1. July 2015 Colorectal Cancer Screening Guidelines Across Canada Environmental Scan

2. Background Quarterly, the Canadian Partnership Against Cancer collects information from the provinces/territories and international organizations on the status of population- based colorectal cancer screening programs and/or strategies. This information compares current guidelines and evidence-based recommendations in order to identify leading practices. July 2015

3. Presentation Outline  Canadian Task Force on Preventive Health Care Guidelines  Colorectal Cancer Screening Program Status/Availability  Fecal Test Recruitment Strategies  Entry Level Fecal Test Sampling Details  Follow-Up after Abnormal Result  Colonoscopy Details  Increased Risk Population Screening Recommendations July 2015

4. Canadian Task Force on Preventive Health Care Guidelines For people at normal risk there is good evidence to support the inclusion of annual or biennial fecal occult blood testing (A recommendation) and fair evidence to include flexible sigmoidoscopy (B recommendation) in the periodic health examinations of asymptomatic individuals over 50 years. Revisions to the current guidelines are in process, for more information please visit: http://canadiantaskforce.ca/ http://canadiantaskforce.ca/ July 2015 The Canadian Task Force on Preventive Health Care (2001) recommends the following for colorectal cancer screening:

5. Colorectal Cancer Screening Program Status Date of Program Announcement Program StatusProgram NameAgency responsible for Program Administration Nunavut (NU)Plans underway to develop an organized screening program Northwest Territories (NT)No organized program Yukon (YK)No organized program British Columbia (BC)2009Full program, province wide Colon Screening ProgramBC Cancer Agency Alberta (AB)March 2007Full program, province wide Alberta Colorectal Cancer Screening Program (ACRCSP) Alberta Health Services Saskatchewan (SK)January 20, 2009Full program, province wide Screening Program for Colorectal Cancer Saskatchewan Cancer Agency Manitoba (MB)2007Full program, province wide ColonCheckCancerCare Manitoba Ontario (ON)January 2007Full program province- wide ColonCancerCheckCancer Care Ontario July 2015

6. Colorectal Cancer Screening Program Status, cont’d Date of Program Announcement Program StatusProgram NameAgency responsible for Program Administration Quebec (QC)December 2010Implementation phaseProgramme québécois de dépistage du cancer colorectal (PQDCCR) Ministry of Health and Social Services New Brunswick (NB) 2009Launched in one Health Zone November 2014 New Brunswick Colon Cancer Screening Program New Brunswick Cancer Network (NB Department of Health) Nova Scotia (NS)2009Province wide program March 2013 Colon Cancer Prevention ProgramCancer Care Nova Scotia Prince Edward Island (PE) 2009Province wide program May 2011 PEI Colorectal Cancer Screening Program Health PEI Newfoundland and Labrador (NL) March 19, 2010Province-wide July 2015 Newfoundland and Labrador Colon Cancer Screening Program Eastern Health, Cancer Care Program July 2015

7. Colorectal Cancer Screening Program Availability

8. Colorectal Cancer Screening Programs: Provincial and Territorial Guidelines Start AgeIntervalStop Age NUPlans underway to develop an organized screening program NT50Every 1-2 years74 YK BC50FIT Every 2 years74 AB50Screen with fecal immunochemical test (FIT) every 1-2 years 75 SK50Every 2 years75 MB50Every 2 years75 ON50Every 2 years74 July 2015 For asymptomatic individuals at average risk:

9. Colorectal Cancer Screening Programs: Provincial and Territorial Guidelines, cont’d July 2015 Start AgeIntervalStop Age QC50Every 2 years74 NB50Invited to complete FIT every 2 years74 NS50Every 2 years74 PE50Every 2 years74 NL50Every 2 years74 For asymptomatic individuals at average risk:

10. Entry Level Test: Fecal Test Guaic (FTg) Sampling Details Number of Test(s) Collected per Sample Screening Interval (annual or biennial) Number of labs processing test results Additional Comments (i.e. brand name of test and other information) NUN/A – No organized program YKN/A – No organized program MB6 samples collected over 3 days Biennial1Hemoccult II SENSA ON2 samples of three different stools Biennial6 labs (7 testing sites)Hema-screen July 2015

11. Entry Level Test: Fecal Immunochemical Testing (FIT) Sampling Details Number of Test(s) Collected per Sample FIT Cut-Off Value Screening Interval (annual or biennial) Number of Labs Processing Test Results Database Collection Measure Recorded (i.e. FIT cut-off value, positivity /negativity or both) FIT Test Brand Name Additional Comments (i.e. any other information) NTThree samples across three days 75ng/ml1-2 years2 labs (Stanton and Inuvik) Positivity/negativityHemoccult ICTNot programmatic BCSingle sample test >49ng/ml = abnormal result Biennial5 instruments in BC. Kit available for pick up at all BC labs (private and public) FIT value and interpretation recorded Alere ABSingle sample test ≥75ng/ml= abnormal result Annual or at least Biennial 2 labs ( Calgary & Edmonton). Kit available for pickup at all lab sites within the province Program currently receives a qualitative FIT result of positive/negative* PolymedcoPolymedco available province wide as of Nov 18 th 2013 SKSingle sample test >100ng/mlBiennial1FIT value recorded by program; positive/negative is shared Polymedco *In AB, the program will receive quantitative FIT result showing numeric value/threshold in near future

12. July 2015 Number of Test(s) Collecte d per Sample FIT Cut- Off Value Screenin g Interval (annual or biennial) Number of Labs Processing Test Results Database Collection Measure Recorded (i.e. FIT cut-off value, positivity /negativity or both) FIT Test Brand Name Additional Comments (i.e. any other information) ONFIT pilot complete and planning for FIT implementation; Systematic review of the evidence for all CRC screening modalities underway (expected release date: August 2015), and updated screening recommendations will follow QCSingle sample test ≥175 ng/ml Biennial1Both recorded, positivity/negativit y provided SomagenFIT is deployed provincially NBOne sample ≥100n g/ml Biennial1 Both recorded, positive/negative provided to clinicians Polymedco NSTwo sample test 0.3 mg Hb/g Biennial1Positive/negativeHemoccult ICT Entry Level Test: Fecal Immunochemical Testing (FIT) Sampling Details, cont’d

13. Number of Test(s) Collected per Sample FIT Cut- Off Value Screening Interval (annual or biennial) Number of Labs Processing Test Results Database Collection Measure Recorded (i.e. FIT cut-off value vs. positivity/negativity or both) FIT Test Brand NameAdditional Comments (i.e. any other information) PETwo sample test ≥ 100ng/ml (abnormal if any 1 of the samples is over the cut-off) Biennial1 (tests received and accessione d at 4 labs) Positivity/ negativityAlereFIT as of April 2013 Completed validation study in 2012 to assess cut-off; resulted in decision to remain at 100ng. NLTwo sample test ≥ 100ng/ml Biennial1Positivity/negativity (value recorded for internal use program use only) AlereCompleted a validation study comparing FIT to guaiac and colonoscopy results in 2011 July 2015 Entry Level Test: Fecal Immunochemical Testing (FIT) Sampling Details, cont’d

14. Entry Level Test: Follow-up to Abnormal Fecal Test Result Standard follow-up diagnostic procedure for abnormal test Target from abnormal result to follow-up procedure or ‘wait time target’ NUNo organized program NTNo organized program YKNo organized program BCColonoscopyWait time target is 60 days ABColonoscopyColonoscopy recommended within <60 days of abnormal FIT result SKColonoscopyWait Time Target ≤ 60 days MBColonoscopyWait time target is 28 days ONColonoscopyWait time benchmark is colonoscopy within 8 weeks QCColonoscopy< 60 days (target) NBColonoscopy Initial goal < 60 days (monitoring) NSColonoscopyTarget is 8 weeks PEColonoscopy≤ 60 days NLColonoscopy< 60 days, with 90 th percentile within 180 days July 2015

15. Process Following Abnormal Results BCPatient is referred to the patient’s regional Health Authority and HA contacts participant to discuss follow-up ABOrdering physician is responsible for follow-up of abnormal FIT results. As per ACRCSP colorectal screening pathway physicians are to refer FIT+ patients for colonoscopy to their local CRC screening centre (if available) or a local colonoscopist. As a safety net the ACRCSP provides result letters to all patients in Alberta with a positive FIT result informing them to follow up with their physician SKPrimary care practitioner and participant notified by direct correspondence regarding abnormal result. Family Physicians sign medical directives which authorizes Nurse Navigators to refer participant for colonoscopy. Nurse Navigator phones FIT positive participants to discuss test results, refer to colonoscopy and complete a standardized assessment. Note: Client Navigation process currently being expanded into all 13 health regions MBFollow-up depends on the regional health authority. Primary care provider is notified Navigator contacts participant by telephone to discuss result and referral process, result and colonoscopy brochure is mailed to participant. ColonCheck refers the majority of participants directly for follow up colonoscopy A pre-colonoscopy assessment is completed by ColonCheck’s Nurse Practitioner for all patients receiving healthcare services in Winnipeg. Procedure is scheduled at one of two facilities ONPrimary care provider contacts participant to arrange for follow-up; CCO refers unattached patients to a family physician for follow-up (clients are contacted via phone and letter). Screening Activity Reports (SAR) are provided to physicians in a Patient Enrolment Model (PEM) practice that allows physician to see the complete screening status for each patient, including those who are due for screening and follow-up QCParticipants are contacted by their family physicians (process following abnormal results depends on the family physician). NBParticipant is contacted by phone to discuss results and follow-up procedures. Pre-colonoscopy assessment is done by a Program Nurse who refers appropriate participants for colonoscopy NSScreening results flow electronically into Primary Care information system. Letter also sent to Primary Care Provider and participant indicating that a District Screening Nurse will be contacting the patient to discuss and arrange for clinical follow-up PEProgram sends results letter to patient. Copy of test results are sent to family physician or nurse practitioner and the care provider determines follow-up. Unaffiliated patients are sent a results letter and referred to a family physician or nurse practitioner for follow up by the program. A standardized colonoscopy referral form is available and use is encouraged NLNurse Follow up Coordinator makes telephone contact with FIT positive participant to provide test results and discuss possible follow up colonoscopy. Results letter sent to primary care provider and participant. Nurse Coordinator will navigate FIT positive participant to colonoscopy through booking clerks within RHA’s

16. Re-screening Recommendations for +Fecal Test and Negative* Colonoscopy * No cancer or adenoma found RecommendationsYears before recall to program NUNo organized program NTNo organized program YKNo organized program BCFIT re-screening in 10 years10 ABResume screening with FIT10 SKRecalled to FIT screening every 2 years2 MBRecalled for FOBT in 5 years5 ONRecalled for FOBT in 10 years10 QCRecalled for FIT screening after 10 years10 (if negative colonoscopy) NBRecalled for FIT screening after 10 years10 NSFIT offered in 2 years2 PE2014 Clinical Practice Guidelines recommend return to FIT after 5 years.5 NLRecalled after 5 years5 July 2015

17. Increased Risk* Definition 1 st first degree relative diagnosed with ≥2 1 st degree relatives diagnosed with Two 2nd degree relative diagnosed with Personal history of CRC**Adenomatous polyps CRC**Adenomatous polyps CRC**Adenomatous polyps CRC**Adenomatous polyps NT  (age <60)  (any age)  BC  (age <60)  (any age)  AB  (age ≤60)  (age ≤60)  Any age  Any age  SK  (age <60 & ≥60) MB***  (age <60)  (age <60)  (any age)  (any age) What is the definition of increased risk? (please check all those that apply) *Increased risk = persons with certain risk factors for colon cancer ; Not all programs coordinate referrals of increased risk populations **CRC = colorectal cancer ***Please note: for MB, slightly above average risk is also defined, see program guidelines for details Nunavut and Yukon are no included as they do not have an organized colorectal cancer screening program ****Screening starts at 40 July 2015

18. Increased Risk* Definition cont’d 1 st first degree relative diagnosed with ≥2 1 st degree relatives diagnosed with Two 2nd degree relative diagnosed with Personal history of CRC**Adenomatous polyps CRC**Adenomatous polyps CRC**Adenomatous polyps CRC**Adenomatous polyps ON  QC***  (age <60 & ≥60)  (age <60 & ≥60)  NB   NS  (age 60)  (age 60)  (age 60)  (age 60) PE  NL***  (age <60)  What is considered in your definition of increased risk? (please check all those that apply) *Increased risk = persons with certain risk factors for colon cancer ; Not all programs coordinate referrals of increased risk populations **CRC = colorectal cancer *** Please note: for QC, slight or moderate increased risk is considered ; For NL, personal history of Crohn’s disease and ulcerative colitis are also considered July 2015

19. Increased Risk* Screening Recommendations Screening recommendation for increased risk population Follow-up recommendations after normal colonoscopy NTColonoscopy at age 40 or 10 years earlier than youngest affected relative (whichever comes first) Repeat colonoscopy every 5 -10 years BCColonoscopy for individuals in the program within the target age of 50-74 (guidelines for those outside of the target age are outlined by the Guideline and Protocol Advisory Committee in BC) Repeat colonoscopy in 5 years AB**1)1 st degree relative of a person with Colorectal Cancer > 60 years at diagnosis 2) 1 st degree relative with Colorectal Cancer ≤ 60 years, or two or more affected relatives 1) Screen with FIT every 1-2 years starting at age 40. If FIT is positive, refer for colonoscopy 2) Refer for consideration of colonoscopy at age 40, or 10 years prior to index case, whichever is earliest. Assist with adherence to recommended follow up SK***1) Colonoscopy beginning at age 40 or 10 years younger than the earliest case in the family 2) Same as average risk but beginning at age 40 1) Repeat colonoscopy every 5 years 2) Same as average risk Follow-up as per CAG guidelines and close monitoring by a physician MBColonCheck recommends colonoscopy beginning at age 40 or 10 years earlier than youngest diagnosis. Referral is not coordinated by ColonCheck, it is the responsibility of the primary care provider to coordinate Recommendations at the discretion of the endoscopist What are the screening recommendations and follow-up protocols by your screening program for those persons at increased risk? (please elaborate below) *Increased risk = persons with certain risk factors for colon cancer ; Not all programs coordinate referrals of increased risk populations **AB: option 1 = for persons with first-degree relative with CRC diagnosed or high risk adenomas <60 OR ≥2 first-degree relatives with CRC or high risk adenomas at any age; option 2 = for persons with first-degree relative with CRC diagnosed or high risk adenomas ≥ 60 ***SK: option 1 = for persons with first-degree relative with CRC <60; option 2 = for persons with first-degree relative with CRC ≥60

20. Increased Risk* Screening Recommendations What are the screening recommendations and follow-up protocols by your screening program for those persons at increased risk? (please elaborate below) Screening recommendation for increased risk population Follow-up recommendations after normal colonoscopy ONColonoscopy at age 50 or 10 years younger than earliest age of diagnosis of relative, whichever comes first Repeat colonoscopy every 5 - 10 years (depending on colonoscopy result, family history, etc) QC**1)Colonoscopy every 5 years at age 40 or 10 years earlier than youngest affected relative 2)Same as average risk but starting at age 40 3)Follow-up (FIT or colonoscopy) according to algorithms 4)Colonoscopy according to algorithms As per risk factors and according to algorithms Detailed algorithms are available from QC NBThe Program recommends follow up with their Primary Health Care Provider or regular Endoscopist (if they have one) to determine and coordinate screening follow up. Detailed algorithm is available from NBCN Recommendations follow CAG guidelines – detailed algorithm available from NBCN *Increased risk = persons with certain risk factors for colon cancer ; Not all programs coordinate referrals of increased risk populations **QC: option 1 = for persons with moderate increased risk first degree relative with CRC or advanced adenomatous polyps at age 60 years old; option 3 = for persons with a personal history of polyps; option 4 = for persons with a personal history of colorectal cancer July 2015

21. Increased Risk* Screening Recommendations What are the screening recommendations and follow-up protocols by your screening program for those persons at increased risk? (please elaborate below) Screening recommendation for increased risk population Follow-up recommendations after normal colonoscopy NS**1) Colonoscopy at 40 or 10 yrs younger than the earliest case in the family, whichever comes first 2) FIT (or FOBT) at age 40 or colonoscopy every 10 yrs younger than the earliest case in the family, whichever comes first 1) Repeat colonoscopy in 5 years 2) Repeat FIT every 2 years or colonoscopy every 10 years PEPromote CAG guidelines.*** Recommendation is at discretion of the physician. (Referral is not coordinated by the Program) Recommendations at the discretion of the endoscopist. Promote CAG guidelines*** NLPromote CAG guidelines*** July 2015 *Increased risk = persons with certain risk factors for colon cancer ; Not all programs coordinate referrals of increased risk populations **NS: option 1 = for persons with 1 first-degree relative with CRC or adenoma diagnosed 60 OR ≥2 second-degree relatives with CRC or adenoma diagnoses in their 60s or 70s ***For details on CAG guidelines please click on the link: CAG Colorectal Screening Guidelines for Increased RiskCAG Colorectal Screening Guidelines for Increased Risk

22. Data Collection for Increased Risk* Factors July 2015 Do you collect data on increased risk factors from persons participating in your screening program? If so, *Increased risk = persons with certain risk factors for colon cancer ; Not all programs coordinate referrals of increased risk populations Please note: Nunavut and Yukon have not responded Do you collect risk factor data? Yes / No If you answered ‘Yes’, which increased risk factor variables are collected (please list below)? NU NTNoNo organized screening program YK BCYesFamily history information and personal adenoma history information ABNo SKYesInflammatory bowel disease is recorded if self-reported. Clients continue to be invited to screen with FIT test unless CRC within past 5 years MBYesColonCheck collects information on CRC and other related cancers in order to exclude participants from the screening program

23. Data Collection for Increased Risk* Factors Cont’d July 2015 Do you collect data on increased risk factors from persons participating in your screening program? If so, *Increased risk = persons with certain risk factors for colon cancer ; Not all programs coordinate referrals of increased risk populations Do you collect risk factor data? Yes / No If you answered ‘Yes’, which increased risk factor variables are collected (please list below)? ONNo QCNoPlanning to collect information on personal history (colon cancer and polyps) NBYesPersonal history of CRC, ulcerative colitis, Crohn’s disease, rectal bleeding and narrowed stools, family history of CRC (1 st and 2 nd degree) NSYes- Personal history of colorectal cancer - Family history of colorectal cancer – first degree relative - Inflammatory Bowel Disease (Crohn’s disease or ulcerative colitis) for more than 8 years - A hereditary disease that causes colorectal cancer (such as HNPCC or FAP) - A history of polyps in the colon or rectum that needs checking with colonoscopy PENo NLNo

24. Reference Slide Please use the following reference when citing information from this presentation: Cancerview.ca. Colorectal Cancer Screening Guidelines Across Canada: Environmental Scan. Toronto: Canadian Partnership Against Cancer; [enter date]. Available from: [enter URL link] July 2015