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 Outline 1.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 studies 6

Cancer Care Ontario Vision and Mission 2012 – Our New Vision Working together to create the best health systems in the world Our New Mission Together, 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 8

CCO’s Screening Goal VISION Working together create the best cancer system in the world VISION Working together create the best cancer system in the world GOAL Increase 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

10 CS Strategic Framework GOAL Accelerate reduction in cancer mortality by implementing a coordinated, organized cancer screening program across Ontario GOAL Accelerate reduction in cancer mortality by implementing a coordinated, organized cancer screening program across Ontario STRATEGIC DIRECTIONS Enhance coordination and collaboration Improve quality Maximize resources and build capacity Maximize resources and 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 11

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 Cancer Type# New Cases# Deaths Breast9,300 (F)1,950 (F) Cervical 610 (F) 150 (F) Colorectal4,800 (M) 3,900 (F) 1,850 (M) 1,500(F)

CCO and Primary Care RPCL 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 15

Cancer Journey and Primary Care 16 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 17

SAR Dashboard 18

Screening Activity Report (SAR) PurposeApproach 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 19

Potential Benefits of Screening 20 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 21 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 22 Cancer Site TestSensitivitySpecificity BreastMammography77% to 95% Less sensitive in younger women and those with dense breasts 94% to 97% BreastMRI71% 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 ColorectalgFOBT (repeat testing) 51% to 73%90% to 100% CervicalPap test44% to 78%91% to 96% CervicalHPV test88% to 93% * * Sensitivityfor CIN II 86% to 93%

Effectiveness of Screening 23 Cancer SiteEffectiveness of ScreeningType of Studies BreastWith mammography: 21% reduction in mortality with regular screening in 50 to 69-year- olds Randomized controlled trials CervicalWith Pap testing: Incidence and mortality reduced by up to about 80% with regular screening Observational studies and Global incidence data ColorectalWith 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 – % 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 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 (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 system 35 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

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

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

Breast Diagnostic Interval 41 National target: ≥ 90% for both categories

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 Resources For more information: 45

Call to Action! Screen Your Patients 46 ScreenedNot Screened Breast 61%39% Cervical 65%35% Colorectal 30%47%