BREAST CANCER SCREENING PROGRAMS AND STRATEGIES IN CANADA ENVIRONMENTAL SCAN March 2013

Background  Quarterly, the Canadian Partnership Against Cancer collects information from the provinces/territories on the status of population-based breast cancer screening programs and/or strategies.  The information is collected through provincial and territorial leads represented on the National Committee of Canadian Breast Cancer Screening Initiative supported by the Canadian Partnership Against Cancer. March 2013

Presentation Outline  Canadian Task Force on Preventive Health Care Guidelines  Provincial and Territorial Guidelines  Breast Cancer Screening Program Distribution and Administration  Recruitment and Recall  Quality Assurance  Breast Cancer Data Reported  Breast MRI (High Risk Screening Guidelines) March 2013

Canadian Task Force on Preventive Health Care Guidelines  The Canadian Task Force on Preventive Health Care (2011) recommends the following for breast cancer screening: 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) March 2013

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) March 2013

Breast Cancer Screening Programs: Provincial and Territorial Guidelines Start AgeIntervalStop Age Nunavut Northwest Territories Begin at age 50 (age 40 – 49 accepted by physician referral and self –referral but not actively recruited) For women aged annual recall For women aged biennial recall For women aged biennial recall 79 Yukon Begin at age 40For women aged biennial recall For women aged biennial recall 70+ British Columbia Begin at age 40 (<40 accepted with physician referral) For women aged annual recall For women aged biennial recall For women aged biennial recall 79 (age 80+ only with physician referral) Alberta Begin at age 50 (age accepted with physician referral for the first screen) For women aged annual recall For women aged biennial recall 70+ Saskatchewan Begin at age 50 (age 49 accepted on the mobile if turning 50 in same calendar year) For women aged biennial recall For women aged biennial recall (only if previously enrolled in the program) 75+ Manitoba Begin at 50 (ages accepted to mobile unit only with physician referral) For women aged biennial recall For women aged biennial recall For women aged biennial recall 75+ Ontario Begin at age 50 (ages accepted if high risk and referred by physician) For high risk women aged annual recall For high risk women aged – annual recall For women aged biennial recall For women aged biennial recall 75+

Breast Cancer Screening Programs: Provincial and Territorial Guidelines (Cont’d) Start AgeIntervalStop Age Québec Begin at age 50 (accept ages only with physician referral if done at a program screening centre) For women aged biennial recall 69 (age 70+ only with a physician referral at a program screening centre) New Brunswick Begin at age 50 (age accepted only with physician referral) For women aged biennial recall69 (age 70+ only with a physician referral) Capacity to increase to age 74 Nova Scotia Begin at age 40For women aged annual recall For women aged biennial recall 70+ Prince Edward Island Begin at age 40 (ages accepted if high risk and referred by physician) For women aged annual recall For women aged annual recall For women aged biennial recall For women aged biennial recall 74 Newfoundland & Labrador Begin at age 50 (age accepted only with physician referral) For women aged biennial recall 69 (age 70+ only if previously enrolled in the program) March 2013

Ontario QuebecManitoba Saskatchewan Alberta British Columbia Yukon Territory Northwest Territories Nunavut New Brunswick Nova Scotia Prince Edward Island Newfoundland & Labrador (1990) (1998)(1995) (1990) (1988) (2003) (1990) (1995) (1991) (1998) (1996) Province/Territory (Program Disribution) Mammography alone Clinical Breast Examination & Mammography & Mammography No Organized Program Distribution of mammography and CBE among breast screening programs

Breast Cancer Screening Program Administration Program Start DateProgram NameAgency Responsible for Program Administration Nunavut Northwest Territories Breast Screening Program, Stanton Territorial Health Authority Breast Screening Program, Hay River Health and Social Services Authority Stanton Territorial Health Authority Hay River Health and Social Services Authority Yukon 1990Yukon Mammography ProgramGovernment of Yukon British Columbia 1988Screening Mammography Program of British Columbia BC Cancer Agency Alberta 1990Alberta Breast Cancer Screening ProgramAlberta Health Services Saskatchewan 1990Screening Program for Breast CancerSaskatchewan Cancer Agency Manitoba 1995BreastCheckCancer Care Manitoba Ontario 1990Ontario Breast Screening ProgramCancer Care Ontario Québec 1998Québec Breast Screening ProgramMinistère de la Santé et des Services sociaux New Brunswick 1995New Brunswick Breast Cancer Screening Services New Brunswick Cancer Network (NB Ministry of Health) Nova Scotia 1991Nova Scotia Breast Screening ProgramGovernment of Nova Scotia Prince Edward Island 1998PEI Breast Screening ProgramGovernment of Prince Edward Island Newfoundland and Labrador 1996Breast Screening Program for Newfoundland and Labrador Eastern Health, Cancer Care Program

Participant Recruitment Doctor referralSelf-referralInitial letter of invitation Age group to which letter is sent Nunavut Northwest Territories  Yukon  British Columbia  Alberta  Saskatchewan  Manitoba  Ontario  Québec  New Brunswick   (not all regions) Nova Scotia*  Prince Edward Island  Newfoundland and Labrador  * NS initially started sending out letters of invitation; however, they have since stopped due to capacity issues. March 2013

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  Centralized management (Program or Agency)  Yukon  Screening centre40-79 British Columbia  Centralized management (Program or Agency)  Alberta  (AHS Screen Test only) Centralized management (Program or Agency)  Saskatchewan  Centralized management (Program or Agency)  Manitoba  Centralized management (Program or Agency)  Ontario  Regional coordination centres/ Screening centre  Québec  Regional coordination centres  New Brunswick  (not all regions) Screening centre  Nova Scotia  (postcard)Centralized management (Program or Agency)  Prince Edward Island  Screening centre  Newfoundland and Labrador  Screening centre  March 2013

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 P/Ts Automatic annual recall based on breast density Value considered high breast density Recommendation for high breast density levels Northwest Territories  > 75%Annual recall Alberta >75%Annual recall Ontario  >75%Annual recall Nova Scotia  >75%Annual recall Newfoundland and Labrador  >75%Annual recall March 2013

Association of Screening Program/Centre with Diagnostic Follow-Up Assessment of abnormal results (radiological or histopathological) occurs within the screening program Screening centre books diagnostic assessments Medical prescription needed for each diagnostic assessment Radiological/ pathological assessment teams have access to screening reports Nunavut Northwest Territories  Yukon  British ColumbiaFacilitates diagnostic referral  Alberta  (Varies by site)   (On request) Saskatchewan  Manitoba  Ontario  (Varies by site)  Québec   (Varies by site) New Brunswick  (Varies by site)  Nova Scotia  Prince Edward Island  Newfoundland and Labrador 

Quality Assurance: General Conduct a review of screening films/digital images of interval cancers* Conduct a review of missed at assessment cancers Require a ‘double read’ of a portion of all screens Have a questionnaire to evaluate client satisfaction Conduct analyses to estimate the effect of organized breast screening on mortality Nunavut Northwest Territories  Yukon British Columbia  Alberta**  Saskatchewan  Manitoba  Ontario   (Done at individual centres)  Québec  New Brunswick   (Provincial Cancer Report) Nova Scotia  ***   (periodically)  Prince Edward Island Newfoundland and Labrador   (in the process) *Classify cancer as either true interval or missed at screening **Alberta Health Services Screen Test sites only ***NS review of all interval cases 1991 to 2004 and CD of various cases are sent to all screening radiologists. Now with full field digital this will be competed electronically.

Quality Assurance: Client Satisfaction Surveys NWT, BC, AB, MB, NS and NL evaluate client satisfaction on an ongoing basis Mammography exam Particular Screening Centre Organized Screening Program Northwest Territories  British Columbia  Alberta  Manitoba  Nova Scotia  Newfoundland and Labrador  Table: Specific information collected when evaluating client satisfaction per province/territory March 2013

Quality Assurance: Evaluation of Radiologist Performance  Most P/Ts evaluate radiologists on their level of performance on an annual basis with the exceptions of YK and PEI. NB collects this data but does not report on it Positive Predictive Value (PPV) Abnormal call rate Cancer detection rate Interval cancers General performance reviews Other (specified) Northwest Territories  British Columbia  Sensitivity/ Specificity Alberta  Sensitivity/ Specificity Saskatchewan  Manitoba  Ontario  Sensitivity/ Specificity and One year recall rate Québec  Nova Scotia  Newfoundland and Labrador  Sensitivity/ Specificity Table: Specific information collected when evaluating radiologist performance per province/territory Table: Specific volume requirement for radiologists per province/territory NLNSNBQCONMBSKABBCNT 1,500 / year2,500 / year1200/ year** 500/ year 1,000 / year1,000 / year*3,000 / year480 / year**2,500 / year480 / year *All radiologists greatly exceed this number **Includes diagnostic and screening mammograms

Quality Assurance: Vital and Cancer Registry-Linkages with Provincial Registries Collection of ‘Vital Status’ variable Collection of ‘Date of Death’ variable Collection of cancer stage (TNM or Collaborative stage) or other cancer variables Nunavut Northwest Territories  Yukon  ** British Columbia  Alberta ** **  Saskatchewan  Manitoba  Ontario  Québec New Brunswick   *** Nova Scotia Prince Edward Island  Newfoundland and Labrador  *Through provincial client registry **Decreased lists are provided to WGH monthly ***linkage for post-screen cancer information only March 2013

Mammography Screening Program: Vital and Cancer Registries – TNM or Collaborative Stage For the provinces and territories that do not currently link with provincial cancer registries to collect cancer stage (TNM or Collaborative Stage) or other cancer variables, it may still be possible:  For the collection of post-screen cancer information (BC, QC, NS*)  For the collection of cancer and stage information (BC, NS*) *Note: Both linkages are possible in NS; however, an agreement has not yet been established For YK it is unknown if this is possible March 2013

Breast MRI: High Risk 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 British Columbia    **** Alberta  Ontario **  ****  *** Nova Scotia   **  Newfoundland and Labrador >=3  Prince Edward Island   Currently there are five provinces (BC, AB, ON, NS, NL) that have developed standard guidelines for MRI referral Table: The criteria or evidence that MRI referral is based upon per province * First degree relative ** >25% using validated assessment tool *** Chest irradiation before age 30 and at least 8 years ago **** BC includes the following syndromes: Li Fraumeni Syndrome, Cowden’s Syndrome, HDGC (CDH-1), Peutz-Jegher’s Syndrome March 2013

Future Implementation of MRI Ontario has implemented an MRI screening component to its organized screening program for women considered at high risk for breast cancer. BC, NS and AB have established guidelines for the use of MRI among women considered to be at elevated risk (i.e. in BC the women considered are confirmed cases of BRCA1 and BRCA2 mutation only). For more information on MRI guidelines for NS please visit NL is exploring the appropriateness of using MRI among women considered to be at elevated risk March 2013

Reference Slide  Please use the following reference when citing information from this presentation: Breast Cancer Screening in Canada: Programs and Strategies. Cancer View Canada. Available at: [Enter Link], Accessed: [Enter Date Accessed]. March 2013