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July 2015
Colorectal Cancer Screening Guidelines Across Canada Environmental Scan
July 2015
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
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
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/
The Canadian Task Force on Preventive Health Care (2001) recommends the following for colorectal cancer screening:
July 2015
Colorectal Cancer Screening Program Status
Date of Program Announcement
Program Status Program Name Agency responsible for Program Administration
Nunavut (NU) Plans underway to develop an organized screening program
Northwest Territories (NT) No organized program
No organized program No organized program No organized program
Yukon (YK) No organized program
No organized program No organized program No organized program
British Columbia (BC) 2009 Full program, province wide
Colon Screening Program BC Cancer Agency
Alberta (AB) March 2007 Full program, province wide
Alberta Colorectal Cancer Screening Program (ACRCSP)
Alberta Health Services
Saskatchewan (SK) January 20, 2009 Full program, province wide
Screening Program for Colorectal Cancer
Saskatchewan Cancer Agency
Manitoba (MB) 2007 Full program, province wide
ColonCheck CancerCare Manitoba
Ontario (ON) January 2007 Full program province-wide
ColonCancerCheck Cancer Care Ontario
July 2015
Colorectal Cancer Screening Program Status, cont’d
Date of Program Announcement
Program Status Program Name Agency responsible for Program Administration
Quebec (QC) December 2010 Implementation phase Programme québécois de dépistage du cancer colorectal (PQDCCR)
Ministry of Health and Social Services
New Brunswick (NB)
2009 Launched in one Health Zone November 2014
New Brunswick Colon Cancer Screening Program
New Brunswick Cancer Network (NB Department of Health)
Nova Scotia (NS) 2009 Province wide program March 2013
Colon Cancer Prevention Program Cancer Care Nova Scotia
Prince Edward Island (PE)
2009 Province wide program May 2011
PEI Colorectal Cancer Screening Program
Health PEI
Newfoundland and Labrador (NL)
March 19, 2010 Province-wide July 2015
Newfoundland and Labrador Colon Cancer Screening Program
Eastern Health, Cancer Care Program
Colorectal Cancer Screening Program Availability
July 2015
Colorectal Cancer Screening Programs: Provincial and Territorial Guidelines
Start Age Interval Stop Age
NU Plans underway to develop an organized screening program
NT 50 Every 1-2 years 74
YK
BC 50 FIT Every 2 years 74
AB 50 Screen with fecal immunochemical test (FIT) every 1-2 years
75
SK 50 Every 2 years 75
MB 50 Every 2 years 75
ON 50 Every 2 years 74
For asymptomatic individuals at average risk:
July 2015
Colorectal Cancer Screening Programs: Provincial and Territorial Guidelines, cont’d
Start Age Interval Stop Age
QC 50 Every 2 years 74
NB 50 Invited to complete FIT every 2 years 74
NS 50 Every 2 years 74
PE 50 Every 2 years 74
NL 50 Every 2 years 74
For asymptomatic individuals at average risk:
July 2015
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)
NU N/A – No organized program
YK N/A – No organized program
MB 6 samples collected over 3 days
Biennial 1 Hemoccult II SENSA
ON 2 samples of three different stools
Biennial 6 labs (7 testing sites) Hema-screen
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)
NT Three samples across three days
75ng/ml 1-2 years 2 labs (Stanton and Inuvik)
Positivity/negativity Hemoccult ICT Not programmatic
BC Single sample test
>49ng/ml = abnormal result
Biennial 5 instruments in BC. Kit available for pick up at all BC labs (private and public)
FIT value and interpretation recorded
Alere
AB Single 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*
Polymedco Polymedco available province wide as of Nov 18th 2013
SK Single sample test
>100ng/ml Biennial 1 FIT 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
July 2015
Number of Test(s)
Collecte
d 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)
ON FIT 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
QC Single sample test
≥175 ng/ml
Biennial 1 Both recorded, positivity/negativity provided
Somagen FIT is deployed provincially
NB One sample
≥100ng/ml
Biennial 1 Both recorded, positive/negative provided to clinicians
Polymedco
NS Two sample test
0.3 mg Hb/g
Biennial 1 Positive/negative Hemoccult ICT
Entry Level Test: Fecal Immunochemical Testing (FIT) Sampling Details, cont’d
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 Name Additional Comments (i.e. any other information)
PE Two sample test
≥ 100ng/ml (abnormal if any 1 of the samples is over the cut-off)
Biennial 1 (tests received and accessioned at 4 labs)
Positivity/ negativity Alere FIT as of April 2013 Completed validation study in 2012 to assess cut-off; resulted in decision to remain at 100ng.
NL Two sample test
≥ 100ng/ml
Biennial 1 Positivity/negativity (value recorded for internal use program use only)
Alere Completed 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
July 2015
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’
NU No organized program No organized program
NT No organized program No organized program
YK No organized program No organized program
BC Colonoscopy Wait time target is 60 days
AB Colonoscopy Colonoscopy recommended within <60 days of abnormal FIT result
SK Colonoscopy Wait Time Target ≤ 60 days
MB Colonoscopy Wait time target is 28 days
ON Colonoscopy Wait time benchmark is colonoscopy within 8 weeks
QC Colonoscopy < 60 days (target)
NB Colonoscopy Initial goal < 60 days (monitoring)
NS Colonoscopy Target is 8 weeks
PE Colonoscopy ≤ 60 days
NL Colonoscopy < 60 days, with 90th percentile within 180 days
Process Following Abnormal Results
BC Patient is referred to the patient’s regional Health Authority and HA contacts participant to discuss follow-up
AB Ordering 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
SK Primary 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
MB Follow-up depends on the regional health authority.Primary care provider is notifiedNavigator 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 colonoscopyA 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
ON Primary 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
QC Participants are contacted by their family physicians (process following abnormal results depends on the family physician).
NB Participant 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
NS Screening 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
PE Program 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
NL Nurse 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
July 2015
Re-screening Recommendations for +Fecal Test and Negative* Colonoscopy
* No cancer or adenoma found
Recommendations Years before recall to program
NU No organized program
NT No organized program
YK No organized program
BC FIT re-screening in 10 years 10
AB Resume screening with FIT 10
SK Recalled to FIT screening every 2 years 2
MB Recalled for FOBT in 5 years 5
ON Recalled for FOBT in 10 years 10
QC Recalled for FIT screening after 10 years 10 (if negative colonoscopy)
NB Recalled for FIT screening after 10 years 10
NS FIT offered in 2 years 2
PE 2014 Clinical Practice Guidelines recommend return to FIT after 5 years. 5
NL Recalled after 5 years 5
July 2015
Increased Risk* Definition
1st first degree relative diagnosed with
≥2 1st 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 detailsNunavut and Yukon are no included as they do not have an organized colorectal cancer screening program****Screening starts at 40
July 2015
Increased Risk* Definition cont’d
1st first degree relative diagnosed with
≥2 1st 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 & >60)
(age <60 & >60)
(age <60 &
>60)
(age <60 &
>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
Increased Risk* Screening Recommendations
Screening recommendation for increased risk population
Follow-up recommendations after normal colonoscopy
NT Colonoscopy at age 40 or 10 years earlier than youngest affected relative (whichever comes first)
Repeat colonoscopy every 5 -10 years
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 in 5 years
AB** 1) 1st degree relative of a person with Colorectal Cancer > 60 years at diagnosis
2) 1st 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 colonoscopy2) 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 riskFollow-up as per CAG guidelines and close monitoring by a physician
MB ColonCheck 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
July 2015
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
ON Colonoscopy at age 50 or 10 years younger than earliest age of diagnosis of relative, whichever comes first
Repeat colonoscopyevery 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
NB The 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; option 2 = for persons with slight increased risk first degree relative(s) 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
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 first2) 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 years2) Repeat FIT every 2 years or colonoscopy every 10 years
PE Promote 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***
NL Promote CAG guidelines*** Promote CAG guidelines***
*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 <60; option 2 = for persons with 1 first-degree relative with CRC or adenomatous polyp >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 Risk
July 2015
Data Collection for Increased Risk* Factors 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
NT No No organized screening program
YK
BC Yes Family history information and personal adenoma history information
AB No
SK Yes Inflammatory bowel disease is recorded if self-reported. Clients continue to be invited to screen with FIT test unless CRC within past 5 years
MB Yes ColonCheck collects information on CRC and other related cancers in order to exclude participants from the screening program
July 2015
Data Collection for Increased Risk* Factors Cont’d 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)?
ON No
QC No Planning to collect information on personal history (colon cancer and polyps)
NB Yes Personal history of CRC, ulcerative colitis, Crohn’s disease, rectal bleeding and narrowed stools, family history of CRC (1st and 2nd degree)
NS Yes - 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
PE No
NL No
July 2015
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]
