To Screen or Not To Screen: Cancer Screening Outside Organized Programs

Transcription

1 To Screen or Not To Screen: Cancer Screening Outside Organized Programs Dr. Ed Kucharski, Southeast Toronto FHT Dr. Lisa Del Giudice, Sunnybrook Academic FHT Dr. Genevieve Chaput, McGill University Health Centre

2 Faculty/Presenter Disclosure Faculty: "To Screen or Not To Screen: Cancer Screening Outside Organized Programs Dr. Genevieve Chaput, McGill University Health Centre Dr. Lisa Del Giudice, Cancer Care Ontario, Regional Primary Care Cancer Lead, DFCM University or Toronto Dr. Ed Kucharski, Cancer Care Ontario, Regional Primary Care Cancer Lead, DFCM University or Toronto

3 Disclosure of Commercial Support Relationship with commercial interests: There is no affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization. 3

4 Mitigating Potential Bias Not applicable 4

5 Learning Objectives Participants will be able to list the risks and benefits of cancer screening outside of organized programs. Participants will appropriately counsel patients, select tests and follow-up on results when the evidence is not clear. Participants will be provided with a list of resources that can help patients in making an informed decision about cancer screening. 5

6 trcp.ca

7 CCFP Cancer Care Committee

8 Number of new cases Why prevention is so important? 90,000 80,000 Estimated ,000 60,000 Additional cases due to aging of the population 50,000 40,000 Additional cases due to population growth 30,000 Change in cancer risk 20,000 Baseline cancer incidence (1981 level) 10, Year *Prevention is the only way to reduce cancer incidence

9 Video for Healthcare Providers: English: French:

10 What is My CancerIQ Website designed for the public to help understand their risk for cancer and what they can do to help lower that risk Developed by Cancer Care Ontario (CCO) and funded by the Ministry of Health and Long-Term Care (MOHLTC) Consists of a series of questionnaires by cancer type (~5 min each) Answers that are common across questionnaires will be prepopulated in the same session 10

11 Homepage FULLY BILINGUAL SITE Social media Risk Assessments About the tool Fact sheet for each cancer + links FAQ for healthcare providers Subscribe for updates About CCO Legal & Privacy Contact FAQ 11

12 Prostate Cancer Screening 12

13 Case 1: John You have a taken over a new practice and are meeting a number of your new patients. You meet John (age 63) who has been getting a PSA test done every year to make sure everything is alright. You want to care for him appropriately and start off on the right foot. What do you do? 13

14 Prostate Cancer Screening There is considerable debate regarding screening for prostate cancer using the PSA test Most commonly diagnosed cancer in men (after skin cancer) and third leading cause of cancer death in men

15 Prostate Cancer Screening No organized programs in Canada Prostate cancer screening policies for example, in Ontario PSA testing is covered under certain circumstances, not screening PSA is funded in all provinces and territories Opportunistic screening is the mainstay of screening offered by primary care providers

16 Prostate Cancer Screening CTFPHC Recommendations (2014) For men aged less than 55 years, we recommend not screening for prostate cancer with the prostate-specific antigen test. Strong recommendation; low quality evidence For men aged years, we recommend not screening for prostate cancer with the prostate-specific antigen test. Weak recommendation; moderate quality evidence For men 70 years of age and older, we recommend not screening for prostate cancer with the prostate-specific antigen test. Strong recommendation; low quality evidence Endorsement: This clinical practice guideline has been endorsed by the CFPC

17 1,000 MEN SCREENED 102 MEN WILL BE DIAGNOSED WITH PROSTATE CANCER of these 102 prostate cancers would not have caused illness or death. Because of uncertainty about whether their cancer will progress, most men will choose treatment and may experience complications of treatment. 5 men will die from prostate cancer despite undergoing PSA screening. 178 MEN WITH A POSITIVE PSA IN WHOM FOLLOW UP TESTING DOES NOT IDENTIFY PROSTATE CANCER 1 1 man will escape death from prostate cancer because he underwent PSA screening. 720 MEN WILL HAVE A NEGATIVE PSA TEST 4 4 of these 178 will experience biopsy complications such as infection and bleeding severe enough to require hospitalization. 17

18 Pearls (and what to do with John) Mike Evans PSA Video Prostate Cancer Canada talks about a baseline PSA Reducing risk with healthy diet and exercise (Pearls: What Not to Do List)

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20 Lung Cancer Screening 20

21 Case 2: James 65 year old male No personal history of cancer No family history of lung cancer Smoker for 31 years and smokes ~20 cigarettes per day Hasn t attempted to quit within the past 12 months Lived in a large city for 10 or more years No history of asbestos, chemical or other occupational exposures 21

22 Burden of Lung Cancer Most common cause of cancer death Most commonly diagnosed cancer in Canada Approximately will be diagnosed and will die in a given year Mortality is extremely high for late stages compared to earlier stages

23 Evidence for Lung Cancer Screening for People at High Risk National Lung Screening Trial evidence: Randomized controlled trial with >50,000 participants 20% reduction in lung cancer mortality over 6 years with LDCT

24 Lung Cancer Screening No fully implemented organized programs in Canada Pilots in Ontario Opportunistic screening is the mainstay of screening offered by primary care providers in seven provinces Business cases/proposals for screening in BC, AB, NS, PEI, NB

25 Cancer Care Ontario Recommendations Cancer Care Ontario recommends: Screening should be organized LDCT for high risk populations Chest X-ray should not be used Embedding smoking cessation in screening program

26 Lung Cancer Screening for People at High Risk in Ontario Cancer Care Ontario conducting pilot in 3 sites Sites with level 1 thoracic surgery centres and Lung Diagnostic Assessment Programs Started April 2017 and data collected over 2 years Results of evaluation will inform provincial program New pilot for Toronto Feb 2019 For more information, contact your Regional Primary Care Lead / Regional Aboriginal Cancer Lead

27 Screening Outside of Cancer Care Ontario s Pilot Lung cancer screening should only occur through an organized screening program If not organized, screening may not occur in appropriate populations, at recommended interval, with appropriate follow-up or with quality monitoring Can only ensure high-quality organized lung cancer screening at pilot sites

28 However.CTFPHC Says: Low Dose CT Recommendation: For adults aged 55 to 74 years with at least a 30 pack-year smoking history, who currently smoke or quit less than 15 years ago, we recommend annual screening with LDCT up to three consecutive times. Weak recommendation; low quality evidence Screening should ONLY be carried out in health care setting with expertise in early diagnosis and treatment of lung cancer

29 Pearls and what to do with James? If in Ontario with a pilot, refer him there! Don t do a CXR Mycanceriq.ca Smoking cessation: my favourites are smokers helpline and Mike Evans Video Alberta TOPS information

30 Alberta College of Family Physicians (ACFP) Tools for Practice Bottom Line: Benefit from screening for lung cancer with LDCT has been demonstrated in only one trial, without a usual care group. The high number of false positives, which require further, sometimes invasive investigations, is worrisome. Smoking cessation should remain the priority to decrease lung cancer mortality.

31 Colorectal Cancer Screening 31

32 CRC Case Study: Part A You are seeing Rahm, a 53 year old man Rahm has heard about colonoscopy examination through a friend on his baseball team and would like to have one What questions should you ask him first to determine if colonoscopy is the appropriate screening modality for him? 32

33 CRC Case Study: Part A What questions should you ask Rahm to determine if colonoscopy is the appropriate screening modality for him? Family History History of IBD CRC Symptoms CRC Signs 33

34 CRC Case Study: Part A Rahm reports that his father was just diagnosed with colorectal cancer at the age of 75 What do you recommend to Rahm? (age of initiation, modality and how often if normal) 34

35 CRC Screening Recommendation: Colonoscopy Colonoscopy is Recommended if: 1 or more first-degree relatives with a history of colorectal cancer Begin at age 50, or 10 years earlier than age relative was diagnosed, whichever is first Re-screening interval is dependent on family history o Relative diagnosed before age 60 screen every 5 years o Relative diagnosed at/after age 60 screen every 10 years

36 CRC Case Study: Part B What if Rahm denied any symptoms that were suspicious for colorectal cancer or family history of colorectal cancer, what risks are associated with screening colonoscopies? 36

37 Colonoscopy-Associated Complications Ontario n=67,632 Bleeding 1 in 671 Perforation 1 in 1,695 Death 1 in 13,513 Colonoscopy is not a benign procedure Rabeneck L., et. al., Gastroenterology 2008;

38 CRC Case Study: Part B After hearing about these risks, Rahm begins to lose interest in having a colonoscopy and asks what other options does he have for colorectal cancer screening? 38

39 CTFPHC 2016 CRC Screening Guidelines Average Risk Recommendations: Screen adults aged 60 to 74 with FOBT (either gfobt or FIT) every two years OR flexible sigmoidoscopy every 10 years Strong recommendation; moderate quality evidence Screen adults aged 50 to 59 with FOBT (either gfobt or FIT) every two years OR flexible sigmoidoscopy every 10 years Weak recommendation; moderate quality evidence Do not screen adults aged 75 years and over Weak recommendation; low quality evidence Do not using colonoscopy as a screening test for CRC Weak recommendation; low quality evidence

40 Provincial and Territorial Programs

41 Provincial and Territorial Programs

42 Transition to FIT in Ontario Cancer Care Ontario is working on changes to the Colon Cancer Check program for the transition to screening with FIT for average risk individuals Until FIT is launched, gfobt remains the recommended CRC screening test in Ontario for people at average risk 42

43 CRC Case Study: Part B Rahm asks how does Fecal Immunochemical Testing (FIT) compare to colonoscopy in terms of performance and possible risks? 43

44 Diagnostic Yield- Intention to Screen Colonoscopy n=26,703 FIT n=26,599 P-value CRC Detection Advanced adenoma detection # needed to screen to find 1 CRC # needed to scope to find 1 CRC Not significant < Complication rate <0.001 Quintero E., et. al., NEJM 2012;366:

45 CRC Case Study: Part C What if Rahm (with no family history) in the end insists on and completes a screening colonoscopy, when should he have his next CRC screening test and with what modality if his screening colonoscopy is: Normal One Hyperplastic polyp One to Two Tubular Adenomas One Tubulovillous Adenoma 45

46 Screening After Normal Colonoscopy Case control studies show patients with a previous negative colonoscopy have a 74-76% lower risk of CRC than those without previous colonoscopy risk reduction persists 10-20y This also applies to patients who have had a low risk adenoma and subsequent normal colonoscopy Brenner et al. Gastroenterology Brenner et al. Gut

47 Reduced mortality risk after low risk adenoma Loberg et al found a 25% significant relative risk reduction in CRC mortality in patients found to have a low risk adenoma compared to the general population Standardized mortality ratio = 0.75 (95% CI: ) Loberg et al. N Engl J Med

48 CRC Case Study: Part C What if Rahm in the end insists on and completes a screening colonoscopy, when should he have his next CRC screening test and with what modality if his screening colonoscopy is: Normal FIT/FOBT 10 yrs One Hyperplastic polyp FIT/FOBT 10 yrs One to Two Tubular Adenomas FIT/FOBT?TBD One Tubulovillous Adenoma Colonoscopy as per endoscopist 48

49 Cervical Cancer Screening HPV 49

50 Case Study Cervical: Part A You are seeing Ashley, a 32 year old woman who has never had cervical cancer screening. She suffers from vulvodynia and is worried about having a speculum exam She completed three doses of Gardasil 4 eight years ago and is hoping that she does not even need a pap She first became sexually active seven years ago and has only been in same sex relationships 50

51 Case Study Cervical: Part A Should Ashley re-booster (3 doses) with Gardasil 9? 51

52 HPV Booster Vaccines Gardasil 9 Booster after Gardasil 4? No current recommendation for additional 9vHPV doses after completion of series of 4vHPV or 2vHPV Protective benefit against additional 5 HPV types in 9vHPV mostly limited to females (only small % HPV male cancer due to extra HPV 5 types) Safety local reaction redness at site Cost-effective to vaccinate wrt quality-adjusted life year gained 52

53 Case Study Cervical: Part A Does Ashley need any screening given that she has received HPV vaccination prior to any sexual activity and she has only had relationships with women? 53

54 Case Study Cervical: Part A Despite Ashley having had HPV vaccination, she should continue to be screened according to current recommendations Currently a lack of evidence to suggest otherwise

55 CTFPHC 2013 Cervical Screening Guidelines Recommendations for women: Aged 25 to 29: routine screening every 3 years (pap) Weak recommendation; moderate quality evidence Aged 30 to 69: routine screening every 3 years (pap) Strong recommendation; high quality evidence Aged 70 who have been adequately screened (i.e., 3 successive negative Pap tests in the last 10 years), routine screening may cease If not adequately screened continue screening until 3 negative test results have been obtained Weak recommendation; low quality evidence

56 Case Study Cervical: Part A Does Ashley need any screening given that she has only had relationships with women? 56

57 Cervical Screening LGBQT Lower rates of screening in this population Women who have sex with women: same screening regimen as women who have sex with men Transgender men with a cervix: screen according to guidelines

58 Case Study Cervical: Part B Ashley heard that HPV causes cervical cancer and asks why can t we just test for HPV? She is hoping this would be a blood test. Is she correct? 58

59 Cervical Cancer and HPV Over 99% of cervical cancer dysplasia is caused by the Human Papilloma Virus (HPV) Over 80% of sexually active people will acquire HPV in their lifetime Most HPV infections are transient; about 90% will clear in <2 years Cervical cancers occur due to persistent infection with high risk (oncogenic) types of HPV

60 Screening for Cervical Cancer and Premalignant Lesions Abnormal pap tests detect cervical cell changes that are a result of HPV infections Testing for HPV directly does exist 60

61 HPV for Primary Cervical Cancer Screening Strong evidence to support HPV as the primary screening modality for cervical cancer International and national RCTs to support this HPV testing will eventually become the primary screening modality for cervical cancer Must be implemented within a publically funded organized program Available patient-pay basis ~ $90 per test

62 HPV for Primary Cervical Cancer Screening HPV DNA testing is not currently used for primary screening within organized screening programs in Canada However, several provinces and territories have begun to implement or are piloting HPV testing for the purposes of triage or follow-up after treatment, or are piloting its use for primary screening. 62

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64 What to expect with HPV Primary Screening Recommendations: Start cervical screening with HPV testing at age 25 Collect cells from the cervix to test for the presence of HPV Screening with HPV testing should occur at fiveyear intervals after an initial negative result

65 What to expect with HPV Primary Screening Recommendations: Cease screening in women age 70 who have had an adequate and negative screening history in the prior 10 years (i.e. two negative five-yearly HPV tests) Continue screening women > 65 years who do not meet these requirements at recommended intervals, until two negative tests

66 HPV testing and abnormal cervical cytology Until there is a publically funded primary HPV screening program, expect HPV testing to be increasingly used to manage women with pap abnormalities 66

67 Case Study Cervical: Part C Ashley undergoes a pap which shows ASCUS The sample is further tested for HPV and found to be high risk HPV DNA positive She is referred to colposcopy and managed there for ~2 years Her gynecologist then discharges her back to you When should she have her next cervical screening test?

68 HPV Exit Testing If high risk HPV oncogene-negative at exit, the woman is at or below population risk and can resume routine screening If HPV-positive at exit, she is at elevated risk and should have more frequent testing; at present annual surveillance is recommended

69 Case Study Cervical: Part E What if Ashley had never been vaccinated against HPV. Is it worthwhile for her to get the vaccine now that she has already acquired HPV? 69

70 HPV Vaccination After Colposcopy There is currently no evidence to support the development of a natural HPV immunity In one study women who were vaccinated after the LEEP were 2/3 less likely to have recurrent disease caused by the same HPV genotype In addition these women received protection against other HPV genotypes in the vaccine A growing body of evidence supports the efficacy of HPV vaccination for all age groups (there is no longer an upper age limit) 70

71 Ovarian Cancer Screening 71

72 Case Study Ovarian: Mary You are seeing Mary, a 54 year old woman who received an from her sister She printed up the for you to see It says that ovarian cancer is deadly and can be prevented with a simple blood test called Ca125. It advises women to go to their doctor and insist on having it done The advises to forward the to 10 women that you care about 72

73 Canadian Task Force on Preventative Health Care: Ovarian Cancer Screening In 2013, the CTFPHC issued a critical appraisal report for the Screening for Ovarian Cancer: U.S. Preventative Services Task Force Reaffirmation Recommendation Statement (2013): High quality guideline that can be used to guide preventative care in Canada Recommendation Grade D = recommend against the service. Moderate or high certainty that the service has no benefit or that harms outweigh the benefits 73

74 Canadian Task Force on Preventative Health Care: Ovarian Cancer Screening Screening for ovarian cancer in asymptomatic women is not recommended: Support USPSTF recommendation against screening with transvaginal ultrasonography or CA-125 Absence of evidence to support the effects of screening on mortality Harms of screening high, outweighing any small potential benefit Transvaginal ultrasonography + CA-125 are associated with high false-positive rate: For every 100 women with positive screening result, only 1 has ovarian cancer False-positive test results may lead to unnecessary surgeries and surgical complications Lack of evidence to support regular bimanual pelvic examination for ovarian cancer screening 74

75 Ovarian Cancer Symptoms Despite current evidence against ovarian cancer screening, clinical vigilance is important Symptoms are vague, common ones include: Bloating Feeling full quickly or loss of appetite Abdominal or pelvic discomfort or pain Urinary changes Less common symptoms include: Fatigue, gas, indigestion, nausea, irregular menstrual cycle, changes in bowel habits, changes in weight 75

76 Increased Risk of Ovarian Cancer Increasing age (over 50 years of age) Family history of breast, uterine, ovarian or colorectal cancers Ashkenazi Jewish descent (increased risk of BRCA gene mutation) Known BRCA 1 or BRCA 2 gene mutation or Lynch Syndrome **Refer for genetics**

77 Useful resource ovarian cancer Canadian Task Force on Preventative Health Care (2013 report) U.S. Preventative Services Task Force: Evidence update ovarian cancer screening Ovarian cancer screening recommendation The Canadian Agency for Drugs and Technologies in Health r%20screening%20final.pdf

78 Breast Cancer Screening 78

79 Breast Cancer in Canada In 2017, estimated Canadian women diagnosed with breast cancer 25% of all new cancer cases in women in 2017 Breast cancer = most frequently diagnosed cancer in women 1 in 8 women will develop it in their lifetime The majority of breast cancers (51%) occur in women ages year survival is high = 87% Canadian Cancer Statistics, 2018

80 Canadian Task Force on Preventative Health Care Guidelines (2011, upcoming update 2018) For average risk women: For women aged we recommend not routinely screening with mammography. (Weak recommendation; moderate quality evidence) For women aged years we recommend routinely screening with mammography every 2 to 3 years. (Weak recommendation; moderate quality evidence) For women aged we recommend routinely screening with mammography every 2 to 3 years. (Weak recommendation; low quality evidence) For detailed information:

81 Canadian Task Force on Preventative Health Care Guidelines (2011, upcoming update 2018) Average risk is defined as: No personal history of breast cancer No 1 st degree relative family history of breast cancer No known mutations in BRCA1/BRCA2 genes No previous exposure of radiation to chest wall For detailed information:

82 Breast Cancer Screening Programs in Canada Nunavut* Northwest Territories 2003 Program start date Program name Agency responsible for program administration 2008 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 1990 Yukon Mammography Program Government of Yukon (Yukon Hospital Corporation) British Columbia 1988 BC Cancer Breast Screening BC Cancer Agency Alberta 1990 Alberta Breast Cancer Screening Program (ABCSP) Alberta Health Services Saskatchewan 1990 Screening Program for Breast Cancer Saskatchewan Cancer Agency Manitoba 1995 BreastCheck CancerCare Manitoba Ontario 1990 Ontario Breast Screening Program (OBSP) Cancer Care Ontario Québec 1998 Programme québécois de dépistage du cancer du sein (PQDCS) New Brunswick 1995 New Brunswick Breast Cancer Screening Services Ministère de la Santé et des Services sociaux New Brunswick Cancer Network (NB Department of Health) Nova Scotia 1991 Nova Scotia Breast Screening Program IWK Health Authority Prince Edward Island 1998 PEI Breast Screening Program Health PEI Newfoundland and Labrador *No organized screening program available in Nunavut 1996 Breast Screening Program for Newfoundland and Labrador Eastern Health, Cancer Care Program Slide reproduced from: Canadian Partnership Against Cancer. Breast Cancer Screening in Canada: Environmental Scan [Internet]. Toronto (ON): Canadian Partnership Against Cancer; 2017 [cited ( )]. Available from: ( 82

83 Provincial and Territorial Breast Cancer Screening Clinical Practice Guidelines For asymptomatic women at average risk: Nunavut* Start age Interval Stop age Exclusion criteria Northwest Territories Begin at age 50 (age accepted by physician referral for initial screen but not actively recruited) Yukon Begin at age 50 (age accepted by self-referral but not actively recruited) For women aged annual recall For women aged biennial recall For women aged biennial recall 74 (age 75+ accepted by self referral, but not recalled) 75 Personal history of breast cancer; no NWT healthcare coverage; no primary healthcare provider; acute symptoms; breast implants; breastfeeding in last 3 months Previous breast cancer; breast implants; signs or symptoms of breast cancer British Columbia Begin at age 50 (age accepted by self-referral but not actively recruited) For women aged biennial recall For women aged biennial recall 74 (age 75+ accepted by self referral but not actively recruited or recalled) Previous breast cancer; breast implants *No organized screening program available in Nunavut Slide reproduced from: Canadian Partnership Against Cancer. Breast Cancer Screening in Canada: Environmental Scan [Internet]. Toronto (ON): Canadian Partnership Against Cancer; 2017 [cited ( )]. Available from: ( 83

84 Provincial and Territorial Breast Cancer Screening Clinical Practice Guidelines For asymptomatic women at average risk: Alberta Start age Interval Stop age Exclusion criteria Begin at age 50 (age accepted with physician referral for the first screen) For women aged annual recall For women aged biennial recall 74 Women less than age 40; signs or symptoms of breast cancer; requiring follow-up with diagnostic imaging; requiring work-up for an unknown primary malignancy or possible metastatic disease to the breast or axilla; known diagnosis/history of breast cancer; men Saskatchewan Begin at age 50 (age 49 accepted to mobile unit if turning 50 in same calendar year) Manitoba Begin at 50 (ages accepted to mobile unit with physician referral) For women aged biennial recall For women aged biennial recall For women aged biennial recall 75+ Breast cancer in last 5 years; breast implants 74 (age 75+ accepted by self referral but not actively recruited or recalled) Previous breast cancer; breast implants; had a mammogram in the last 12 months Ontario Begin at age 50 For women aged biennial recall 74 (women 75+ can be screened but require a physician referral; not actively recruited or recalled by the OBSP) Acute breast symptoms; previous breast cancer; breast implants; mastectomy; had a mammogram in the last 11 months Slide reproduced from: Canadian Partnership Against Cancer. Breast Cancer Screening in Canada: Environmental Scan [Internet]. Toronto (ON): Canadian Partnership Against Cancer; 2017 [cited ( )]. Available from: ( 84

85 Provincial and Territorial Breast Cancer Screening Clinical Practice Guidelines For asymptomatic women at average risk: Start age Interval Stop age Exclusion criteria (e.g. no previous breast cancer) Québec Begin at age 50 (accept ages only with physician referral, at a program designated screening or referral centre) For women aged biennial recall 69 (age 70+ only with a physician referral, at a program designated screening or referral centre) Previous breast cancer New Brunswick Begin at age 50 (age accepted only with physician or nurse practitioner referral) For women aged biennial recall 74 (age 74+ only with a physician or nurse practitioner referral) Previous breast cancer Nova Scotia Begin at age 50 (age accepted by selfreferral but not actively recruited) For women aged annual recall For women aged biennial recall 70+ Breast implants; previous breast cancer; signs or symptoms of breast cancer Prince Edward Island Begin at age 40 (accepted by self - referral) For women aged annual recall For women aged biennial recall 74 Previous breast cancer; had a mammogram in the last 12 months; breast implants Newfoundland and Labrador Begin at age 50 For women aged biennial recall 74 (age 74+ only if previously enrolled in the program) Previous breast cancer; breast implants This age group may change to 50-74; currently pending institutional approval Slide reproduced from: Canadian Partnership Against Cancer. Breast Cancer Screening in Canada: Environmental Scan [Internet]. Toronto (ON): Canadian Partnership Against Cancer; 2017 [cited ( )]. Available from: ( 85

86 Breast Cancer Screening Case 1 Joan is 47 years old. She s come into the office with questions about mammograms. Some of her friends have said mammograms are useless, while others underwent mammograms starting at the age of 40 so is she late? What should we tell Joan?

87 Effectiveness of Mammography Are Mammograms Useless? In Nelson et al most recent review - mammography screening is associated with lower breast cancer mortality in women International Agency for Research on Cancer (IARC) reaffirmed - mammographic screening reduces mortality in women and in shows substantial reduction in risk of death from breast cancer In Canada the breast screening programs using mammography are associated with a 40 % decrease in mortality from breast cancer 87

88 So Should Joan proceed to a mammogram? For women between 40 and 49 years of age: Among women who do not screen, the risk of dying from breast cancer is: 1 in 313 With regular screening your risk of dying of breast cancer is: 1 in 370 However, with regular screening: your risk of having a false positive mammogram requiring further screening is: 1 in 3 you risk of having a biopsy is: 1 in 28 your risk of having part or all of a breast removed unnecessarily is: 1 in

89 CTFPHC Recommendation: Mammography (40-49 years) For women aged years we recommend not routinely screening with mammography (Weak recommendation; moderate quality evidence) Slide reproduced from: CTFPHC Breast Cancer Screening Recommendations

90 Findings and Implications: years Significant reduction in RR, but: Screening in women aged decreased the absolute risk of dying from breast cancer by 0.05% CTFPHC judgment: Most women should not receive screening but many could receive it o Less favourable balance of benefit vs. harm, compared to older women o Risk of FP higher, compared to older women o Clinicians must consider patient preferences and values Slide reproduced from: CTFPHC Breast Cancer Screening 90 Recommendations 2011

91 Breast Cancer Screening Case 2 Jane 35 years old, pre-menopausal No personal history of cancer Positive family history of breast cancer (her mother and sister) Not received any genetic testing and is unaware of any carriers within her family G1, P1 (no breastfeeding) Menses before age 15 On oral contraceptives What is your breast cancer screening recommendation for Jane? 91

92 Breast Cancer Screening Case 2: Risk Assessment 92

93 High risk breast cancer screening 93

94 Breast Cancer Screening Case 2: Risk Assessment Ontario Breast Screening Program (OBSP): Who Is Eligible? Women ages 30 to 69 are eligible for screening mammography and screening breast magnetic resonance imaging (MRI) (or, if MRI is not medically appropriate, screening breast ultrasound) every year at High Risk OBSP sites Must be at high risk for breast cancer as identified through Category A OR Category B on the Requisition for High Risk Screening Category A: eligible for direct entry into the High Risk OBSP based on personal and family history Category B: genetic assessment required to determine eligibility for the High Risk OBSP Women with bilateral mastectomies are not eligible for the High Risk OBSP 94

95 High Risk OBSP The High Risk OBSP includes the following features: A navigator for specialized support to women at high risk for breast cancer. Organizes genetic assessment and screening tests. Provides counseling regarding the screening and assessment process Facilitation of genetic assessment (i.e., counselling and/or testing) for women who may be at high risk for breast cancer (i.e., fall under Category B) Annual screening for women through the High Risk OBSP with mammography and MRI (or ultrasound if MRI is contraindicated) No self-referrals women at high risk for breast cancer must be referred to the High Risk OBSP by a physician For further information, visit cancercare.on.ca/obsphighrisk.

96 Management of High Risk* by Screening Program Nunavut** Does your program screen women who are identified at high risk (Yes; No) If yes, what is the screening protocol administered by the program Screening modality used (e.g. MRI) Interval (e.g. annual) Start and stop age *High risk = women who are at a greater lifetime risk of developing breast cancer and/or developing more aggressive breast cancers at an earlier age **No organized screening program available in Nunavut ---- No information was provided at the time the data was collected N/A = Not applicable Additional information Northwest Territories Guidelines currently under review Yukon No N/A N/A N/A No current program policies for high risk British Columbia Yes Mammography Annual Women under age 40 are accepted with a physician referral Annual breast MRI is available outside the screening program by physician referral for women with BRCA1/2 gene mutations or very strong family history of breast cancer Alberta No N/A N/A N/A ---- Saskatchewan No N/A N/A N/A ---- Manitoba Yes Mammography Annual Women can access genetic counselling and MRI through physician Ages accepted to mobile unit with physician referral; age 75+ accepted by selfreferral but not actively recruited or recalled Slide reproduced from: Canadian Partnership Against Cancer. Breast Cancer Screening in Canada: Environmental Scan [Internet]. Toronto (ON): Canadian Partnership Against Cancer; 2017 [cited ( )]. Available from: ( 96

97 Management of High Risk* by Screening Program Does your program screen women who are identified at high risk (Yes; No) If yes, what is the screening protocol administered by the program Screening modality used (e.g. MRI) Interval (e.g. annual) Start and stop age Additional information Ontario Québec Yes MRI (or ultrasound if MRI is contraindicated) and mammogram Annual Women who are 70 years and above are screened annually with mammogram only Yes Mammography Biennial Women at high risk are not excluded from the program at this time, they are invited in the same way as women at moderate risk, and the additional investigation is the responsibility of the primary care provider New Brunswick No N/A N/A N/A ---- Nova Scotia Yes Mammography Annual NSBSP is in the process of standardizing the management of high risk women in the breast screening program. Women over the age of 69 are not sent a reminder postcard to book their next screen, but are accepted into the program should they choose to screen Prince Edward Island Newfoundland and Labrador Yes Mammography Annual Ultrasound & MRI are not used as screening modalities No N/A N/A N/A ---- *High risk = women who are at a greater lifetime risk of developing breast cancer and/or developing more aggressive breast cancers at an earlier age ---- No information was provided at the time the data was collected N/A = Not applicable Slide reproduced from: Canadian Partnership Against Cancer. Breast Cancer Screening in Canada: Environmental Scan [Internet]. Toronto (ON): Canadian Partnership Against Cancer; 2017 [cited ( )]. Available from: ( 97

98 Referral for High Risk* Nunavut** Managed by screening program Surveillance/High risk program Diagnostic centre OR referred to: Referral back to primary physician Other (please specify) Northwest Territoriesᶲ No Yukon No N/A N/A N/A N/A British Columbia No (MRI where available in BC) Alberta No (high risk clinics) High risk clinics 2 Genetics clinics Saskatchewan No ---- Centre of Care Manitoba N/A N/A N/A Women identified as high risk may be managed by BreastCheck or by their family physician. They may attend BreastCheck to access screening or a Diagnostic Centre. There are plans to review these guidelines, but currently this work has not yet started *High risk = women who are at a greater lifetime risk of developing breast cancer and/or developing more aggressive breast cancers at an earlier age **No organized screening program available in Nunavut ᶲ Guidelines currently under review ---- No information was provided at the time the data was collected N/A = Not applicable Slide reproduced from: Canadian Partnership Against Cancer. Breast Cancer Screening in Canada: Environmental Scan [Internet]. Toronto (ON): Canadian Partnership Against Cancer; 2017 [cited ( )]. Available from: ( 98

99 Referral for High Risk* Managed by screening program Surveillance/High risk program Diagnostic centre OR referred to: Referral back to primary physician Other (please specify) Ontario No N/A N/A N/A Québec No New Brunswick No** N/A N/A N/A ---- Nova Scotia φ N/A N/A N/A ---- Prince Edward Island N/A N/A N/A N/A Newfoundland and Labrador No *High risk = women who are at a greater lifetime risk of developing breast cancer and/or developing more aggressive breast cancers at an earlier age **The Screening Program only has guidelines for average risk individuals; there is no formal process to identify and manage women at high risk Φ Women under 40 are imaged in a diagnostic centre; they are not part of the screening program Currently standardizing the practice of radiological screening of women at high lifetime risk of breast cancer ---- No information was provided at the time the data was collected N/A = Not applicable Slide reproduced from: Canadian Partnership Against Cancer. Breast Cancer Screening in Canada: Environmental Scan [Internet]. Toronto (ON): Canadian Partnership Against Cancer; 2017 [cited ( )]. Available from: ( 99

100 Breast Cancer Screening: Case 3 The resident you are supervising comes in to ask you to chaperone a clinical breast exam at Sara s (age 52) health visit. Sara, who recently underwent mammography as part of breast screening program, is also inquiring if she should be performing routine breast self examinations. Sara s personal and family history is negative for breast cancer. What do you tell your resident about clinical breast exams? What about breast self examinations?

101 CTFPHC Recommendation: Clinical Breast Exam (CBE) We recommend not routinely performing CBE alone or in conjunction with mammography to screen for breast cancer. (Weak recommendation; low quality evidence) Slide reproduced from: CTFPHC Breast Cancer Screening Recommendations

102 Effectiveness & Harm: Clinical Breast Exam (CBE) Effectiveness of CBE has not been established Harm of CBE: o For each additional cancer detected with CBE per 10,000 women, there would be an additional 55 false-positives (Chiarelli et al, 2009) Slide reproduced from: CTFPHC Breast Cancer Screening 102 Recommendations 2011

103 CTFPHC Recommendation: Breast Self Exam (BSE) We recommend not advising women to routinely practice BSE (Weak recommendation; moderate quality evidence) Slide reproduced from: CTFPHC Breast Cancer Screening Recommendations

104 Effectiveness: Breast Self Exam (BSE) Outcomes Illustrative Comparative Risks* (95% CI) Relative Assumed Risk Corresponding Risk Effect per million per million (range) (95% CI) Control BSE No of Participants (Studies) Quality of the Evidence (GRADE) Breast Cancer Mortality Follow-up: mean 5 years 1,540 1,509 (1,278 to 1,771) RR 0.98 (0.83 to 1.15) 387,359 (2 studies) Moderate 1,2,3 *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). 1 blinding and concealment were not clear 2 no heterogeneity exists. P-value for testing heterogeneity is and I 2 =0%. 3 the question addressed is the same for the evidence regarding the population, comparator and outcome. Slide reproduced from: CTFPHC Breast Cancer Screening Recommendations

105 Breast Cancer Screening: Case 3 Sara asks you if she should also undergo a breast MRI or a breast ultrasound as part of her routine breast cancer screening. What should we tell Sara?

106 CTFPHC Recommendation: Magnetic Resonance Imaging (MRI) We recommend not routinely screening with MRI (Weak recommendation; no evidence) Slide reproduced from: CTFPHC Breast Cancer Screening Recommendations

107 Screening with Breast Ultrasound Mammography is the only primary imaging technique that has been licensed by Health Canada for breast cancer screening for the general population, and is the only screening test that is recommended by evidencebased clinical practice guidelines. The use of MRI as an adjunct for women at very high risk is known and in these women ultrasound has been used but only when MRI is not possible. 107

108 Screening with Breast Ultrasound No evidence to support using bilateral breast ultrasound as a screening tool Has shown to find a few occult cancers on mammography in some studies, but in all studies it has also shown a very large number of false positives resulting in unacceptable numbers of women undergoing unnecessary procedures. 108

109 Estimates of Adverse Outcomes To save one life from breast cancer over 11 years Screening every 2 3 years Unnecessary breast biopsy False positive mammogram Women aged years Women aged years Women aged years 2100 women 75 women 690 women 720 women 26 women 204 women 450 women 11 women 96 women Slide reproduced from: CTFPHC Breast Cancer Screening Recommendations

110 Canadian Task Force of Preventative Health Care: Breast Cancer Screening Recommendations For women aged years we recommend not routinely screening with mammography (Weak recommendation; moderate quality evidence) For women aged years we recommend routinely screening with mammography every 2 to 3 years (Weak recommendation; moderate quality evidence) For women aged years we recommend routinely screening with mammography every 2 to 3 years (Weak recommendation; low quality evidence) Slide reproduced from: CTFPHC Breast Cancer Screening Recommendations

111 Useful Resources 111

112 Canadian Task Force Preventive Health

113 Michael Evans Reframe Health Lab

114 CCO Screening Mobile App/ Web-site App decommissioned February 23th 2018 Removed from app stores No longer up to date CCO launched new responsive website Designed to provide optimal viewing for all devices including mobile phones, tablets, desktops Bookmark pages from cancercareontario.ca website to your favourites 114

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