Spotlight on  Breast Cancer Screening

Maximizing Benefits and Minimizing Harms

Faculty/Presenter Disclosure

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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

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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

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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

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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

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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

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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

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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 13

Ontario Cancer Statistics 2013

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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

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RPCL LHIN

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RPCL LHIN

13

RPCL LHIN

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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

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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

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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

Screening Recommendations

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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

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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

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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)

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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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• 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

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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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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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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%

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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

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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?

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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 ResourcesFor more information: www.cancercare.on.ca/obspresources

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Call to Action!Screen Your Patients

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Screened Not Screened

Breast 61% 39%

Cervical 65% 35%

Colorectal 30% 47%