged 50-69 - biennial recallFor women aged 70-74 - biennial recall

75+

British Columbia Begin at age 50 (age 40-49 accepted by self referral but not actively

recruited)

For women aged 40-49 - biennial recallFor women aged 50-69 - biennial recallFor women aged 70-74 - biennial recallFor higher than average risk women aged 40-74 – annual recall

74 (age 75+ accepted by self referral but not actively

recruited or recalled)

Alberta Begin at age 50 (age 40-49 accepted with physician referral for the first

screen)

For women aged 40-49 - annual recallFor women aged 50-74 - biennial recall**

75+ **(Since September 2013)

Saskatchewan Begin at age 50 (age 49 accepted on the mobile if turning 50 in same

calendar year)

For women aged 50-69 - biennial recallFor women aged 70-74 - biennial recall (only if previously enrolled in the program)

75+

Manitoba Begin at 50 (ages 40-49 accepted to mobile unit only with physician

referral)

For women aged 40-49 - biennial recallFor women aged 50-69 - biennial recallFor women aged 70-74 - biennial recall

74 (age 75+ accepted by self referral but not actively

recruited or recalled)

Ontario Begin at age 50 (ages 30-49 accepted if high risk and referred by physician)

For high risk women aged 30-49 - annual recallFor high risk women aged 50-69 – annual recallFor women aged 50-69 - biennial recall**For women aged 70-74 - biennial recall**

74 (75+ only with a primary care provider referral)

*No screening program available in Nunavut but guidelines are under review**Women who meet specific criteria that may put them at increased risk for breast cancer will be recalled annually

For asymptomatic women at average risk:

Breast Cancer Screening Programs: Provincial and Territorial Clinical Practice Guidelines, cont’d

Start Age Interval Stop Age

Québec

Begin at age 50 (accept ages 35-49 only with physician referral, at a

program designated screening or referral center)

For women aged 50-69 - biennial recall

69 (age 70+ only with a physician referral, at a program designated screening or referral

center)

New Brunswick Begin at age 50 (age 40-49 accepted only with physician or nurse practitioner

referral)

For women aged 50-74- biennial recall 74 (age 74+ only with a physician or nurse practitioner

referral)(Since June 1, 2013)

Nova Scotia Begin at age 40 For women aged 40-49 - annual recallFor women aged 50-69 - biennial recall

70+

Prince Edward Island Begin at age 40 For women aged 40-49 - annual recallFor women aged 50-69 - biennial recallFor women aged 70-74 - biennial recall

74

Newfoundland & Labrador

Begin at age 50 (age 40-49 accepted only with physician referral)

For women aged 50-74 - biennial recall 74 (age 74+ only if previously enrolled in the program)

For asymptomatic women at average risk:

Distribution of mammography and CBE among breast screening programs

Ontario

QuebecManitobaSaskatchewan

Alberta

British Columbia

Yukon Territory

NorthwestTerritories

Nunavut

New Brunswick

Nova Scotia

Prince Edward Island

Newfoundland & Labrador

(1990)

(1998)(1995)

(1990)

(1990)

(1988)

(2003)

(1990)

(1995) (1991)

(1998)

(1996)

Province/Territory(Program Distribution)

Mammography alone

Clinical Breast Examination & MammographyNo Organized Program

Breast Cancer Screening Programs in Canada

Program Start Date Program Name Agency Responsible for Program Administration

Nunavut*

Northwest Territories 2003

2008

Breast Screening Program, Stanton Territorial Health AuthorityBreast Screening Program, Hay River Health and Social Services Authority

Stanton Territorial Health Authority

Hay River Health and Social Services Authority

Yukon 1990 Yukon Mammography Program Government of Yukon (Yukon Hospital Corporation)

British Columbia 1988 Screening Mammography Program of British Columbia

BC Cancer Agency

Alberta 1990 Alberta Breast Cancer Screening Program Alberta Health Services

Saskatchewan 1990 Screening Program for Breast Cancer Saskatchewan Cancer Agency

Manitoba 1995 BreastCheck CancerCare Manitoba

Ontario 1990 Ontario Breast Screening Program Cancer Care Ontario

Québec 1998Programme québécois de dépistage du cancer du sein (PQDCS)

Ministère de la Santé et des Services sociaux

New Brunswick 1995 New Brunswick Breast Cancer Screening Services

New Brunswick Cancer Network (NB Department of Health)

Nova Scotia 1991 Nova Scotia Breast Screening Program Government of Nova Scotia

Prince Edward Island 1998 PEI Breast Screening Program Government of Prince Edward Island

Newfoundland and Labrador

1996 Breast Screening Program for Newfoundland and Labrador

Eastern Health, Cancer Care Program

*No screening program available in Nunavut but guidelines are under review

Recall Following a Normal Mammogram

Send out recall letters

Coordination of recall for women following a normal screening episode performed by

Any additional follow-up to first recall letter after no reply

Age group for recall

Nunavut*

Northwest Territories

Regional Coordination Centres 40-74

Yukon Screening centre 40-74

British Columbia Centralized management (Program or Agency) 40-74

Alberta (AHS Screen Test only)

Centralized management (Program or Agency) 40-74

Saskatchewan Centralized management (Program or Agency) 50-74

Manitoba Centralized management (Program or Agency) 50-74

Ontario Centralized management (Program or Agency) 50-74**

Québec Regional coordination centres 50-69

New Brunswick (not all regions)

Screening centre 50-74

Nova Scotia (postcard) Centralized management (Program or Agency) 40-69

Prince Edward Island

Screening centre 40-74

Newfoundland and Labrador

Screening centre 50-74

*No screening program available in Nunavut**includes ages 30-49 if part of the high risk screening program

High Breast Density Recall and Recommendations

Five provinces and territories recall women based on high breast density.Recommendations following a high breast density reading varies across the country.

Automatic annual recall based on breast density

Value considered high breast density

Recommendation for high breast density levels

Northwest Territories > 75% Annual recall

Saskatchewan >75% Annual recall

Ontario > 75% Annual recall

Nova Scotia >75% Annual recall

Newfoundland and Labrador >75% Annual recall

July 2015

High Risk Screening: MRI Referral Guidelines

Self-reported family history (>=2) of breast cancer (first degree relative)

Self-reported family history of BRCA 1/2

Genetic testing BRCA 1 or 2

Risk of breast cancer >20% (scored by validated assessment tools)

Chest irradiation between the ages of 10 and 30 years

Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome

e-cadherin mutation

British Columbia * **

Alberta

Ontario ⱡ *** **** ***** ⱡ ⱡ

Nova Scotia ****

Newfoundland and Labrador

(>=3)

Currently there are five provinces (British Columbia, Alberta, Ontario, Nova Scotia, Newfoundland and Labrador) that have developed standard guidelines for MRI referral.

Table: The criteria or evidence that MRI referral is based upon per province

*British Columbia allows women with a 50% risk of BRCA mutation who have not yet received their BRCA testing

** British Columbia includes the following syndromes: Li Fraumeni Syndrome, Cowden’s Syndrome, HDGC (CDH-1), Peutz-Jegher’s Syndrome

***First degree relative, and have declined genetic testing themselves

**** ≥25% using validated assessment tool

***** Chest irradiation before age 30 and at least 8 years prior to the screen

ⱡ Upon confirmation of high risk status after genetic assessment

High Risk Screening: MRI Referral Guidelines, cont’d

Ontario has implemented an MRI screening component to its organized screening program for women considered at high risk for breast cancer.

British Columbia, Nova Scotia and Alberta have established guidelines for the use of MRI among women considered to be at high risk (i.e. in British Columbia the women considered are confirmed cases of BRCA1 and BRCA2 mutation only). For more information on MRI guidelines for Nova Scotia please visit http://breastscreening.nshealth.ca/guidelines.pdf

Newfoundland and Labrador is exploring the appropriateness of using MRI among women considered to be at high risk

July 2015

Quality Assurance:Client Satisfaction Surveys

Northwest Territories, British Columbia, Alberta, Manitoba, Nova Scotia and Newfoundland and Labrador evaluate client satisfaction on an ongoing basis.

Mammography exam Particular Screening Centre

Organized Screening Program

Northwest Territories (STHA site)

British Columbia

Alberta

Manitoba

Nova Scotia

Newfoundland and Labrador

Table: Specific information collected when evaluating client satisfaction per province/territory

July 2015

Quality Assurance:Evaluation of Radiologist Performance

Most provinces and territories evaluate radiologists on their level of performance on an annual basis with the exceptions of Yukon and Prince Edward Island. New Brunswick collects this data but does not report on it.

Table: Specific information collected when evaluating radiologist performance per province/territoryPositive Predictive Value (PPV)

Abnormal call rate

Cancer detection rate

Interval cancers

Specific volume requirements for radiologists

Northwest Territories (STHA site)ᶲ

480 / year

British Columbia 2,500 / year

Alberta 480 / year*†

Saskatchewan 1,000 / year

Manitoba 1,000 / year**

Ontario 1,000 / year*†

Québec 750/ year

New Brunswick*** 1,200/ year*

Nova Scotia 2,000 / year

Newfoundland and Labrador

2,000 / year

*Includes diagnostic and screening mammograms**All radiologists greatly exceed this number*** New Brunswick program policies stipulate that the RHAs must have a system for the annual review of mammography screening outcome data with Radiologists† This figure is currently under review and will likely be changed to align with CAR MAP requirements.ᶲ For Northwest Territories, the level of performance is done on the program as a whole (not specific radiologist) due to small volume numbers.

Reference Slide

Please use the following reference when citing information from this presentation:

Cancerview.ca. Breast Cancer Screening Guidelines Across Canada: Environmental Scan. Toronto: Canadian Partnership Against Cancer; [enter date]. Available from: [enter URL link]

July 2015