breast cancer screening programs and strategies in canada environmental scan march 2013

BREAST CANCER SCREENING PROGRAMS AND STRATEGIES IN CANADA

ENVIRONMENTAL SCAN

March 2013

Background

Quarterly, the Canadian Partnership Against Cancer collects information from the provinces/territories on the status of population-based breast cancer screening programs and/or strategies.

The information is collected through provincial and territorial leads represented on the National Committee of Canadian Breast Cancer Screening Initiative supported by the Canadian Partnership Against Cancer.

March 2013

Presentation Outline

Canadian Task Force on Preventive Health Care Guidelines

Provincial and Territorial Guidelines Breast Cancer Screening Program Distribution and

Administration Recruitment and Recall Quality Assurance Breast Cancer Data Reported Breast MRI (High Risk Screening Guidelines)

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Canadian Task Force on Preventive Health Care Guidelines

The Canadian Task Force on Preventive Health Care (2011) recommends the following for breast cancer screening:

Mammography For women aged 40-49, routine screening not recommended (Weak

recommendation; moderate quality evidence) For women aged 50-69, routine screening every 2 to 3 years (Weak

recommendation; moderate quality evidence) For women aged 70-74, routine screening every 2 to 3 years (Weak

recommendation; low quality evidence)

Magnetic Resonance Imaging Routine screening not recommended (Weak recommendation; no

evidence)

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Canadian Task Force on Preventive Health Care Guidelines (Cont’d)

Clinical Breast Exam Routine screening for breast cancer is not recommended when

performing clinical breast exam alone or in conjunction with mammography (Weak recommendation; low quality evidence)

Breast Self Exam Routine practice of breast self exam is not advised by the Task Force

(Weak recommendation; moderate quality evidence)

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Breast Cancer Screening Programs: Provincial and Territorial Guidelines

Start Age Interval Stop Age

Nunavut

Northwest Territories Begin at age 50 (age 40 – 49 accepted by physician referral and self –referral

but not actively recruited)

For women aged 40-49 - annual recall

For women aged 50-69 - biennial recall

For women aged 70+ - biennial recall

79

Yukon Begin at age 40 For women aged 50-69 - biennial recall

For women aged 70+ - biennial recall

70+

British Columbia Begin at age 40 (<40 accepted with physician referral)




79 (age 80+ only with physician referral)

Alberta Begin at age 50 (age 40-49 accepted with physician referral for the first

screen)



70+

Saskatchewan Begin at age 50 (age 49 accepted on the mobile if turning 50 in same calendar

year)


For women aged 70-74 - biennial recall (only if previously enrolled in the program)

75+

Manitoba Begin at 50 (ages 40-49 accepted to mobile unit only with physician referral)




75+

Ontario Begin at age 50 (ages 30-49 accepted if high risk and referred by physician)

For high risk women aged 30-49 - annual recall

For high risk women aged 50-69 – annual recall



75+

Breast Cancer Screening Programs: Provincial and Territorial Guidelines (Cont’d)

Start Age Interval Stop Age

QuébecBegin at age 50 (accept ages 35-49 only

with physician referral if done at a program screening centre)

For women aged 50-69 - biennial recall69 (age 70+ only with a

physician referral at a program screening centre)

New Brunswick Begin at age 50 (age 40-49 accepted only with physician referral)

For women aged 50-69 - biennial recall 69 (age 70+ only with a physician referral)

Capacity to increase to age 74

Nova Scotia Begin at age 40 For women aged 40-49 - annual recall


70+

Prince Edward Island Begin at age 40 (ages 30-39 accepted if high risk and referred by physician)





74

Newfoundland & Labrador

Begin at age 50 (age 40-49 accepted only with physician referral)

For women aged 50-69 - biennial recall 69 (age 70+ only if previously enrolled in the program)

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Ontario

QuebecManitobaSaskatchewan

Alberta

British Columbia

Yukon Territory

NorthwestTerritories Nunavut

New BrunswickNew Brunswick Nova ScotiaNova Scotia

Prince Edward IslandPrince Edward Island

Newfoundland Newfoundland & Labrador& Labrador

(1990)

(1998)(1995)(1990)

(1990)

(1988)

(2003)

(1990)

(1995)(1995) (1991)(1991)

(1998)(1998)

(1996)(1996)

Province/TerritoryProvince/Territory(Program Disribution)(Program Disribution)

Mammography aloneMammography alone

Clinical Breast ExaminationClinical Breast Examination & Mammography& Mammography

No Organized No Organized ProgramProgram

Distribution of mammography and CBE among breast screening programs

Breast Cancer Screening Program Administration

Program Start Date Program Name Agency Responsible for Program Administration

Nunavut

Northwest Territories 2003

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

British Columbia 1988 Screening Mammography Program of British Columbia

BC Cancer Agency

Alberta 1990 Alberta Breast Cancer Screening Program Alberta Health Services

Saskatchewan 1990 Screening Program for Breast Cancer Saskatchewan Cancer Agency

Manitoba 1995 BreastCheck Cancer Care Manitoba

Ontario 1990 Ontario Breast Screening Program Cancer Care Ontario

Québec 1998 Québec Breast Screening Program Ministère de la Santé et des Services sociaux

New Brunswick 1995 New Brunswick Breast Cancer Screening Services

New Brunswick Cancer Network (NB Ministry of Health)

Nova Scotia 1991 Nova Scotia Breast Screening Program Government of Nova Scotia

Prince Edward Island 1998 PEI Breast Screening Program Government of Prince Edward Island

Newfoundland and Labrador

1996 Breast Screening Program for Newfoundland and Labrador

Eastern Health, Cancer Care Program

Participant Recruitment

Doctor referral Self-referral Initial letter of invitation

Age group to which letter is sent

Nunavut

Northwest Territories

Yukon

British Columbia 50-69

Alberta 50-69

Saskatchewan 50-70+

Manitoba 50-69

Ontario

Québec 50-69

New Brunswick (not all regions) 50-69

Nova Scotia*

Prince Edward Island


* NS initially started sending out letters of invitation; however, they have since stopped due to capacity issues.

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Recall Following a Normal Mammogram

Send out recall letters

Coordination of recall for women following a normal screening episode performed by

Any additional follow-up to first recall letter after no reply

Age group for recall

Nunavut

Northwest Territories Centralized management (Program or Agency) 40-79

Yukon Screening centre 40-79

British Columbia Centralized management (Program or Agency) 40-79

Alberta (AHS Screen Test only)

Centralized management (Program or Agency) 40-69

Saskatchewan Centralized management (Program or Agency) 50-70+

Manitoba Centralized management (Program or Agency) 50-74

Ontario Regional coordination centres/ Screening centre 50-74

Québec Regional coordination centres 50-69

New Brunswick (not all regions)

Screening centre 50-69

Nova Scotia (postcard) Centralized management (Program or Agency) 40-69

Prince Edward Island Screening centre 40-74


Screening centre 50-74

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High Breast Density Recall and Recommendations

Five provinces and territories recall women based on high breast density

Recommendations following a high breast density reading varies across P/Ts

Automatic annual recall based on breast density

Value considered high breast density

Recommendation for high breast density levels

Northwest Territories > 75% Annual recall

Alberta >75% Annual recall

Ontario >75% Annual recall

Nova Scotia >75% Annual recall

Newfoundland and Labrador >75% Annual recall

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Association of Screening Program/Centre with Diagnostic Follow-Up

Assessment of abnormal results (radiological or histopathological) occurs within the screening program

Screening centre books diagnostic assessments

Medical prescription needed for each diagnostic assessment

Radiological/ pathological assessment teams have access to screening reports

Nunavut


Yukon

British Columbia Facilitates diagnostic referral

Alberta (Varies by site) (Varies by site) (On request)

Saskatchewan

Manitoba

Ontario (Varies by site)

Québec (Varies by site)

New Brunswick (Varies by site)

Nova Scotia



Quality Assurance: General

Conduct a review of screening films/digital images of interval cancers*

Conduct a review of missed at assessment cancers

Require a ‘double read’ of a portion of all screens

Have a questionnaire to evaluate client satisfaction

Conduct analyses to estimate the effect of organized breast screening on mortality

Nunavut


Yukon

British Columbia

Alberta**

Saskatchewan

Manitoba

Ontario (Done at individual centres)

Québec

New Brunswick (Provincial Cancer Report)

Nova Scotia *** (periodically)



(in the process)

*Classify cancer as either true interval or missed at screening**Alberta Health Services Screen Test sites only***NS review of all interval cases 1991 to 2004 and CD of various cases are sent to all screening radiologists. Now with full field digital this will be competed electronically.

Quality Assurance:Client Satisfaction Surveys

NWT, BC, AB, MB, NS and NL evaluate client satisfaction on an ongoing basis

Mammography exam

Particular Screening Centre

Organized Screening Program


British Columbia

Alberta

Manitoba

Nova Scotia


Table: Specific information collected when evaluating client satisfaction per province/territory

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Quality Assurance:Evaluation of Radiologist Performance

Most P/Ts evaluate radiologists on their level of performance on an annual basis with the exceptions of YK and PEI. NB collects this data but does not report on it

Positive Predictive Value (PPV)

Abnormal call rate

Cancer detection rate

Interval cancers

General performance reviews

Other (specified)


British Columbia Sensitivity/ Specificity

Alberta Sensitivity/ Specificity

Saskatchewan

Manitoba

Ontario Sensitivity/ Specificity and

One year recall rate

Québec

Nova Scotia


Sensitivity/ Specificity

Table: Specific information collected when evaluating radiologist performance per province/territory

Table: Specific volume requirement for radiologists per province/territory

NL NS NB QC ON MB SK AB BC NT

1,500 / year 2,500 / year 1200/ year** 500/ year 1,000 / year 1,000 / year* 3,000 / year 480 / year** 2,500 / year 480 / year

*All radiologists greatly exceed this number**Includes diagnostic and screening mammograms

Quality Assurance:Vital and Cancer Registry-Linkages with Provincial Registries

Collection of ‘Vital Status’ variable

Collection of ‘Date of Death’ variable

Collection of cancer stage (TNM or Collaborative stage) or other cancer variables

Nunavut


Yukon ** **

British Columbia

Alberta * *

Saskatchewan

Manitoba

Ontario

Québec

New Brunswick ***

Nova Scotia



*Through provincial client registry**Decreased lists are provided to WGH monthly***linkage for post-screen cancer information only

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Mammography Screening Program:Vital and Cancer Registries – TNM or Collaborative Stage

For the provinces and territories that do not currently link with provincial cancer registries to collect cancer stage (TNM or Collaborative Stage) or other cancer variables, it may still be possible:

For the collection of post-screen cancer information (BC, QC, NS*) For the collection of cancer and stage information (BC, NS*)

*Note: Both linkages are possible in NS; however, an agreement has not yet been established

For YK it is unknown if this is possible

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Breast MRI: High Risk Guidelines

Self-reported family history (>=2) of breast cancer (first degree relative)

Self-reported family history of BRCA 1/2

Genetic testing BRCA 1 or 2

Risk of breast cancer >20% (scored by validated assessment tools)

Chest irradiation between the ages of 10 and 30 years

Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome

British Columbia ****

Alberta

Ontario * ** ***

Nova Scotia **


>=3


Currently there are five provinces (BC, AB, ON, NS, NL) that have developed standard guidelines for MRI referral

Table: The criteria or evidence that MRI referral is based upon per province

* First degree relative

** >25% using validated assessment tool

*** Chest irradiation before age 30 and at least 8 years ago

**** BC includes the following syndromes: Li Fraumeni Syndrome, Cowden’s Syndrome, HDGC (CDH-1), Peutz-Jegher’s Syndrome

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Future Implementation of MRI

Ontario has implemented an MRI screening component to its organized screening program for women considered at high risk for breast cancer.

BC, NS and AB have established guidelines for the use of MRI among women considered to be at elevated risk (i.e. in BC the women considered are confirmed cases of BRCA1 and BRCA2 mutation only). For more information on MRI guidelines for NS please visit www.breastscreening.ns.ca

NL is exploring the appropriateness of using MRI among women considered to be at elevated risk

March 2013

Reference Slide

Please use the following reference when citing information from this presentation:

Breast Cancer Screening in Canada: Programs and Strategies. Cancer View Canada. Available at: [Enter Link], Accessed: [Enter Date Accessed].

March 2013

breast cancer screening programs and strategies in canada environmental scan march 2013

Documents

high breast density

biennial recall

breast density value

annual recall ontario

annual recall newfoundland

annual recall alberta

annual recall nova scotia

pts automatic annual