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Spotlight on Breast Cancer Screening
Maximizing Benefits and Minimizing Harms
Faculty/Presenter Disclosure
2
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
Disclosure of Commercial Support
3
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
Mitigating Potential Bias
4
Not applicable
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
5
Agenda Outline1. 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 studies6
Cancer Care OntarioVision and Mission 2012–2018
7
Our New VisionWorking together to create the best health systems in
the world
Our New MissionTogether, we will improve the
performance of our health systems by driving quality, accountability, innovation,
and value
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
Chronic Kidney Disease – Ontario Renal Network
launched June 2009
Access to Care– Building on Ontario’s
Wait Times Strategy; provides information solutions that enable
improvements to access
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CCO’s Screening Goal VISION
Working together create the best cancer system in the world
GOALIncrease screening rates for breast, cervical and
colorectal cancers, and integrate into primary care
Increase patient participation in
screening
Increase primary care provider
performance in screening
Establish a high-quality, integrated screening program
9
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CS Strategic FrameworkGOAL
Accelerate reduction in cancer mortality by implementing a coordinated, organized cancer screening program across Ontario
STRATEGIC DIRECTIONS
Enhance coordination
and collaboration
Improve quality
Maximize resourcesand build capacity
Promote innovation
and flexibility
Advance clinical
engagement
Deliver patient-centred
care
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
Offered systematically to all individuals in defined target group within a framework of
agreed policy, protocols, quality management,
monitoring and evaluation
Opportunistic Case-Finding
Offered to an individual without symptoms of the
disease when he/she presents to a healthcare provider for
reasons unrelated to that disease
12
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 13
Ontario Cancer Statistics 2013
14
14
Cancer Type # New Cases
# Deaths
Breast 9,300 (F) 1,950 (F)
Cervical 610 (F) 150 (F)
Colorectal 4,800 (M)3,900 (F)
1,850 (M)1,500(F)
CCO and Primary CareRPCL
LHIN 1
RPCL LHIN 2
RPCL LHIN 3
RPCL LHIN 4
RPCL LHIN 5
RPCL LHIN 6
RPCL LHIN 7
RPCL LHIN 8
RPCL LHIN 9
RPCL LHIN
10
RPCL LHIN
11
RPCL LHIN
12
RPCL LHIN
13
RPCL LHIN
14
Primary Care Program
Provincial Lead
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Cancer Journey and Primary Care
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PRIMARY CARE
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 screening-related 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
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• 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
Possible Harms of Screening
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• 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
Sensitivity and Specificity
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Cancer Site Test Sensitivity Specificity
Breast Mammography 77% to 95%Less sensitive in younger women and those with dense breasts
94% to 97%
Breast MRI 71% to 100%Studies conducted in populations of women at high risk for breast cancer
81% to 97%Studies conducted in populations of women at high risk for breast cancer
Colorectal gFOBT (repeat testing)
51% to 73% 90% to 100%
Cervical Pap test 44% to 78% 91% to 96%
Cervical HPV test 88% to 93% *
* Sensitivityfor CIN II
86% to 93%
Effectiveness of Screening
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Cancer Site Effectiveness of Screening Type of Studies
Breast With mammography:21% reduction in mortality with regular screening in 50 to 69-year-olds
Randomized controlled trials
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
24
Spotlight on Breast Cancer Screening
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 25
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
26
27
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
Screening Recommendations
28
Screening Modality
Canadian Task Force on Preventive Health Care (2011)
Mammography • 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
MRI • 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)
Screening Recommendations
29
Screening Modality
Canadian Task Force on Preventive Health Care (2011)
Breast self examination (BSE)
Recommend not advising women to routinely practice BSE
Clinical breast examination (CBE)
Recommend not routinely performing CBE alone or in conjunction with mammography
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) 30
OBSP Eligibility Criteria
Average-risk screening:
• Women aged 50 to 74 years
• Asymptomatic
• No personal history of breast cancer
• No current breast implants
31
OBSP Eligibility CriteriaHigh 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)
32
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
33
• 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 34
OBSP Screening Intervals
• 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 system35
OBSP Features
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
36
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
37
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
38
Digital Mammography
0
10
20
30
40
50
60
70
80
90
100
OBSP Non OBSP 39
Breast Cancer Screening Participation Rate, by LHIN
National target: ≥ 70%
40
Breast Cancer Screening Participation Rate, by LHIN
Ontario
Erie S
t. Clai
r
South W
est
Wate
rloo W
ellin
gton
Hamilt
on Niag
ara H
aldim
and B
rant
Centra
l Wes
t
Miss
issau
ga Halt
on
Toronto
Cen
tral
Centra
l
Centra
l Eas
t
South E
ast
Champlai
n
North S
imco
e Musk
oka
North E
ast
North W
est
0
20
40
60
80
100
2004-2005 2006-2007 2008-2009 2010-2011
National target: ≥ 70%
Breast Diagnostic Interval
41
National target: ≥ 90% for both categories
2008 2009 2010 20110
20
40
60
80
100
Without Biopsy Within 5 Weeks With Biopsy Within 7 Weeks
Year
Dia
gnos
tic
Inte
rval
(%
)
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?
42
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?
43
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?
44
OBSP ResourcesFor more information: www.cancercare.on.ca/obspresources
45
Call to Action!Screen Your Patients
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Screened Not Screened
Breast 61% 39%
Cervical 65% 35%
Colorectal 30% 47%