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April 2017 Colorectal  Cancer Screening April 2017 Colorectal  Cancer Screening

April 2017 Colorectal Cancer Screening - PowerPoint Presentation

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April 2017 Colorectal Cancer Screening - PPT Presentation

in Canada Environmental Scan 1 Background The Canadian Partnership Against Cancer collects information annually on national provincial and territorial colorectal cancer screening guidelines ID: 777258

cancer screening colorectal program screening cancer program colorectal care fit risk years primary age test colonoscopy provider follow individuals

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Slide1

April 2017

Colorectal Cancer Screening in Canada

Environmental Scan

1

Slide2

Background

The Canadian Partnership Against Cancer collects information annually on national, provincial and territorial colorectal cancer screening guidelines, strategies and activities.

This scan summarizes the data collected from provincial and territorial screening programs

and is intended to provide information on policy and practice.

2

Slide3

Outline

Colorectal Cancer Screening Programs and GuidelinesColorectal Cancer Screening PathwayColorectal Cancer Screening Program Status

Canadian Task Force on Preventive Health Care GuidelinesProvincial and Territorial Screening Guidelines

Recruitment and Retention Strategies for Colorectal Cancer Screening

Fecal Testing Information

Diagnostic Follow-Up After an Abnormal ResultScreening Recommendations for Individuals at Increased Risk

3

Slide4

Colorectal Cancer Screening Programs

and Guidelines

Organized colorectal cancer screening programs are available in Canada to individuals who are asymptomatic (no signs or symptoms of colorectal cancer present) and at average risk for colorectal cancer. Currently, there are organized colorectal cancer screening programs in all provinces and Yukon. There are no colorectal cancer screening programs available in Northwest Territories. Plans are underway to develop programs in Nunavut.

W

here organized screening programs are not available, screening services may be provided opportunistically by a primary care provider.

4

Slide5

Colorectal Cancer Screening Programs and Guidelines - HighlightsColorectal Cancer Screening Program Status (refer to slide #7-8)

Eight provinces and one territory have fully implemented organized colorectal cancer screening programs across Canada. These programs started in March 2007 (Alberta) to December 2016 (Yukon). The colorectal cancer screening program in New Brunswick was first implemented in November 2014 and covers 60% of the target

population. Quebec has also begun implementation of a colorectal cancer screening program. Currently, there is no organized colorectal cancer screening program available in the Northwest Territories and plans are underway to develop a program in Nunavut. Provincial and Territorial Colorectal Cancer Screening Guidelines (refer to slide #11-12)

Provinces and territories

screen asymptomatic individuals at average risk

between the ages of 50 and 74-75 every 1-2 years with a fecal occult blood test (either guaiac or FIT). Most provinces and territories have a two year interval, with the exception of Northwest Territories and Alberta, which

have

a

one to two

year

interval.

5

Slide6

Colorectal Cancer Screening Pathway

Adapted from: Canadian Partnership Against Cancer. Colorectal Cancer Screening in Canada: Program Performance Results Report, January 2009– December 2011. Toronto: Canadian Partnership Against Cancer; December 2013

6

Slide7

Colorectal Cancer Screening Program Status

Program Start Date

Program Status (as of Jan 1, 2017)Program Name

Agency

responsible for Program Administration

Nunavut (NU)Currently no organized screening program but plans are underwayNorthwest Territories

(NT)

No organized screening program available

Yukon (YK)

December 2016

Full program, territory wide

ColonCheck

Yukon

Government of Yukon Health and Social Services

British

Columbia

(BC)

2009 pilot, November 2013 province wide

Full program, province wide

Colon

Screening Program

BC Cancer Agency

Alberta (AB)

March 2007Full program, province wideAlberta Colorectal Cancer Screening Program (ACRCSP)Alberta Health ServicesSaskatchewan (SK)January 20, 2009Full program, province wideScreening Program for Colorectal Cancer Saskatchewan Cancer AgencyManitoba (MB)April 2007Full program, province wideColonCheck CancerCare ManitobaOntario (ON)March 2008Full program, province-wideColonCancerCheckCancer Care Ontario

7

Slide8

Colorectal Cancer Screening Program Status, cont’d

Program Start Date

Program Status (as of Jan 1, 2017)

Program Name

Agency

responsible for Program AdministrationQuebec (QC)N/A

In implementation (opportunistic screening available through physician)

Programme québécois de dépistage du cancer colorectal (PQDCCR)

Ministry

of Health and Social Services

New Brunswick (NB)

November 2014

Partial program, inviting 60% of target population and expanding

New Brunswick Colon Cancer Screening Program

New Brunswick Cancer Network (NB Department of Health)

Nova Scotia

(NS)

April 1, 2009

Full program, province wide

Colon Cancer Prevention Program

Cancer Care Nova Scotia,

Nova Scotia Health Authority

Program of Care for Cancer

Prince Edward Island (PE)April 2011Full program, province widePEI Colorectal Cancer Screening ProgramHealth PEINewfoundland and Labrador (NL)March 19, 2010Full program, province wide Newfoundland and Labrador Colon Cancer Screening ProgramEastern Health, Cancer Care ProgramN/A = Not applicable8

Slide9

Colorectal Cancer Screening Program Availability

9

Slide10

Canadian Task Force on Preventive Health Care Guidelines (2016)

Additionally, the Canadian Task Force on Preventive Health Care does not recommend the following:Screening

individuals aged 75 and over for colorectal cancer

Using colonoscopy as a screening test for colorectal cancer

For more information please visit:

http://canadiantaskforce.ca/The Canadian Task Force on Preventive Health Care (2016) recommends individuals at average risk, aged 50-74, screen for colorectal cancer with an FOBT [either fecal test guaiac (

FTg

) or FIT] every 2 years or flexible sigmoidoscopy every 10 years.

10

Slide11

Provincial and Territorial Colorectal Cancer Screening Guidelines

Start

AgeInterval

Stop Age

Primary Screening Test

(FTg, FIT or both; flexible sigmoidoscopy)NU*50Every 2 years

74

Currently

under review

NT*

50

Every 1-2 years

74

FIT

YK

50

Every 2 years

74

FIT

BC

50

Every 2 years

74

FIT

AB50Every 1-2 years75FITSK50Every 2 years75FITMB50Every 2 years75FTgON50Every 2 years74FTg**For asymptomatic individuals at average risk:

*There is no organized colorectal cancer screening program available in Nunavut

and the Northwest Territories (NT). Responses refer to opportunistic colorectal cancer screening

**In ON, people

aged 50 to 74 without a family history of colorectal cancer who choose to be screened with flexible sigmoidoscopy should be screened every 10 years

.

11

Slide12

Provincial and Territorial Colorectal Cancer Screening Guidelines, cont’d

Start Age

IntervalStop Age

Primary Screening Test

(

FTg, FIT or both; flexible sigmoidoscopy)QC50Every 2 years74

FIT

NB

50

Every 2 years

74

FIT

NS

50

Every 2 years

74

FIT

PE

50

Every 2 years

74

FIT

NL

50

Every 2 years74FITFor asymptomatic individuals at average risk:12

Slide13

Recruitment and Retention Strategies for Colorectal Cancer Screening

Organized colorectal cancer screening programs administer recruitment, reminder and promotional strategies to invite eligible individuals to screen (as per guidelines).

Recruitment strategies and

methods vary across the country and may include: physician or self-referral or mailed letters. Reminders in the form of letters, phone calls or emails, may be sent to eligible individuals to ensure the highest participation rate is achieved for the screening program.

13

Slide14

Recruitment and Retention Strategies for Colorectal Cancer Screening - Highlights

Colorectal Cancer Screening Recruitment and Retention Methods (refer to slide #15-18)Many screening programs recruit individuals to screen for colorectal cancer by offering fecal immunochemical testing (FIT). There are various recruitment methods being implemented across the country such that many provinces require a referral from a physician prior to distributing a FIT kit; others distribute the FIT kit to eligible individuals with a mailed invitation letter or after

the letter has been sent; and clients can obtain FIT kits by directly contacting some screening programs. Examples of promotional strategies for colorectal cancer screening delivered by provinces include: promotional information via program website or program related correspondences (e.g. flyers distributed with screening result letters),

educational

resources for the public and healthcare providers, marketing campaigns (e.g. Colon Cancer Month), media, newsletters, as well as radio and print advertising (e.g. posters).

Many provincial/territorial colorectal cancer screening programs send a recall letter two years after a client receives a normal result. 14

Slide15

Colorectal Cancer Screening Recruitment and Retention Methods

How are individuals recruited into the screening program?

Promotional

Strategy

Reminder Strate

gy After No Reply Recall Method After Normal ResultPhysician Referral*

Self-Referral**

Self-Referral through Pharmacy

With Mailed Invitation Letter (Specify if

Kit is Sent with Letter)

Other (Please Specify)

NU

C

urrently no organized screening program but plans are underway

NT

No organized screening program available

YK

----

----

----

----

Program website, Facebook page, promotional and educational resources for health care providers and patients; program campaign; community visitsReminder methods are being consideredRecall letter sent every 2 years to primary care providers and participants due for screeningBC----

----

----

----

Program website, promotional and educational resources for health care providers and patients

----

Recall letter sent every 2 years to primary care providers and participants due for screening

What are the

recruitment and retention strategies for your

colorectal cancer screening

program?

*Physician

referral: physician refers

individual to

the colorectal cancer screening program

**Self-referral

: an individual contacts the colorectal cancer screening program directly to participate in the program

Self-referral through pharmacy:

individuals pick-up fecal testing kit at a pharmacy

----

No information was provided at the time the data was

collected

15

Slide16

Colorectal Cancer Screening Recruitment and Retention Methods, cont’d

How are individuals recruited into the screening program?

Promotional

Strategy

Reminder Strate

gy After No Reply Recall Method After Normal Result

Physician Referral*

Self-Referral**

Self-Referral through Pharmacy

With Mailed Invitation Letter (Specify if

Kit is Sent with Letter)

Other (Please Specify)

AB

(primary method)

No

No

No

No

Program website, promotional and educational resources for health care providers and public,

program marketing campaigns

--------SK (by calling the program)---- (primary method)----Program website, promotional and educational resources for health care providers and public, radio and print ads

Reminder letter sent 9 weeks after invitation

Recall letter sent every 2 years to target population

MB

(phone, email, in person, online request)

----

(primary method)

Walk-ins from breast screening appointments

Mailed letters, public advertising and events, combined screening promotion (

GetChecked

Manitoba), web and social media, education and events for health providers

Reminder letter sent 56 days after test

Recall letter sent 2 years after test is completed

What are the recruitment and retention strategies for your colorectal cancer screening program?

*Physician

referral: physician refers

individual to

the colorectal cancer screening program

**Self-referral

: an individual contacts the colorectal cancer screening program directly to participate in the program

Self-referral through pharmacy:

individuals pick-up fecal testing kit at a pharmacy

----

No information was provided at the time the data was

collected

16

Slide17

Colorectal Cancer Screening Recruitment and Retention Methods, cont’d

How are individuals recruited into the screening program?

Promotional

Strategy

Reminder Strate

gy After No Reply Recall Method After Normal ResultPhysician Referral*

Self-Referral**

Self-Referral through Pharmacy

With Mailed Invitation Letter (Specify if

Kit is Sent with Letter)

Other (Please Specify)

ON

(primary method)

 *

(for patients without a primary care provider)

*Self-referral is available by calling Telehealth ON (for patients without a primary care provider); and via mobile services

Public advertising, provider education campaigns

Reminder letter

sent 4 months after invitation (if no screening has taken place)

Recall letter sent 2 years after test is completedQC(opportuni-stic screening is available)----

----

(for those in the program)

----

Public educational campaign held March 2017. Information is made available on the MSSS portal

----

Recall letter sent every 2 years to the target population

(for those in the program)

NB

N/A

N/A

N/A

(i

nvitation

by program; FIT available through program)

----

Promotional

and

educational

campaigns for health care provider

s,

professionals and public

Program

sends

reminder

letters

12

weeks

after

initial invitation

Recall

letter

sent

2

years

from the date of last negative result

What are the recruitment and retention strategies for your colorectal cancer screening program?

*Physician referral: physician refers participant into the colorectal cancer screening program**Self-referral: an individual contacts the colorectal cancer screening program directly to participate in the programᶧSelf-referral through pharmacy: individuals pick-up fecal testing kit at a pharmacy---- No information was provided at the time the data was collectedN/A = Not applicable

17

Slide18

Colorectal Cancer Screening Recruitment and Retention Methods, cont’d

How are individuals recruited into the screening program?

Promotional

Strategy

Reminder Strate

gy After No Reply Recall Method After Normal ResultPhysician Referral*

Self-Referral**

Self-Referral through Pharmacy

With Mailed Invitation Letter (Specify if

Kit is Sent with Letter)

Other (Please Specify)

NS

----

----

----

(invitation letter sent at entry point (age 50 or new resident) then FIT kit follows)

----

Promotional resources for public, education for health care professionals

No

Recall letter and FIT kit sent every 2 years

PE

 (toll-free line)---- (after invitation letter has been sent, individuals call to order or pick-up a FIT kit at their physician’s office)----Colon Cancer Month including public advertising: print, web; TV, radio. Joint flyer about screening for breast, cervical and colorectal cancer is distributed with FIT result letter

----

Recall letter sent every 2 years

after FIT is completed

NL

----

----

Referral through breast screening

centres

Promotional resources for public (radio/print/web)

, m

edia and advertising

Reminder letter sent 8

weeks after FIT kit is mailed

----

What are the recruitment and retention strategies for your colorectal cancer screening program?

*Physician referral: physician refers participant into the colorectal cancer screening program

**Self-referral: an individual contacts the colorectal cancer screening program directly to participate in the

program

Self-referral through pharmacy:

individuals pick-up fecal testing kit at a pharmacy

----

No information was provided at the time the data was

collected

18

Slide19

Colorectal Cancer Screening Fecal Testing Information

The modality commonly used as an entry level screening test for colorectal cancer is fecal testing. In Canada, a number of screening program features may differ, including type of fecal test offered (guaiac or immunochemical testing) and sampling details for the particular fecal test.

19

Slide20

Colorectal Cancer Screening Fecal Testing Information - Highlights

Entry Level Test: Fecal Test Guaiac (FTg) Sampling Details (refer to slide #21)There are only two provinces (Manitoba and Ontario) which currently offer fecal test guaiac (FTg) as a screening test for colorectal cancer. FTg is offered to eligible individuals every two years. In Canada, the number of labs processing the results ranges from one lab (Manitoba) to six labs (Ontario). The FTg

brands include Hemoccult II SENSA (Manitoba) and Hema-screen (Ontario).

Entry

Level Test: Fecal Immunochemical Testing (FIT) Sampling Details (refer to slide #

22-23)Eight provinces and two territories offer fecal immunochemical testing (FIT) up to every two years as a primary screening test for colorectal cancer. The most common brand for FIT in Canada is Alere (four provinces/one territory) and Polymedco (three provinces). Most provinces/territories require a single sample collection method for the FIT, whereas, one province and one territory collects two samples. The FIT cut-off value varies across Canada and ranges from 75 ng/ml (NWT) to ≥175 ng/ml (QC). The number of labs processing

the FIT

results ranges from one lab (six provinces/one territory) to five labs (one province).

20

Slide21

Entry Level Test: Fecal Test Guaiac (FTg) Sampling Details

Brand Name

Number of

Samples Over the Number of Stools (e.g. XX samples per YY stools)

Number

of Labs Processing Test ResultsNUCurrently under review

MB

Hemoccult

II

SENSA

2 samples per

3 stools

1 lab

ON

Hema

-screen

2 samples per 3 stools

6 labs (7 testing sites)

Does your program offer

FTg

as an entry level test? If so, what are the specific sampling details for this test?

21

Slide22

Entry Level Test: Fecal Immunochemical Testing (FIT) Sampling Details

FIT

Test Brand Name

Number of

Samples Over the Number of Stools (e.g. XX samples per YY stools)

FIT Cut-Off ValueFIT Cut-Off Value (in mcg of Hbg/g)Number of Labs Processing Test ResultsAdditional Comments

NT*

Hemoccult

ICT

2

samples per stool

75ng/ml

N/A

2 labs (Stanton and Inuvik)

Opportunistic

screening only

YK

Alere

1 sample per stool

>100ng/ml

N/A

1 lab (Whitehorse General Hospital)

Kits available at all lab sites, medical clinics and community health centres.

The program receives quantitative FIT results showing numeric value; the providers receive results as either positive or negative

BCAlere1 sample per stool≥ 50ng/ml = abnormal resultN/A5 instruments in BC. Kit available for pick up at all BC labs (private and public)----ABPolymedco1 sample per stool≥75ng/ml= abnormal result15 mcg of Hbg/g2 labs (Calgary & Edmonton)The program receives quantitative FIT results showing numeric value/thresholdDoes your program offer FIT testing as an entry level test? If so, what are the specific sampling details for this test? *There is no organized colorectal cancer screening program available in the Northwest Territories. Responses refer to opportunistic colorectal cancer

screening

----

No information was provided at the time the data was

collected

N/A = Not

applicable

22

Slide23

Entry Level Test: Fecal Immunochemical Testing (FIT) Sampling Details, cont’d

FIT

Test Brand Name

Number of

Samples Over the Number of Stools (e.g. XX samples per YY stools)

FIT Cut-Off ValueFIT Cut-Off Value (in mcg of Hbg/g)Number of Labs Processing Test Results

Additional Comments

SK

Polymedco

1 sample per stool

100ng/ml

20

mcg of

Hbg

/g

1 lab

----

QC

Somagen

----

≥175 ng/ml

----

1 lab

----NBPolymedco1 sample per stool≥100ng/ml20 mcg of Hbg/g1 lab----NSAlere 1 sample per stool≥ 100ng/ml 20 mcg of Hbg/g1 lab

----

PE

Alere

1 sample per stool for 2 stools

100ng/ml

20 mcg of

Hbg

/g

1 lab

Abnormal result,

if

1 sample is over the cut-off

value

Validation study, 2012: 100ng FIT cut-off value continued

NL

Alere

2 samples per 2 stools

≥ 100ng/ml

10 mcg of

Hbg

/g

1 lab

Completed a validation study comparing FIT to

FTg

and colonoscopy results in 2011

Does your program offer FIT testing as an entry level test? If so, what are the specific sampling details for this test?

---- No information was provided at the time the data was collected

23

Slide24

Diagnostic Follow-Up After an Abnormal Fecal Test Result

Individuals who have an abnormal

fecal test are notified of their result and

invited

for diagnostic follow-up, most commonly with colonoscopy.

Timely follow-up after an abnormal

fecal test is optimized with an

efficient referral

process, which can be

facilitated by a navigation

system and/or screening program. It is important to monitor colonoscopy quality to maximize the benefits of screening.

24

Slide25

Diagnostic Follow-Up After an Abnormal Fecal Test Result - Highlights

Follow-Up After an Abnormal Fecal Test Result (refer to slide #27-28)Colorectal cancer screening programs will follow-up with an individual after they receive an abnormal (positive) fecal test result. Eight provinces send result letters after an abnormal fecal test to both the individual and their primary care provider. Others only send result letters either to the individual or the primary care provider; and seven provinces also contact individuals by phone.

Process for Following-Up After an Abnormal Result (refer to slide #29-30)Processes for communicating the abnormal result back to the individual and primary care provider differs across the country. Some provinces have coordinated systems where a program administrator/ nurse navigator/patient coordinator contacts the individual and/or primary

care

provider and schedules

a colonoscopy; others directly communicate with the primary care providers through centralized databases/referral processes to allow them to book a follow-up colonoscopy; and with individuals through program databases or by phone. Recall After and Abnormal Fecal Test and Negative Colonoscopy (refer to slide #31)Recall recommendations vary after an individual receives an abnormal fecal test but a negative colonoscopy result. All provinces and one territory recall individuals for FIT testing after two years (two provinces), five years (two provinces) or ten years (five provinces/one territory). Manitoba and Ontario recall individuals using both fecal occult blood tests (FTg and FIT) but individuals are recalled at different intervals; in Manitoba recall is after five years and in Ontario recall is after

ten

years.

25

Slide26

Follow-Up After an Abnormal Fecal Test Result

Who

is the result letter sent to?

Other Notification Method (e.g. phone call, email) and to Whom is it Directed to (e.g. PCP, individual, both)?

Additional Comments

 

Primary Care

Provider* only

Individual** only

Both Primary Care Provider and Individual

NU

C

urrently no organized screening program but plans are underway.

For

opportunistic screening, results are sent to primary care providers and they follow-up with clients

NT

No organized screening program available

YK

----

----

----

Clients are contacted by their primary care provider. Reminder letters are sent to clients to follow-up with their provider if program has not received a response from physician to complete referral. Other methods for follow-up after an abnormal results are being considered.

BC------------Abnormal result letters are sent to clients from the program. Primary care provider receive results from the lab directly.AB

No

No

No

Alberta Colorectal Cancer

Screenin

g

Program sends

abnormal result letters to clients instructing them to contact their primary care provider to discuss the abnormal result and necessary follow-up. Primary care provider receives abnormal results through

Netcare

messaging.

SK

----

----

Phone call to clients

If the client is in a health

region where SPCRC client navigator has assessed and arranged for a colonoscopy then date of procedure is sent to primary care provider.

MB

----

----

Phone call to clients

ColonCheck

phones all clients with positive test results and mails letters to clients and primary care providers.

How are individuals notified of an abnormal fecal test result?

*Primary Care Provider: abnormal fecal test (

FTg

or FIT) result is sent to

the individual’s

primary care provider

**Individual: abnormal fecal test

(

FTg

or

FIT)

result is sent directly to the individual

----

No information was provided at the time the data was

collected

26

Slide27

Follow-Up After an Abnormal Fecal Test Result, cont’d

Who

is the result letter sent to?

Other Notification Method (e.g. phone call, email) and to Whom is it Directed to (e.g. PCP, individual, both)?

Additional Comments

 

Primary Care

Provider* only

Individual** only

Both Primary Care Provider and Individual

ON

----

----

Phone call to clients (with no primary care provider) if there is no response received to the result letter

Results are sent directly to the primary care provider by the lab. In addition CCO sends abnormal result letters and reminders

are sent

to clients asking them to speak with their primary care provider.

Reminder letters are sent to clients 30 days after an abnormal result letter

i

s sent (if colonoscopy

has not been completed).

QC

(for opportunistic screening)----(for those in the program)Phone call to client (for those in the program)For opportunistic screening, clients are contacted by their primary care provider. When clients are in the program, they will receive a letter and a call from a nurse.

NB

----

----

Phone call

to client

or letter sent (if unable to contact by phone)

Lab sends letters

to primary care provider. Program nurse calls client about abnormal test.

NS

----

----

Phone call to client by program’s Screening Nurse

Result letters are sent to the primary care provider and client indicating a Screening Nurse will contact client for follow-up.

PE

----

----

----

Colorectal Cancer Screenin

g

Program sends

letters of abnormal results to clients instructing them to follow-up with a primary care provider. Primary care provider gets abnormal results through lab.

Follow-up activity/referral (

e.g. colonoscopy

)

is monitored.

NL

----

----

Phone call to client

Nurse

coordinator phones the FIT positive client to provide test results.

Result letter is sent to primary care provider and client.

How are individuals notified of an

abnormal fecal

test

result?

*Primary Care Provider: abnormal fecal test (

FTg

or FIT) result is sent to the individual’s primary care provider

**Individual: abnormal fecal test

(

FTg

or

FIT)

result is sent directly to the individual

---- No information was provided at the time the data was

collected

27

Slide28

Process for Following-Up After an Abnormal Result

NUCurrently no organized screening program but plans are underway.

For opportunistic screening, results are sent to the primary care provider and patients and they follow-up with clients.NT

No organized screening program available.

YK

Ordering primary care provider is responsible for follow-up of abnormal FIT results. A standardized colonoscopy referral form is available. A reminder letter of the referral process for positive FITs is sent to primary care providers . Colonoscopies are performed at Whitehorse General Hospital only.BC

Clients are referred to their corresponding regional Health Authority and Health Authority contacts client to discuss follow-up by

assessing the client and booking a colonoscopy as appropriate.

AB

Ordering primary care provider is responsible for follow-up of abnormal FIT results. As per Alberta Colorectal Cancer Screening Program (ACRCSP) screening pathway, primary care providers are to refer FIT positive clients promptly for colonoscopy using the local colorectal cancer screening program or

endoscopist

(depending on available resources).

SK

Primary care provider

and client notified by direct correspondence regarding abnormal result. P

rimary

care providers

sign medical directives which authorizes client navigators to refer client for a colonoscopy. Client navigator phones FIT positive clients to discuss test results, refer participants to colonoscopy and complete a standardized assessment. Please note: client navigation process currently being expanded into all 13 health regions.

MB

ColonCheck’s

navigator contacts the primary care provider (PCP)

and client by direct mail correspondence regarding the abnormal result and follow-up referral process (a colonoscopy brochure is included in the mail out to the client). Process for follow-up colonoscopy referral is dependent on agreements with each of the 5 Regional Health Authorities and on permissions granted from the PCP (Note:

ColonCheck

has received permission from a majority of PCPs to directly refer clients).A pre-colonoscopy assessment is completed by ColonCheck’s nurse practitioner for all patients receiving healthcare services in Winnipeg. Procedures are scheduled at one of two facilities.What is the process for following-up with an abnormal fecal test result?28

Slide29

ON

Primary care provider contacts client to arrange for follow-up. CCO refers unattached clients to a primary care provider 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 primary care provider

to see the complete screening status for each patient, including those who are due for screening and follow-up. QC

For opportunistic screening, clients are contacted by their

primary care provider

(process following abnormal results depends on the primary care provider). Future planning is underway which will include more guidelines on the screening modalities for organized screening programs. NB

Clie

nt is contacted by phone to discuss results and follow-up procedures. Pre-colonoscopy assessment is done by a program nurse who

refers appropriate clients for colonoscopy in regional hospitals.

NS

Screening results flow electronically into the primary care information system. Additionally, result letters are sent to primary care provider and clients indicating a Screening Nurse will contact the client to discuss and arrange for clinical follow-up. Screening nurse conducts pre-colonoscopy assessment and books colonoscopy procedure with one of the program’s credentialed

colonoscopists

.

PE

Colorectal Cancer

Screenin

g

Program (CCSP) sends

letter of abnormal results to clients instructing them to follow-up with a primary care provider. The primary c

are provider determines follow-up. A standardized colonoscopy referral form is available.

Follow-up activity/referral (

e.g. colonoscopy

)

is monitored. Primary care provider is contacted if there is no activity/referral in the client’s chart. NLNurse follow-up coordinator contacts FIT positive client by phone to provide test results and discuss a potential follow-up colonoscopy. Nurse coordinator will navigate FIT positive client to colonoscopy through booking clerks within Regional Health Authorities.Process for Following-Up After an Abnormal Result, cont’dWhat is the process for following-up with an abnormal fecal test result?29

Slide30

Recall After an Abnormal Fecal Test and Negative* Colonoscopy

* No cancer or adenoma found

RecommendationsNU

C

urrently no organized screening program but plans are underway

NTNo organized screening program availableYK

Recalled for FIT screening in 10 years

BC

Recalled for FIT screening in 10 years

AB

Recalled for FIT screening in 10 years

SK

Recalled for FIT screening in 2 years

MB

Recalled for FOBT screening in 5 years

ON

Recalled for FOBT screening in 10 years

QC

Recalled for FIT screening in 10 years

NB

Recalled for FIT screening in 10 years

NS

Recalled in

FIT screening in 2 yearsPERecalled for FIT screening in 5 yearsNLRecalled for FIT screening in 5 yearsHow are individuals recalled after an abnormal fecal test and negative colonoscopy result?30

Slide31

Colorectal Cancer Screening in Canada for Individuals at Increased Risk

Individuals

at

increased

risk

have certain risk factors

which put

them at a

greater lifetime risk of developing

colorectal

cancer and/or developing more aggressive

colorectal

cancers at an earlier

age. Individuals at increased risk may be screened differently than individuals at average risk.

31

Slide32

Colorectal Cancer Screening in Canada for Individuals at Increased Risk - Highlights

Increased Risk Definition (refer to slide #35-36)Many provinces have specific factors which they consider when placing an individual at increased risk for colorectal cancer. The most common risk factor documented by screening programs (in ten provinces and two territories) which places individuals at increased risk is having a 1st degree relative that was diagnosed with colorectal cancer. There are age stipulations in some provinces/territories where the 1st degree relative needs to be on average <60, ≤60 or >60 years to be considered high risk.Other more common risk factors for high risk include: having more than two 1

st degree relatives diagnosed with colorectal cancer (where 1st degree relative is at any age) (as seen in eight provinces and two territories), having a personal history of colorectal cancer (seven

provinces and

two

territories) and adenomatous polyps (seven provinces and one territory). Four provinces include the following risk factors in their definition of high risk: having more than two 1st degree relatives with adenomatous polyps, two 2nd degree relatives diagnosed with colorectal cancer and adenomatous polyps.32

Slide33

Colorectal Cancer Screening in Canada for Individuals at Increased Risk – Highlights, cont’d

Increased Risk Screening Recommendations (refer to slide #37-39)Colorectal cancer screening programs manage individuals at increased risk by implementing specific screening protocols and follow-up measures. The Canadian Association of Gastroenterologists (CAG) has issued guidelines for screening individuals at increased risk. For more information about the CAG guidelines please visit https://www.cag-acg.org/uploads/guidelines/Colorectal cancer screening 2004.pdfMost provinces and territories screen individuals starting at age 40 (or 10 years earlier than the youngest affected relative) with a colonoscopy every five

years for those who have a 1st degree relative with colorectal cancer (at age <60 years). In some cases, provinces screen individuals at increased risk similarly to those at average risk; however, they begin screening at age 40. Other provinces follow the recommendations outlined in the CAG guidelines for screening individuals at increased risk.

33

Slide34

Increased Risk* Definition

One 1

st degree relative diagnosed with

Two or more

1

st degree relatives diagnosed withTwo 2nd degree relatives diagnosed withPersonal history of

Colorectal

cancer

Adenomatous polyps

Colorectal

cancer

Adenomatous polyps

Colorectal

cancer

Adenomatous polyps

Colorectal

cancer

Adenomatous polyps

NU

C

urrently no organized screening program but plans are underway

NT

(age <60)

----(any age)

----

----

----

----

YK

(age ≤60)

(age ≤60)

(any age)

(any age)

----

----

BC

(age <60)

----

(any age)

----

----

----

----

AB

(age ≤60)

(age ≤60)

(any age)

(any age)

(any age)

(any age)

SK

(age ≤60)

No

(any age)

No

No

No

No

MB**

(age <60)

(age <60)

(any age)

(any age)

(any age)

(any age)

(any age)

(any age)

What is

included

in

your screening program’s

definition of increased risk? (please check all those that apply)

*Increased risk: persons with

certain risk factors for colon

cancer; n

ot

all programs coordinate referrals

of

increased risk

populations

**For MB,

slightly above average risk is also defined, see program guidelines for details

----

No information was provided at the time the data was

collected

34

Slide35

Increased Risk* Definition, cont’d

One

1st degree relative diagnosed with

Two or more

1

st degree relatives diagnosed withTwo 2nd degree relatives diagnosed with

Personal history of

Colorectal cancer

Adenomatous polyps

Colorectal cancer

Adenomatous polyps

Colorectal cancer

Adenomatous polyps

Colorectal cancer

Adenomatous polyps

ON

No

No

No

No

No

NoQCᶴ (any age)

(any age)

NB

----

----

NS

(age <60 & >60)

(age <60 & >60)

----

----

(age <60 & >60)

(age <60 & >60)

----

----

PE

NLᶲ

(age <60)

----

----

----

What is included in your screening program’s definition of increased risk? (please check all those that apply)

*Increased

risk:

persons with certain risk factors for colon

cancer;

n

ot

all programs coordinate referrals

of

increased risk

populations

ᶴ For QC, slight or moderate increased risk is considered

For NL, personal history of Crohn’s disease and ulcerative colitis are also considered

---- No information was provided at the time the data was

collected

35

Slide36

Increased Risk* Screening Recommendations

Screening Recommendation for Increased Risk Population

Follow-up Recommendations After Normal Colonoscopy

NU

C

urrently no organized screening program but plans are underway NT

Colonoscopy at age 40

or 10 years earlier than youngest affected relative (whichever comes first)

Repeat

colonoscopy every 5 -10 years

YK

One first-degree relative diagnosed with CRC or adenomatous polyps ≤60 years OR two or more first-degree relatives diagnosed with CRC or adenomatous polyps at any age. Refer for colonoscopy

at age 40 years, or 10 years prior to index case (whichever comes first). FIT is not recommended

Repeat colonoscopy every 5 years or as directed by specialist

BC

Colonoscopy 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 every 5 years

AB

One first-degree relative >60 years or two or more second-degree relatives at any age diagnosed with CRC, and/or high risk adenomas: Screen with FIT every 1-2 years starting at age 40. If FIT is positive, refer promptly for colonoscopy

One or more first-degree relative ≤ 60 years OR two or more first-degree relatives at any age diagnosed with CRC, and/or high risk adenomas: Refer for colonoscopy at age 40, or 10 years prior to the youngest index case (whichever comes first)

1) Wait 10 years after a normal (i.e., no polyps) colonoscopy result to screen with FIT.

2) Assist individuals with adherence to follow-up as recommended by local CRC screening program or

endoscopist.What are the screening recommendations and follow-up protocols by your screening program for individuals 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** The Canadian Association of Gastroenterologists (CAG) guidelines are available at: CAG Colorectal Screening Guidelines for Increased RiskCRC= colorectal cancer 36

Slide37

Increased Risk* Screening Recommendations, cont’d

What are the screening recommendations and follow-up protocols by your screening program for individuals at increased risk?

Screening Recommendation for Increased Risk Population

Follow-up Recommendations After Normal Colonoscopy

SK

1) Colonoscopy beginning at age 40 or 10 years younger than the earliest case in the family (for persons with a f

irst-degree relative with CRC <60)

2) Same as average risk but beginning at age 40 (

for persons with a first-degree relative with CRC ≥60

)

Recommendations at the discretion of the

endoscopist

and individual monitored by primary care provider

Follow CAG guidelines**

MB

ColonCheck

recommends colonoscopy beginning at age 50 or 10 years earlier than the

youngest relative’s 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

ON

Colonoscopy at age 50 or 10 years earlier than youngest affected relative (whichever comes first)1) For persons with a first-degree relative diagnosed < 60 years old 2) For persons with a first-degree relative diagnosed at ≥ 60 years old 1) Repeat colonoscopy every 5 years2) Repeat colonoscopy every 10 years QC1) Colonoscopy every 5 years at age 40 or 10 years earlier than youngest affected relative

(whichever comes first) (

for persons with

moderate increased risk,

first-degree relative with CRC or polyps at age < 60 years)

2) Same as average risk but starting at age 40 (

for persons with

slight increased risk,

first-degree relative(s) with CRC or polyps at age

>

60 years old)

3) Follow-up (FIT or colonoscopy) according to algorithms (

for persons with

a personal history of polyps)

4) Colonoscopy according to algorithms (

for persons with a personal history of CRC)

As per risk factors and according to algorithms for QC

*Increased

risk:

persons with certain risk factors for colon

cancer;

n

ot

all programs coordinate referrals

of

increased risk

populations

**The Canadian Association of Gastroenterologists (CAG) guidelines are available at:

CAG Colorectal Screening Guidelines for Increased

Risk

CRC= colorectal cancer

37

Slide38

Increased Risk* Screening Recommendations, cont’d

What are the screening recommendations and follow-up protocols by your screening program for individuals at increased risk?

Screening Recommendation for Increased Risk Population

Follow-up Recommendations After Normal Colonoscopy

NB

The Program recommends follow-up with primary care provider or endoscopist

(if they have one) to determine and coordinate screening follow-up.

Detailed algorithm is available from New Brunswick

Cancer Network

Recommendations

follow CAG guidelines**

Detailed algorithm available from

New Brunswick

Cancer Network

NS

Colonoscopy at age 40 or

10

years earlier than youngest affected relative

(whichever comes first) (

for persons with a

first-degree relative with CRC or adenoma diagnosed <60 OR two

or more

second-degree relatives with CRC or adenoma <60)2) FIT (or FOBT) or colonoscopy, beginning at age 40. FIT available through Program every 2 years beginning at age 50. FOBT available by a primary care provider (for persons with a first-degree relative with CRC or adenomatous polyp >60 OR two or more second-degree relatives with CRC or adenoma diagnoses in their 60s or 70s)1) Repeat colonoscopy every 5 years2) Repeat FIT every 2 years; repeat colonoscopy every 10 years or after abnormal FITPEFollow CAG guidelines**Recommendation is at discretion of the primary care provider (referral is not coordinated by the Program)Recommendations at the discretion of the endoscopistFollow CAG guidelines**NLFollow CAG guidelines**Follow CAG guidelines***Increased risk:

persons with certain risk factors for colon

cancer;

n

ot

all programs coordinate referrals

of

increased risk

populations

**The Canadian Association of Gastroenterologists (CAG) guidelines are available at:

CAG Colorectal Screening Guidelines for Increased Risk

CRC= colorectal

cancer

38

Slide39

Reference

Please use the following reference when citing information from this presentation: Canadian Partnership Against Cancer. Colorectal

Cancer Screening in Canada: Environmental Scan [Internet]. Toronto (ON): Canadian Partnership Against Cancer; 2017 [cited (Enter Date Accessed – formatted as YYYY MM)]. Available from: (Enter Link)

39

Slide40

Acknowledgements

Production of this environmental scan has been made possible through financial support from Health Canada through the Canadian Partnership Against Cancer

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