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Colorectal Cancer Screening in CanadaMONITORING & EVALUATION OF QUALITY INDICATORS

RESULTS REPORT JANUARY 2013 – DECEMBER 2014

Acknowledgements TheCanadianPartnershipAgainstCancer(thePartnership)wouldliketogratefullyacknowledgethecontributionsofthefollowinggroupsandindividualsintheproductionofthisreport:membersoftheNationalColorectalCancerScreeningNetwork;membersoftheColorectalCancerScreeningMonitoringandEvaluationWorkingGroup;membersofthe2013-14ReportWorkingGroup;stafffromthecanceragenciesinallprovincesandterritories;CherylLouzado,fromthePartnership’sDataIntegrationTeamforherworkonindicatorspecificationdevelopmentanddatafeasibility;andSharonFungandJinNiufromthePartnership'sAnalyticsTeamfortheirworkontheanalysisandpresentationofthedata.

Colorectal Cancer Screening Monitoring and Evaluation Working Group Members

David Armstrong,Chair,NationalColorectalCancerScreeningNetwork;Winson Cheung,Chair,ColorectalCancerScreeningMonitoringandEvaluationWorkingGroup;Laura Gentile, OperationsDirector,CancerScreening,ColonCheck,Hereditary Cancer Program & Cervical Cancer Screening Program,BCCancerAgency;Zahida Esmail,OperationsDirector,CancerScreening,ColonScreeningProgram,HereditaryCancerProgram,CervicalCancerScreeningProgram,BCCancerAgency;Danielle Swerhone,ImplementationSpecialist,AlbertaColorectalCancerScreeningProgram(ACRCSP);Annamae Perry,Manager,ScreeningProgramforColorectalCancer,EarlyDetection-PopulationHealthDivision,SaskatchewanCancerAgency;Riaz Alvi,Director,Epidemiology&PerformanceMeasurement,SaskatchewanCancerAgency;Kelly Bunzeluk, ProgramManager,CancerCareManitoba;Jill Tinmouth,LeadScientist,CervicalCancerCare,CancerCareOntario;Katleen Busque,Conseillère,Directionquébécoisedecancérologie,Programmequébécoisdedépistageducancercolorectal,MinistèredelaSantéetdesServicessociaux;Grlica Bolesnikov, Coordinator,QualityManagementandAccountability,GovernmentofNewBrunswick;Linda Varner,NewBrunswickColonCancerScreeningProgramImplementationManager,NewBrunswickCancerNetwork;Eileen Kilfoil,OperationsManager,ScreeningPrograms,CancerCareNovaScotia;Ann Millar,ProgramCoordinator,PEIColorectal/CervicalCancerScreening,ChronicDiseasePreventionandManagement,HealthPEI;Anja Nied-Kutterer,ProgramCoordinator,PEIColorectal/CervicalCancerScreening,ChronicDiseasePreventionandManagement,HealthPEIScottAntle,Manager,NewfoundlandandLabradorColonCancerScreeningProgram;Kimberly Butler, RegionalAccessManager,NewfoundlandandLabradorColonCancerScreeningProgram; Brendan Hanley,ChiefMedicalOfficerofHealth,GovernmentoftheYukonTerritories;Kami Kandola,DeputyChiefPublicHealth

Officer,GovernmentofNorthwestTerritoriesHealthandSocialServices;Katherine Canil,Surgeon,NunavutDepartmentofHealth;Diane Major,Advisor,Cross-ProgrammaticInitiatives,CanadianPartnershipAgainstCancer;Verna Mai, ExpertLead,ScreeningandEarlyDetection,CanadianPartnershipAgainstCancer;Anna Crosskill,Specialist,ScreeningandEarlyDetection,CanadianPartnershipAgainstCancer;Carol Irwin, Coordinator,ScreeningandEarlyDetection,CanadianPartnership Against Cancer

2013-14 Colorectal Cancer Screening Report Working Group Members

David Armstrong,Chair,NationalColorectalCancerScreeningNetwork;Winson Cheung,Chair,ColorectalCancerScreeningMonitoringandEvaluationWorkingGroup;Danielle Swerhone, ImplementationSpecialist,AlbertaColorectalCancerScreeningProgram(ACRCSP);Tong Zhu,Epidemiologist,EpidemiologyandPerformanceMeasurement,SaskatchewanCancerAgency;Fatima Jalili,ScreeningProgramsEvaluationLead,CancerCareManitoba;Linda Varner,NewBrunswickColonCancerScreeningProgramImplementationManager,NewBrunswickCancerNetwork;Diane Major,Advisor,Cross-ProgrammaticInitiatives,CanadianPartnershipAgainstCancer;Verna Mai, ExpertLead,ScreeningandEarlyDetection,CanadianPartnershipAgainstCancer;Anna Crosskill,Specialist,ScreeningandEarlyDetection,CanadianPartnershipAgainstCancer;Carol Irwin,Coordinator,ScreeningandEarlyDetection,CanadianPartnershipAgainstCancer

Suggestedcitation:CanadianPartnershipAgainstCancer.ColorectalCancerScreeninginCanada:Monitoring&EvaluationofQualityIndicators–ResultsReport,January2013–December2014.Toronto:CanadianPartnershipAgainstCancer;2017.

1Colorectal Cancer Screening in Canada: Monitoring & Evaluation of Quality Indicators – Results Report

Table of Contents

List of Figures and Tables 2

Executive Summary 4

Introduction 6

Screening for Colorectal Cancer 9

Organized Colorectal Cancer Screening in Canada 10

Quality Indicator Framework 16

Data Considerations 18

Quality Indicators 20 Participation rate 20 Fecal test utilization 23 Retention rate 26 Fecal test inadequacy rate 28 Positivity rate 30 Follow-up colonoscopy uptake 34 Wait times to follow-up colonoscopy 37 Wait times from follow-up colonoscopy to definitive pathological diagnosis 39 Positive predictive value adenoma(s) 40 Program adenoma detection rate 44 Program invasive colorectal cancer detection rate 46 Invasive colorectal cancer stage distribution 49 Interval colorectal cancer 52

Future Directions 53

References 54

Appendix A: Colorectal Cancer Screening QualityIndicatorDefinitions 56

2 Colorectal Cancer Screening in Canada: Monitoring & Evaluation of Quality Indicators – Results Report

ListofFiguresandTablesLIST OF FIGURES

Figure 1 Colorectalcancerincidencerates,bysexandprovince,2010–12diagnosisyearscombined 8

Figure 2 Colorectalcancermortalityrates,byprovince,2009–11yearscombined 8

Figure 3 Colorectalcancerscreeningprogramavailabilityovertime 11

Figure 4 Colorectalcancerscreeningpathwaywithnationalqualityindicators 17

Figure 5 Colorectalcancerscreeningprogramparticipationina30-monthperiod,bothsexescombined, byprovince,2013and2014screeningyearscombined 21

Figure 6 Colorectalcancerscreeningprogramparticipationina30-monthperiod,byagegroupandsex,2013and2014screeningyearscombined 22

Figure 7 Percentageofpopulationaged50–74thatreportedhavinghadafecaltestinthepasttwoyearsforscreeningpurposes,byprovince/territory,CCHS2013and2014reportingyears 24

Figure 8 Percentageofpopulationaged50–74uptodateforcolorectalcancerscreening(anymodality,anyreason),CCHS2013and2014reportingyears 25

Figure 9 Colorectalcancerscreeningretentionrateina30-monthperiod,age50–72,byprovince,2011and2012screeningyearscombined 26

Figure 10 Colorectalcancerscreeningretentionrateina30-monthperiod,byprovinceandagegroup,2011and2012screeningyearscombined 27

Figure 11 Colorectalcancerscreeningretentionrateina30-monthperiod,byprovinceandscreeninground,2011and2012screeningyearscombined 27

Figure 12 Fecaltestinadequacyrate,byprovince,2013and2014screeningyearscombined 28

Figure 13 Fecaltestinadequacyrate,byprovinceandscreeninground,2013and2014screening years combined 29

Figure 14 Positivityratesforfecaltests,byprovince,2013and2014screeningyearscombined 31

Figure 15 Positivityratesforfecaltests,byprovinceandsex,2013and2014screeningyearscombined 32

Figure 16 Positivityratesforfecaltests,byprovinceandscreeninground,2013and2014screening years combined 33

Figure 17 Positivityratesforfecaltests,byprovinceandagegroup,2013and2014screeningyearscombined 33

Figure 18 Follow-upcolonoscopyuptakeamongindividualswithabnormalfecaltestresults,bothsexescombined,byprovince,2013and2014screeningyearscombined 35


ListofFiguresandTables

LIST OF FIGURES

Figure 19 Follow-upcolonoscopyuptakeamongindividualswithabnormalfecaltestresults,byprovinceandscreeninground,2013and2014screeningyearscombined 36

Figure 20 Medianand90thpercentilewaittimesfromabnormalfecaltestresulttofollow-upcolonoscopy,byprovince,2013and2014screeningyearscombined 37

Figure 21 90thpercentilewaittimesfromabnormalfecaltestresulttofollow-upcolonoscopy,byprovince,2011–12and2013–14screeningyears 38

Figure 22 Medianand90thpercentilewaittimesfromfollow-upcolonoscopytodefinitivepathologicaldiagnosis,byprovince,2013and2014screeningyearscombined 39

Figure 23 Positivepredictivevalueofafecaltestfordetectionofadenomas,byprovince,bothsexescombined,2013and2014screeningyearscombined 41

Figure 24 Positivepredictivevalueofafecaltestfordetectionofadenomas,byprovinceandscreeninground,bothsexescombined,2013and2014screeningyearscombined 42

Figure 25 Positivepredictivevalueoffollow-upcolonoscopyfordetectionofadenomas,byprovince,2013and2014screeningyearscombined 42

Figure 26 Positivepredictivevalueoffollow-upcolonoscopyfordetectionofadenomas,byprovinceandscreeninground,2013and2014screeningyearscombined 43

Figure 27 Programadenomadetectionrate,byprovince,2013and2014screeningyearscombined 44

Figure 28 Programadenomadetectionrate,byprovinceandsex,2013and2014screeningyearscombined 45

Figure 29 Programadenomadetectionrate,byprovinceandscreeninground,2013and2014screeningyears combined 45

Figure 30 Programinvasivecolorectalcancerdetectionrate,byprovinceandsex,2013and2014screeningyears combined 47

Figure 31 Programinvasivecolorectalcancerdetectionrate,byprovinceandscreeninground,2013and2014screeningyearscombined 48

Figure 32 Incidenceratesforcolorectalcancer,bystageatdiagnosisandbyprovince,2011–13diagnosisyears combined 49

Figure 33 Distributionofinvasivecolorectalcancercasesfromfollow-upcolonoscopiesafterabnormalfecaltestresults,bystageandprovince,2013and2014screeningyearscombined 50

Figure 34 Distributionofcolorectalcancercasesfromfollow-upcolonoscopiesafterabnormalfecaltestresults,bystageandscreeninground,2013and2014screeningyearscombined 51

Figure 35 Intervalcolorectalcancerrate,byprovince,2011and2012screeningyearscombined 52

LIST OF TABLES

Table 1 Overviewofcolorectalcancerscreeningacrossprovincesandterritoriesin2013–14 15

Table 2 Relationshipbetweenkeyindicatorsforcolorectalcancerscreening,2013and2014screeningyears combined 47


ExecutiveSummary ThisreportpresentstheresultsfornationalmonitoringofcolorectalcancerscreeningprogramsbytheNationalColorectalCancerScreeningNetwork(NCCSN)fromJanuary1,2013,toDecember31,2014.TheNCCSNdevelopedasetofqualityindicatorsforcolorectalcancerscreeningforreportingatthenationallevelinCanadain2009,includingqualityindicatorswithinfivedomains:coverage,follow-up,qualityofscreening,detectionanddiseaseextentatdiagnosis.

Resultsareintendedtofacilitateimprovementsincolorectalcancerscreeningdelivery.Forthefirsttime, thereportprovidesabreakdownofindicatordatabyfirstandsubsequentscreensbecausethecharacteristicsofindividualsscreenedforthefirsttimedifferfromthose ofindividualsreturningforsubsequentscreens.

Colorectal cancer is the second most commonly diagnosed cancer(excludingnon-melanomaskincancers)andthesecondleadingcauseofdeathfromcancerinCanada.1 Colorectal cancer burden is projected to increase from 25,100casesin2015to35,075casesby2028–32,arelativeincreaseof40%.1 Strong evidence demonstrates that regular colorectal cancer screening with a fecal test enables early detectionofcolorectalcancerandallowsformoresuccessfultreatment,leadingtoareductionincolorectalcancermortality.2–6Fortheperiodcoveredbythisreport,theCanadianTaskForceonPreventiveHealthCare’s2001guidelines on colorectal cancer screening recommended colorectal cancer screening with a fecal test every one to two yearsorwithflexiblesigmoidoscopyeveryfiveyearsstartingatage50forpeopleataverageriskforcolorectalcancer.7

Organizedcolorectalcancerscreeningprogramswerefirstannouncedin2007(inAlberta,ManitobaandOntario).Bytheendof2014,programmaticcolorectalscreeninghadbeenimplementedinfiveadditionalprovinces(BritishColumbia,Saskatchewan,NovaScotia,PrinceEdwardIslandandNewfoundlandandLabrador).8Organizedpopulation-basedscreeningprogramsprovideanadministrativestructureresponsibleforservicedelivery,follow-upofabnormalresults,qualityassuranceandongoingevaluation.9Organizedcolorectalcancerscreeningmaythereforeoffermorepotentialtoreducemortality,minimizeharmsandreducecoststhanopportunisticcolorectalcancerscreening.10

Participationratesshouldnotbeusedtoevaluatetheprograms’effectivenessduringthistimeperiodasprovinceswereindifferentstagesofimplementationofcolorectalcancerscreeningprograms.Inaddition,theparticipationfiguresaredefineddifferentlyindifferentprovinces(seethe‘DataConsiderations’sectionforadditionalinformation).Withtheselimitationsinmind,thefollowingcommentsaremade.


ExecutiveSummary

Highlights of the results

•Whileprogramparticipationratesfor2013–14fellshortofthenationaltargetof60%,therangefrom8.6%to53.0%representsanincreaseoverprogramparticipationratesfor2011–12.However,programparticipationrepresentsonlyonecomponentofthepercentageofthepopulationthatisuptodateforcolorectalcancerscreening.Lookingatthepercentageofthepopulationthatreportedhavinghad a colorectal cancer screening test for screening or for anyotherreason,therangewas44%to70%in2013and48%to68%in2014.

•Retentionratesrangedfrom38.9%to77.4%andwerehigherwithageandforparticipantsundergoingsubsequentscreenscomparedtofirstscreens.

• Whilethefecaltestinadequacyratesvariedbyprovince,allmetthetargetof5%orless.

•Asexpected,positivityratesvariedasaresultofthetypeoffecaltestused,thebrandandthecut-offpointselected.Positivityratesrangedfrom3.4%to4.0%forprovincesusingguaiacfecaltests(FTg)andfrom8.3%to16.1%forprovincesusingimmunochemicalfecaltests(FTi).Noprovincemetthetargetof85%forfollow-upcolonoscopyuptake,thoughManitobawasclose(82.8%)anduptakewashigheramongthosecompletingasubsequentscreen.

•Forwaittimesforfollow-upcolonoscopyafteranabnormalfecaltest,whilethetargetof60dayswasmetforhalfofthepopulationinfourprovinces,90thpercentilewaittimesinsevenprovincesindicatedthatmanystillwaittwice the recommended number of days (ranging from 104to151days).

•Themedianwaittimefromfollow-upcolonoscopytodefinitivepathologicaldiagnosisvariedfromthreedaysto12days.NinetiethpercentilewaittimesintwoprovincesmettheEuropeantargetof15days.

•Thepositivepredictivevalueofafecaltestforthedetectionofadenomasrangedfrom28.9%to49.7%amongthosewithanabnormalfecaltestandfrom34.9%to67.5%amongthosewithanabnormalfecaltestwhoalsocompletedafollow-upcolonoscopywithin180days.

Theprogramadenomadetectionrateandprogram invasivecolorectalcancerdetectionratevariedsubstantiallyacrossprovincesfrom9.8to80.0per1,000individualsscreenedandfrom1.0to7.7per1,000individualsscreened,respectively.Asexpected,asmallerproportionofinvasivecancersdetectedinsubsequentscreenswereatStageIIIorIVcomparedwithfirstscreens.

Finally,intervalcancerratesrangedfrom0.3to1.9per1,000peoplescreened.

Whilemoreprovinceswereabletoprovidemonitoringandevaluationdataforthisreportthanforpreviousreports,significantvariationinavailableinformationremains,intermsofboththestageofprogramimplementationanddataavailableacrossthecountry.Inthisreport,datawerecollectedforfirst-timescreeningparticipantsandforindividualsundergoingasubsequentscreen.Whilethedifferenceinqualityindicatorresultsforthetwogroupsissmall,infuturetheeffectofadditionalroundsofscreeningisexpectedtoresultinlowercancerandadenomadetectionratesinindividualsundergoingasubsequentscreen.Asprogramsmature,increasedstandardizationofdatadefinitions,collectionandsubmission will improve the ability to evaluate the impact oforganizedcolorectalcancerscreeningprogramsoncolorectalcancermortality,screening-relatedharmsandcost-effectiveness,aswellasidentifybestpractices.

•

•


Introduction

Purpose of the reportThisreportpresentstheresultsfornationalmonitoring ofcolorectalcancerscreeningactivitiesfromJanuary1,2013,toDecember31,2014.Thefindingspresentedinthisreportaimtoinformorganizedcolorectalcancerscreeningdelivery in order to reduce colorectal cancer morbidity and mortalityinCanada.

Comparedwiththepreviousnationalcolorectalcancerscreeningmonitoringandevaluationreportfor2011–12,more provinces were able to provide data and those data coveredagreaterproportionoftheCanadianpopulation.Ofthe13provincesandterritories,thefollowingprovidedatleastsomedataforthisreport:Alberta,Saskatchewan,Manitoba,Ontario,NovaScotia,PrinceEdwardIslandandNewfoundlandandLabrador.Theincreaseddataavailableforanalysisforthisreportallowsforamorein-depthassessment of the status and impact of colorectal cancer screeningacrossthecountry.

The2013–14ColorectalCancerScreeningMonitoringandEvaluationofQualityIndicators–ResultsReport

• provides an overview of key indicators and progress toward targets in colorectal cancer screening programs in Canadafor2013–14;

•presentsabreakdownofdatabyscreeninground(firstorsubsequentscreen)foreachindicator,whereavailable;and

•contextualizesthedatabyhighlightingtheinterrelationshipbetweenindicatorssuchaspositivityrate,positivepredictivevalue(PPV)foradenomaandcancerdetectionrate.

Burdenofdisease ColorectalcancerisasignificanthealthprobleminCanada,

where it is the second most commonly diagnosed cancer (excludingnon-melanomaskincancers).ItisalsothesecondleadingcauseofdeathfromcancerinCanada.1

Thelifetimeprobabilityofdyingfromcolorectalcancer is3.5%formenand3.1%forwomen.11 Figures1 and 2provide the colorectal cancer incidence and mortality ratesacrossCanada.

It is estimated that in 2015,

25,100 Canadians will be diagnosed with

colorectalcancer,withanaverageof69 Canadiansdiagnosedeveryday.

9,300 Canadians will die from colorectal cancer,withanaverageof25 Canadiansdyingeveryday.

1/14males

1/16females

areexpectedtodevelopcolorectalcancerintheirlifetime.1


Introduction

There are a number of known risk factors for colorectal cancer.Ameta-analysisofcolorectalcancerriskfactorsfound a much higher risk of colorectal cancer among those withinflammatoryboweldiseaseorafirst-degreerelativewithcolorectalcancer.12Additionalriskfactorsassociated

with a moderately increased risk of colorectal cancer includeincreasedbodymassindex,redmeatintake,cigarettesmoking,lowphysicalactivity,lowvegetableconsumption,andlowfruitconsumption.12

8 ColorectalCancerScreeninginCanada:Monitoring&EvaluationofQualityIndicators–ResultsReport

Introduction

Male Female

FIGURE 1

Colorectal cancer incidence rates, by sex and province, 2010–12 diagnosis years combined

0

25

50

75

100

125

Rate per 100,000 population

ProvinceBC AB SK MBON QCNB NSPE NL

69.3

49.1

73.8

49.0

84.0

59.2

111.3

78.481.1

58.2

92.6

67.2

77.9

52.7

80.6

55.3

68.0

48.7

87.2

57.3

Age-standardizedtothe2011Canadianpopulation.DataextractedDecember2015.Datasource:StatisticsCanada,CanadianCancerRegistry.

FIGURE 2

Colorectal cancer mortality rates, by province, 2009–11 years combined

0

10

20

30

40

50

Rate per 100,000 population

ProvinceBCAB SK MBON QCNB NSPE NL

23.1 23.5 24.4 24.8 26.027.9 27.9 28.1

32.8

40.0

Age-standardizedtothe2011Canadianpopulation.DataextractedAugust2014.Datasource:StatisticsCanada,VitalStatisticsDeathDatabase.

9ColorectalCancerScreeninginCanada:Monitoring&EvaluationofQualityIndicators–ResultsReport

Screening for Colorectal Cancer

Evidence for the effectiveness of colorectal cancer screening

There is strong evidence that regular colorectal cancer screeningwithafecaltestenablesearlydetectionofcolorectalcancerandallowsformoresuccessfultreatment,leadingtoareductionincolorectalcancermortality.2–6 Colorectalcancerscreeninghasthepotentialtobeeffectivebecausemostcolorectalcancersevolvefromcolonic polyps that can become malignant over an extendedperiodoftime.7Less-invasivesurgerymayberequiredforthetreatmentofcancersthataredetectedatanearlierstagebyscreening.4

Preventionandearlydetectionofcolorectalcancerthroughorganizedscreening,combinedwitheffectivetreatment,is intended to prevent disease and reduce colorectal cancer mortalityinanasymptomaticpopulation.13 Comprehensive qualityassuranceisrequiredinordertomaximizethebenefitswhileminimizinganypotentialharmsthatcouldoccurinotherwisehealthyindividuals.Organizedpopulation-basedscreeningprogramsprovideanadministrativestructureresponsibleforservicedelivery,follow-upofabnormalresults,qualityassuranceandongoingevaluation.9

Colorectal cancer screening tests

Thereareanumberofmodalitiesforscreeningforcolorectalcancer,includingtheguaiac(FTg)orimmunochemical(FTi)fecaltests,flexiblesigmoidoscopyandcolonoscopy.Datafromrandomizedcontrolledtrialsdemonstratethatscreeningforcolorectalcancerwithguaiacfecaloccultbloodtestingorflexiblesigmoidoscopyreducescolorectalcancermortalityandtheincidenceoflate-stagecolorectalcancer.7AsystematicreviewconductedbyCancerCareOntariofoundthatFTihad higher advanced adenoma and colorectal cancer

detectionratesaswellasincreasedparticipationratescomparedwithFTg.PositivityrateswerehigherwithFTi,butbothtestshadsimilarpositivepredictivevaluesforthedetectionofadvancedadenomaandcolorectalcancerwhenusingthemanufacturer’sstandardcut-offlevels.14 Pooledanalysesfromanumberofstudies,includingrandomizedcontrolledtrials,foundthattheuseofflexiblesigmoidoscopyasascreeningtestinindividualsaged55to74reducedcolorectalcancermortalityandincidenceoflate-stagecolorectalcancer.15Asnorandomizedcontrolledtrialshavereportedonthemortalitybenefitofscreeningcolonoscopy,thereisinsufficientevidenceoftheefficacyofcolonoscopyincomparisonwithotherscreeningtests.7 Whileitmaybeassumed,tobeatleastaseffectiveasflexiblesigmoidoscopy,waittimesmaybelongerandthepotentialharmsaregreaterthanforflexiblesigmoidoscopy.7

Colorectal cancer screening recommendations

Fortheperiodcoveredbythisreport,theCanadianTaskForceonPreventiveHealthCare’s2001guidelinesoncolorectal cancer screening recommended colorectal cancer screeningwithafecaltesteveryonetotwoyearsorflexiblesigmoidoscopyeveryfiveyearsstartingatage50forpeopleataverageriskforcolorectalcancer.16 The guideline did not includerecommendationsspecifyinguseofthesescreeningmodalitiesaloneorincombination,norwhethertoincludeorexcludecolonoscopyasaninitialscreeningtest.InMarch2016,theCanadianTaskForceonPreventiveHealth Care issued updated guidelines that recommended screeningforcolorectalcancerinaverage-riskadultsaged50to74withafecaltesteverytwoyearsorwithflexiblesigmoidoscopyevery10years.7 The use of colonoscopy as ascreeningtestforcolorectalcancerwasnotrecommended.


OrganizedColorectalCancer Screening in Canada

HistoryOrganizedcolorectalcancerscreeningprogramswerefirstannouncedinthreeprovincesin2007(Alberta,ManitobaandOntario).Bytheendof2014,programmaticcolorectalscreeninghadbeenimplementedinfiveadditionalprovinces(BritishColumbia,Saskatchewan,NovaScotia,PrinceEdwardIslandandNewfoundlandandLabrador);8NewBrunswickimplementedaprogramin2015.

Figure3 provides an overview of the availability of colorectal cancerscreeningprogramsacrossCanadaovertimefromMarch2013untilJuly2016basedonpan-Canadianenvironmental scans conducted by the Canadian

PartnershipAgainstCancer(thePartnership).Whilethedatainthisreportpertainto2013–14;asofthedateofreportpublicationin2016,organizedscreeningprogramshavebeenannouncedinQuebecandYukon.TheNorthwestTerritoriesandNunavutarereviewingthefeasibilityofimplementingorganizedcolorectalcancerscreening.TheimplementationoforganizedscreeninginsomepartsofCanadahasbeenassociatedwithanincreaseinscreeninguptake.17


OrganizedColorectalCancerScreeninginCanada

Noorganizedprogram

Reviewingfeasibility 1–9% 50–99%

Announced or planning 10–49% 100%

FIGURE 3.1

Colorectal cancer screening program availability over time

%ofthepopulationforwhomorganizedCRCprogramswereavailable

March 2013

YUKON TERRITORY

NORTHWEST TERRITORIES

NUNAVUT

BRITISH COLUMBIA

ALBERTA

MANITOBA

ONTARIO

QUÉBEC

NOVASCOTIA

PRINCEEDWARDISLANDSASKATCHEWAN

NEWFOUNDLAND &LABRADOR

NEW BRUNSWICK


Noorganizedprogram



FIGURE 3.2



August 2014

YUKON TERRITORY


NUNAVUT

BRITISH COLUMBIA

ALBERTA

MANITOBA

ONTARIO

QUÉBEC


NEW BRUNSWICK

NOVASCOTIA



Noorganizedprogram



FIGURE 3.3



July 2016

YUKON TERRITORY


NUNAVUT

BRITISH COLUMBIA

ALBERTA

MANITOBA

ONTARIO

QUÉBEC


NEW BRUNSWICK

NOVASCOTIA


Datasource:ColorectalCancerScreeningGuidelinesAcrossCanada:EnvironmentalScan,March2013;ColorectalCancerScreeningGuidelinesAcrossCanada:EnvironmentalScan,August2014;NationalColorectalCancerScreeningNetworkReportSurvey;July2016.



National Colorectal Cancer Screening Network

ThePartnershipconvenedtheNationalColorectalCancerScreeningNetwork(NCCSN)in2007.TheNCCSNexistsasanationalplatformforknowledgeexchangetosupportthecolorectalcancerscreeningcommunity,improvethepatientexperience,leverageexpertiseandmakeevidence-basedrecommendationstothecancercontrolsystem.TheNCCSN’sprimaryaimistoimproveappropriateparticipationandenhancequalityincolorectalcancerscreeninginCanada.

TheNCCSNbringstogetherrepresentativesfromthefollowingareas:

•provincial/territorialministriesofhealth

•provincial/territorialcancerscreeningprograms

•thePublicHealthAgencyofCanada,HealthCanada,andonerepresentativefromotherrelevantnationalhealth/cancerorganizations,professionalorganizationsandpatientadvocacyorganizations

•patient/familyadvisor(s)

OneoftheNCCSN’sprioritiesisreportingoncolorectalcancerscreeningindicatorstomonitorparticipationandfacilitatequalityimprovement.Tothatend,astandingNCCSNworkinggroup,theColorectalCancerMonitoringandEvaluationWorkingGroup,istaskedwith

•developingqualitydeterminantsandindicatorsforcolorectal cancer screening in Canada

•monitoringqualityindicators(basedonthe qualitydeterminants)

•settingnationaltargets

•reportingpan-Canadianresultsregularly

Screening approaches

Thisreportprovidesdatafor2013–14andfocusesonqualityindicatorsfororganizedcolorectalcancerscreening(i.e.,population-basedprogrammaticscreening)ratherthanonopportunisticscreening(i.e.,screeningthatoccursoutsideofprograms,ornon-programmaticscreening).Bothprogrammaticandnon-programmaticscreeningoccurinCanadaandmustbetakenintoaccountwhenevaluatingcolorectalcancerscreeninguptakeoverall.

Table1providesanoverviewofcolorectalcancerscreeningacrossallprovincesandterritoriesfor2013–14.Evenamongprovinceswithorganizedcolorectalcancerscreeningprograms,approachestoscreeningdeliveryvary.ColorectalscreeningprogramsinCanadahaveevolvedatdifferentratesandareshapedbyprovincialcharacteristicsandfactors,includingtheavailabilityofresources,theadoptionofdifferententry-levelscreeningfecaltests,andthe cut-offvalueforanabnormalscreeningresult.Someofthesedifferenceshaveimplicationswhencomparingsomeof the indicators across provinces and the results that follow shouldbeinterpretedcautiouslyinthiscontext.Whilethedata presented in this report provide the opportunity to makeinitialhypothesesaboutthestatusandimplicationsofdifferentapproachestocolorectalcancerscreeningacrossCanada,nationaldatamonitoringoveralongerperiodwillberequiredinordertodrawmoreformalconclusions.



TABLE 1

Overview of colorectal cancer screening across provinces and territories in 2013–14

Province/ territory Program start date

Target population

Screening interval

Primary screening test

Primary screening test brand

FTi cut-off value for an abnormal screening result*

AB March2007 50–74 Annual or biennial

FTireplacedFTginNovember2013

Polymedco ≥75ng/ml

BC 2009pilot;province-wideNovember2013

50–74 Biennial FTi Alere ≥50ng/ml

MB April2007 50–74 Biennial FTg Hemoccult II SENSA

NB November2014 50–74 Biennial FTi Polymedco ≥100ng/ml

NL July2012 50–74 Biennial FTi Alere ≥100ng/ml

NT Noorganizedscreeningprogram

50–74 Annual or biennial

FTi Hemoccult ICT ≥75ng/ml

NS April2009 50–74 Biennial FTi Hemoccult ICT ≥100ng/ml

NU Noorganizedscreeningprogram

FTi

ON March2008 50–74 Biennial FTg Hema-screen

PE 2009;province-wideMay2011

50–74 Biennial FTi Alere ≥100ng/ml

QC Noorganizedscreeningprogram

50–74 Biennial FTi ≥175ng/ml

SK January2009 50–74 Biennial FTi Polymedco ≥100ng/ml

YT Noorganizedscreeningprogram

50–74 According to physician

FTg Hemoccult

*UnabletoreportinmcgHb/gstoolasvolumeinformationunavailable.Futurereportswilllistcut-offvaluesinmcgHb/gstool.FTi=immunochemicalfecaltest;FTg=guaiacfecaltest;ng/ml=nanogram/milliletre.AB:Polymedcoavailableprovince-wideasofNovember18,2013.NB:Although22%oftargetpopulationwasinvitedtoparticipateinNovember2014,distributionofFTikitsonlystartedinJanuary2015.DatawillbeavailableforJanuary2015onwards.NL:Province-wideasofJuly2015.Datasource:Provincial/territorialcanceragenciesandprograms.

The screening process Fortheperiodcoveredinthisreport,allprovincesexceptOntarioandManitobausedFTiastheprimaryscreening

AsofDecember2016,Canadianprovincesdelivering test.AlbertatransitionedfromusingFTgtoFTiinNovembercolorectal cancer screening programs recommend a fecal 2013.AsofDecember2016,Ontarioisdevelopingaplantest,eitherimmunochemical(FTi)orguaiac(FTg),asthe toimplementFTiandManitobawaspilotingFTitocompareprimaryscreeningtestandtargetpeopleaged50to74of itwiththehighlysensitiveFTgHemoccultIISENSAcurrentlyaveragerisk(i.e.,thosewithnopersonalorfamilyrisk inuse.Individualswithanabnormalfecaltestresultarefactorsforcoloncancerotherthanbeing50orolder).Some thenreferredforacolonoscopy.Colonoscopymaybecolorectal cancer screening programs also recommend the recommended as the screening test for individuals useofflexiblesigmoidoscopyasascreeningtest. consideredtobeatabove-averageriskofcolorectalcancer.


QualityIndicatorFramework

Asetofqualityindicatorsforcolorectalcancerscreeningwasdevelopedin2009forreportingatthenationallevelinCanada.SubsequentworkbytheNCCSNin2011resultedinthedevelopmentoftargetsforsixoftheindicators.

In2013,thePartnershipreleasedarevisedversionofthereportQualitydeterminantsandindicatorsformeasuringcolorectalcancerscreeningprogramperformanceinCanada,whichincludednewandrevisedqualitydeterminantsandindicatorsincludedinthisreport.18

AppendixAdescribesthe13qualityindicatorsandassociatedsixtargetsforwhichdataareprovidedinthisreport.Figure4 outlines the colorectal cancer screening pathwayandprovidesanoverviewofthequalityindicatorsincludedinthisreport.


QualityIndicatorFramework

FIGURE 4

Colorectal cancer screening pathway with national quality indicators

Target Population

Participation rate

Retention rate

(AVERAGE RISK)

(HIGH RISK)

Interval cancer

Participant

Test Results

Abnormal(Positive)

Inadequate Normal(Negative)

Cancer & StagesAdenoma/Serrated Polyps (i.e., other than hyperplastic)

Program invasive CRCdetection rate

CRC stage distribution

Case ManagementSurveillance

Other Polyps

SCREENING

Colonoscopy

Specimen

Pathology

Normal

Entry-level Screening Test(i.e., Fecal test, FTi, FTg, Flex sig, other)

RETEST

Positivity rate

30 day mortality

Fecal test inadequacy rate

Fecal Test Utilization*

Follow-upcolonoscopy uptake

Wait time tofollow-up colonoscopy

14 day unplannedhospitalization

Wait time to definitivepathological diagnosis

Program adenomadetection rate

Positive predictive value adenoma(s)

SCREENING

*Notaprogrammaticindicator.FT=fecaltest;FTi=immunochemicalfecaltest;FTg=guaiacfecaltest;Flexsig=flexiblesigmoidoscopy;PPV=positivepredictivevalue;CRC=colorectalcancer.


DataConsiderations

Dataforthisreportwereobtainedfromprovincesandterritoriesforscreeningandfollow-up,fromcancerregistriesandfromtheCanadianCommunityHealthSurvey.Notethatinsomecases,provinceswereunabletoprovidedataforsome(orall)ofthe13indicatorsinthisreport.Forexample,CCHSdataarereportedonlyforprovincesorterritoriesthatoptedtoparticipateinthescreeningmodule,whichwasoptionalin2013–14.

Inthisreport,forsevenindicators(retentionrate,fecaltestinadequacyrate,positivityrate,follow-upcolonoscopyrate,positivepredictivevalueforadenoma(s),adenomadetectionrate,andprograminvasivecolorectalcancerscreeningrate)dataarepresentedforfirstandsubsequentscreens.Thisapproach provides more comprehensive monitoring of qualitybecausecharacteristicsofindividualsscreenedforthefirsttimedifferfromthosereturningforsubsequentscreens.

Forthepurposesofthereport,onlyonefecaltestwas countedperindividualforthereportperiodfromJanuary1,2013,toDecember31,2014.Ifmorethanonewascompleted,thetestwiththemostsevereabnormalresultwascounted.Iftherewasmorethanonenormalfecaltest,themostrecentonewascounted.Provincesclassifiedallindividuals who completed a fecal test within the report

period(successfulorinadequate)asfirstscreensiftherewasnorecordofapreviousprogrammaticfecaltest(successfulorinadequate)priortoJanuary1,2013.Allotherindividuals who completed a fecal test within the report period(successfulorinadequate)wereclassifiedassubsequentscreens.Whiletheinclusionofbothsuccessfulandinadequatescreensasfirstscreensmayintroducesomebias,itisconsistentacrossindicatorsandprovincesforwhichsubsequentscreenswerereported.

Tosimplifythepresentationoffiguresandtables,thefollowinginformationdescribingprogramexclusions,changesintypeoffecaltest,oravailabilityofdataduringthereporttimeframeispresentedonlyonce,below.Onlyadditionalpertinentinformationwillappearinthefootnotesoffiguresandtableswhereneeded.


DataConsiderations

• Alberta: The Alberta Colorectal Cancer Screening Program waslaunchedin2007.FTiwasimplementedprovince-wideinNovember2013,replacingFTgastheprimaryscreeningtestforcolorectalcancer.DatareportedforallindicatorsexceptpositivityrateincludebothFTgandFTitests;however,where the provinces are separated by test modality in the figures,AlbertaislistedunderFTigivenitwasinuseforagreaterproportionofthereportingperiod.DatareportedforthepositivityrateincludeonlyFTitests.

• Saskatchewan: The Saskatchewan Screening Program for ColorectalCancerreceivesallFTiresultsfromboththeprogrammaticandopportunisticpathways.Oncescreened,all individuals are followed by the program and invited when theirnextscreenisdue.

• Manitoba: Fortheperiodcoveredinthisreport,ManitobausedFTgastheprimaryscreeningtestforcolorectalcancer.Individualsareexcludedfrominvitationiftheyhavehadafecal test within the previous two years or a colonoscopy withinthepreviousfiveyears(viaopportunisticscreening)oriftheyhavehadarelatedcancer.Thisisdonetopreventoverscreeningorinappropriatescreening.Ifanindividualhasinvalidhealthcoverageoraninvalidmailingaddress,theyarealsoexcluded.

• Ontario:Fortheperiodcoveredinthisreport,OntariousedFTgastheprimaryscreeningtestforcolorectalcancer. Thefollowingindividualsareexcludedfrominvitation:thoseundertheageof50orovertheageof74years;thosewithamissingorinvalidhealthinsurancenumber,dateofbirth,orpostalcode;thosewhohavewithdrawnfromcorrespondence;thosewithanFTginthepasttwoyears,aflexiblesigmoidoscopyinthepast10years;andthosewithapreviousinvasivecolorectalcancerand/ortotalcolectomy.

• Newfoundland and Labrador:TheNewfoundlandandLabradorColonCancerScreeningProgramwasimplementedusingaphased-inapproach.Fortheperiodofthisreport,thedataarerepresentativeofthreeoftheprovince’sfourregionalhealthauthorities:WesternRegionalHealthAuthority,CentralRegionalHealthAuthorityandLabrador-GrenfellRegionalHealthAuthority.Thepopulationincludesthosemeanttobeexcludedfromthescreeningprogram(e.g.,thosewhorecentlyreceivedacolonoscopy).Theprogram was launched in the Eastern Health Authority regionaftertheperiodofthisreport,inJuly2015.

• Nova Scotia: Allindividualsinthetargetagerange(50to74years)weresentakitunlesstheylefttheprovince (i.e.,theynolongerappearintheprovincialinsurancefile)orcontactedtheprogramtooptout.TheparticipationdenominatorisinterpretedasthenumberofFTikitssenttouniqueparticipantsfromJanuary1,2013,toDecember31,2014.

• Prince Edward Island:TheparticipationdenominatorusesStatisticsCanadapopulationdata.Thepopulationthereforeincludesthosemeanttobeexcludedfromthescreeningprogram(e.g.,thosewhorecentlyreceivedacolonoscopy).Multi-sitedistributionofkitspreventedthoroughscreeningforprogrameligibility.Individualsinthetargetpopulationmay also have been tested via primary care providers and wouldthereforenotbelinkedtotheprogram.


QualityIndicators

ParticipationRateParticipationisthepercentageofthetargetpopulationwhosuccessfullycompletedatleastonefecaltestintheprogramwithinthemeasurementtimeframe.

Target: ≥60%

Screeningparticipantsserveastheentrycohortforthemeasurement of the rest of the indicators along the screeningpathway.Thedenominatorusedisthepopulationtowhichtheprogramisavailable.Aparticipantisincludedinthenumeratorifscreenedwithin30monthsasopposedto24monthsfromthebeginningofthemeasurementtimeframetoallowindividualswhobecomepartofthe

target age group near the end of the measurement timeframeagraceperiodofsixmonthswithinwhichto bescreened.Programparticipationratesrangebetween8.6%inNewfoundlandandLabradorand53.0%inSaskatchewan (Figure5).Comparedwithdatainthecolorectalcancerscreeningreportfor2011–12,whereprogramparticipationratesrangedbetween12.1%inManitobaand36.3%inSaskatchewan,programmaticparticipationrateshaveincreasedoverall.Colorectalcancerscreeningparticipationratesarehigherinolderage groups and in women (Figure6).


QualityIndicators

FIGURE 5

Colorectal cancer screening program participation in a 30-month period, both sexes combined, by province, 2013 and 2014 screening years combined

0

20

40

60

80

100

Percent (%)

Province

Target ≥60%

AB

41.8

SK

53.0

MB

16.9

NS

25.8

PE

20.4

NL

8.6

NL* MB PE NS AB SK

Individuals with successful fecal tests — 50,655 9,831 85,523 443,026 161,071

Population to whom the programs were available — 298,891 48,120 331,455 1,060,110 303,640

—:Datanotavailable*:Numeratoranddenominatorwerenotprovided.TheestimateinFigure5wascalculatedusingpopulationweighting.NL:Programwasimplementedinphases.Participationratewascalculatedusingpopulationweighting.Datarepresentapproximately40%ofthetotaleligiblepopulationaged50–74yearsintheprovincefortheeligiblepopulationofthespecifichealthregionwheretheprogramwasoffered.Programwasnotavailabletotheremainderofthepopulationduringthereportingperiod.PE:ParticipationdenominatorusesStatisticsCanadapopulationdata,whichincludeindividualsmeanttobeexcludedfromthescreeningprogram(e.g.,individualswhorecentlyobtainedacolonoscopy).SK:Dataincludeindividualscompletingafecaltestobtainedthroughtheprogramoropportunistically.Datasource:Provincialcanceragenciesandprograms.


Quality Indicators

Bothsexes Male Female

FIGURE 6

Colorectal cancer screening program participation in a 30-month period, by age group and sex, 2013 and 2014 screening years combined

0

20

40

60

80

100

Percent (%)

Age group

50–54 55–59

Target ≥60%

60–64 65–69 70–74

30.0 27.932.1 33.5 31.7

35.340.0 38.3

41.7 43.6 42.6 44.650.0 49.5 50.5

DataincludeAB,SK,MBandNS.NL:Dataexcludedasitonlyprovidednumbersforthe50–74agegroupcombined.PE:DataexcludedasparticipationdenominatorusesStatisticsCanadapopulationdata,whichincludeindividualsmeanttobeexcludedfromthescreeningprogram (e.g.individualswithcolorectalcancer).Datasource:Provincialcanceragenciesandprograms.


Quality Indicators

FecaltestutilizationFecaltestutilizationisdefinedasthepercentageofthetargetpopulationwhocompletedatleastonefecaltest,eitherprogrammaticornon-programmaticwithinthemeasurementtimeframe.

Target: Notyetdetermined

WhenevaluatingcolorectalcancerscreeninginCanada,bothprogrammaticandopportunisticscreeningmustbetakenintoconsideration.Datafromavarietyofsources,includingfee-for-servicedataandself-reporteddata,maybeusedinconjunctionwithprogrammaticdatatopresenta more comprehensive assessment of the percentage of the eligiblepopulationthatcompletedafecaltestwithinthelasttwoyears.Untilscreeningprogramsareabletoobtaindataonfecaltestusefrommultiplesources,theCanadianCommunity Health Survey (CCHS) provides valuable insight intooverallfecaltestuse–beitprogrammaticoropportunistic.Notethatcolorectalcancerscreeningquestionswerepartofanoptionalmodulein2013and2014,whichiswhydataaremissingforsomeprovincesandterritories.

Figure7showsthepercentageofCanadiansaged50to74at average risk for colorectal cancer who reported having had a fecal test in the past two years for screening purposes usingCCHSdata.Thisisdefinedasrespondentswhoreportedhavingafecaltestforanyofthefollowingreasons:familyhistory,regularcheck-up/routinescreening,ageorrace.Itexcludesrespondentswhoreportedhavingafecaltestforthefollowingreasons:follow-upofproblem,follow-upofcolorectalcancertreatment,or'other'reason.Fecaltestutilizationratesfor2013rangedfrom12.1inQuebecto51.0inManitoba.For2014,fecaltestutilizationratesrangedfrom16.9inNewfoundlandandLabradorto49.0inManitoba.Fecaltestingmaybecarriedoutforreasonsotherthanscreeningandthedatawerealsoanalyzedfurthertoexaminetowhatdegreethiswasoccurring.Onlyasmallpercentageof fecal test were reported as being done for reasons other thanscreening.

Comparingparticipationratesandfecaltestutilizationforscreeningpurposesforeachprovince,someofthedifferencesmaybeduetothetimeframeused(30monthsversus24months).ThedifferencebetweenManitoba’sprogramparticipationrateinFigure5(16.9%in2013–14)andself-reportedutilizationinFigure7(51.0%in2013and49.0%in2014)maybeduetothefactthatalargeproportionoffecaltestsinManitobaarecompletedoutsidethescreeningprogram.Inanefforttoavoid

overscreening,Manitobadoesnotinviteindividualsknownto have completed a fecal test from another source individualswhohadacolonoscopyintheprevious5years,orthosewhohaveacolorectal-relatedcancerdiagnosis.Whilenoscreeningprogramparticipationrateshavereachedthenationaltargetofatleast60%,self-reportedfecaltestutilizationforscreeningpurposesisgenerallyarounddoubletherateofprogramparticipation,suggestingthatacompleteassessmentofscreeninguptakeinthepopulationrequiresbothindicators.

Monitoringscreeningprogramparticipationratesprovidesonly one component of the total uptake of colorectal cancer screening.Individualswhohaveundergonetestingwitheitherafecaltest,flexiblesigmoidoscopyorcolonoscopywithinspecifiedtimeperiodsmaybeconsideredtobeuptodatewithregardtotheirscreeninghistory.Thisstatuswouldapplyevenifindividualswerenottestedexplicitlyforcancerscreeningpurposes,sincetestingwouldnotneedtoberepeatedforscreening.19CCHSdataonself-reportedfecaltestingorendoscopyuseforanyreasonamongindividualsareusefultoestimatethepercentageofthepopulationthatisuptodateforcolorectalcancerscreeninginCanada.Thepercentageofthepopulationaged50to74that reported having a fecal test in the past two years or a flexiblesigmoidoscopyorcolonoscopyinthepast10yearsforanyreasonrangedfrom44%to70%in2013andfrom48%to68%in2014(Figure8).

In ScreeningratesforcolorectalcancerinCanada:Across-sectionalstudy,datafromthe2012CCHSsurveywereusedtocalculatetheprevalenceofpeopleaged50to74whowereuptodatewithscreeningusingfecaltestingorendoscopictestsinCanada.19 The results showedthatthepercentageofthepopulationuptodatecolorectalcancerscreeningamongpeopleaged50to74in2012(definedashavinghadafecaltestwithinthepasttwoyearsorflexiblesigmoidoscopyorcolonoscopywithinthepast10years,orboth)was55.2%,rangingfrom41.3%intheterritoriesto67.2%inManitoba.Therateforsigmoidoscopyorcolonoscopywas37.2%(highestinOntario,at43.3%);forfecaltestingitwas30.1%(highestinManitoba,at51.7%).Further,about41%ofthosewhohadafecaltestalsohadasigmoidoscopyorcolonoscopy.Finally,individualsinthehighestincomegroupweremorelikelythanthoseinlower-incomegroupstobeuptodatewithcolorectalcancerscreening,eveninprovinceswithwell-establishedpopulation-basedscreeningprograms.19


Quality Indicators

2013 2014

FIGURE 7

Percentage of the population aged 50–74 that reported having had a fecal test in the past two years for screening purposes, by province/territory, CCHS 2013 and 2014 reporting years

0

20

40

60

80

100

Percent (%)

Province

AB MBQC NB YTNT PENL

21.0E 23.0E 22.0E

—

15.8 16.9

37.0 38.0

18.0 17.012.1

20.0

51.0 49.0

31.0 33.0

—:Datanotavailable.ᴱ:Interpretwithcautionowingtolargevariabilityintheestimate.Datapresentedforprovincesandterritoriesparticipatinginthecolorectalcancerscreeningmoduleforthe2013and2014CanadianCommunityHealthSurvey.Datasource:StatisticsCanada,CanadianCommunityHealthSurvey.


Quality Indicators

2013 2014

FIGURE 8

Percentage of the population aged 50–74 up to date for colorectal cancer screening (any modality, any reason), CCHS 2013 and 2014 reporting years

0

20

40

60

80

100

Percent (%)

Province

AB MBNBYTNT PE

44.048.0

45.0

—

NL

47.0

57.0 59.063.0

57.0 57.0

QC

48.053.0

70.0 68.0

61.0 60.0

—:Datanotavailable.Uptodateforcolorectalcancerscreeningdefinedashavinghadafecaltestinthepasttwoyearsand/orasigmoidoscopy/colonoscopyinthepast10yearsforanyreason.Datapresentedforprovincesandterritoriesparticipatinginthecolorectalcancerscreeningmoduleforthe2013and2014CanadianCommunityHealthSurvey.Datasource:StatisticsCanada,CanadianCommunityHealthSurvey.


Quality Indicators

RetentionrateRetentionrateisdefinedasthepercentageofindividuals retentionrateincreaseswithageandisalsohigherafter aged50to72yearsrescreenedwithin30monthsaftera asubsequentscreenthanafterafirstscreen(Figures10 normalfecaltestinthemeasurementtimeframe. and 11).Thispatternisalsoobservedinotherorganized screeningprograms,suchasthoseforbreastcancer.AsTarget: Notyetdetermined programscontinuetoreachfullimplementation,an increaseinretentionratesshouldbeobservedovertimeMonitoringcolorectalcancerscreeningprogramretention forallscreeningprograms.Notethatthedenominatorforratesareparticularlyimportantgiventhesensitivityoffecal theretentionrateincludesindividualsuptotheageof72testsisnot100%,whichmeansthatlesionsmaybemissed asindividualsolderthan72wouldnolongerbeofifthetestisnotrepeatedataregularinterval.20Retention screeningageforasubsequentscreen30monthsafteraratesvaryconsiderablyamongprovinces,from38.9%to successful fecal test based on most provincial colorectal 77.4%(Figure9).Exceptforthe70to72agegroup,the cancerscreeningguidelines.

FIGURE 9

Colorectal cancer screening retention rate in a 30-month period, age 50–72, by province, 2011 and 2012 screening years combined

0

20

40

60

80

100

Percent (%)

Province

AB SKMB ON NLNSPE

77.4

38.945.3

59.753.0

75.9

61.7

ON:2011dataonly.Thefollowingexclusionswereapplied:individualswhohadanabnormaltestresultinthegivenyear,whodiedduringthefollow-upperiod,whohadinvasivecolorectalcancerand/ortotalcolectomyduringthefollow-upintervalorwhowereuptodatewithcolonoscopyorflexiblesigmoidoscopyuptoandincludingthefollow-upinterval.Datasource:Provincialcanceragenciesandprograms.


Quality Indicators

Firsteverfecaltest Subsequentfecaltest

70–7265–6960–6455–5950–54All agesAgegroup:

FIGURE 10

Colorectal cancer screening retention rate in a 30-month period, by province and age group, 2011 and 2012 screening years combined

0

20

40

60

80

100

Percent (%)

ProvinceProvincescombined

AB SKMB ONNSPE NL

58.4

53.0 58

.0 60.2 63

.360

.6

61.7

56.2 60

.9 64.5 67

.861

.6

75.9

70.2 74

.1 78.4

80.1

79.8

53.0

48.5 53

.255

.255

.556

.4 59.7

52.2 57

.2 63.4 67

.266

.3

45.3

37.6 42

.5 46.5 49

.3 52.7

38.9

30.4 36

.4 40.0 44

.9 49.3

77.4

61.1

76.1

76.5 82

.778

.8

ProvincescombinedexcludesON.PE:ProgrambeganinMay2011.DataincludepilotparticipationJanuary–April2011,whichwasasubsetofthetargetpopulation.Alltestscompletedwerefirstscreen(programmaticandpilot).Retentionratedoesnotreflectthoserescreenedoutsidetheprogram(e.g.,throughprimarycareprovider).NS:ThelargesthealthdistrictinNovaScotia,CapitalDistrictHealthAuthority(CDHA),starteditsfirstcycleofthecolorectalcancerscreeningprogramApril1,2011.CDHAcontainsapproximatelyhalfofNovaScotia’spopulation,somostscreenswerefirst-timescreens.Additionally,programwassuspendedforsixmonthswithinthereportingperiodowingtomanufacturingproblemswithFTitestingcards.ON:2011dataonly.Thefollowingexclusionswereapplied:individualswhohadanabnormaltestresultinthegivenyear,whodiedduringthefollow-upperiod,whohadinvasivecolorectalcancerand/ortotalcolectomyduringthefollow-upintervalorwhowereuptodatewithcolonoscopyorflexiblesigmoidoscopyuptoandincludingthefollow-upinterval.NL:Datarepresentlastfivemonthsofthereportingperiod.Datasource:Provincialcanceragenciesandprograms.

FIGURE 11

Colorectal cancer screening retention rate in a 30-month period, by province and screening round, 2011 and 2012 screening years combined

0

20

40

60

80

100

Percent (%)

ProvinceAB SKMBNS

53.862.1

75.8 78.9

49.3

63.2

41.0

61.7

Datasource:Provincialcanceragenciesandprograms.


Quality Indicators

FecaltestinadequacyrateFecaltestinadequacyrateisdefinedasthepercentageofindividualswhosefecaltestwasinadequateandwhohavenotrepeatedthetestwithinthemeasurementtimeframetogetasuccessfulfecaltestresult. Target: ≤5% Thefecaltestinadequacyrateprovidesinformationaboutthesuccessfulcompletionoftheprocessofperformingthetestbythetargetpopulation.Factorsthatmayinfluenceinadequateresultsincludeimproperfecalsampling,missingparticipantinformation,excessivetimefromsamplecollectiontoanalysis,orqualityassuranceproblemsassociatedwiththelaboratoryorvendor.21Notethattheproportionofindividualtestswhichareinadequatewillbehigherthantheratesquoted,whichrefertoinadequacyoftestingpatientswithinthetimeperiod.

In2013–14,fecaltestinadequacyratesvariedamongthereportingprovinces(Figure12)butallmetthetargetof5%orless.Inprovinceswiththehighestinadequacyrates,thoserateswerelowerinsubsequentscreens(Figure13).InthecaseofNewfoundlandandLabrador,thenumberofinadequatefecaltestswassolowthattheratebyscreeningroundhadtobesuppressed.TheCanadiantarget,whichwassetin201122,ishigherthanthetargetssetbytheEuropeanUnionguidelinesoflessthan3%astheacceptablelevelandlessthan1%asthedesiredlevel.23

FIGURE 12

Fecal test inadequacy rate, by province, 2013 and 2014 screening years combined

0

2

4

6

8

10

Percent (%)

MB

1.7

SK

2.5

NS

1.7

PE

1.2

AB

0.4

NL

0.5

Target <5%

FTiFTgProvince

FTg=guaiacfecaltest;FTi=immunochemicalfecaltest. Datasource:Provincialcanceragenciesandprograms.


Quality Indicators


FIGURE 13

Fecal test inadequacy rate, by province and screening round, 2013 and 2014 screening years combinedParticipation Rate (%)

ProvinceFTiFTg

0

2

4

6

8

10

Target <5%

MB

2.2

1.0

NL* *

AB

0.3 0.4

PE

1.40.9

SK

2.7

1.7

NS

3.1

1.1

FTg=guaiacfecaltest;FTi=immunochemicalfecaltest. —:Datanotavailable.*:Suppressedowingtosmallnumbers.Datasource:Provincialcanceragenciesandprograms.


Quality Indicators

PositivityratePositivityrateisdefinedasthepercentageof individualswithanabnormalfecaltestresultin themeasurementtimeframe. Target: Notyetdetermined Monitoringthepositivityrategivesanindicationofwhatproportionofthescreenedpopulationhasreceivedanabnormalscreeningtestresult.Abnormalscreeningtestresultsincludebothindividualswhohavesignificantpathology,suchasadenomasorcolorectalcancer(truepositives),andindividualswhodonothaveanyneoplasticlesion(falsepositives).Positivityrateisinfluencedbycolorectalcancerprevalenceandthesensitivityofthefecaltestused.Factorsinfluencingsensitivityincludethetypeandsubtypeoffecaltest(FTgorFTi—qualitativeorquantitative,andthemanufacturer),thenumberoffecalsamplesrequiredandthresholdcut-offvalues.Seethetable below Figure14formoredetails. Thepositivityrateshouldbeassessedalongsidethepositivepredictivevalue(PPV)(Figures23–26) and adenomaandcancerdetectionrates(Figures27 and 28).Anincreaseinsensitivitymustbebalancedagainstapotentiallossofspecificity;ifhighpositivityratesarenot

relatedtohighPPVsandadenomaandcancerdetectionrates,thenumberofindividualswithfalse-positiveresultswilllikelyalsobehigh.Theseindividualscouldexperienceunnecessaryanxietyandtherisksoffollow-upcolonoscopy.Highpositivityrateswillincreasetheburdenonendoscopyresources(humanandfinancial). Positivityratesvariednoticeablyamongprovinces(Figure14),withthelowestratesoccurringinprovincesthatuseFTg(3.4%inManitoba,4.0%inOntario)andmuchhigherratesamongprovincesusingFTi(rangingfrom8.3%inSaskatchewanto16.1%inNewfoundlandandLabrador).Provincialdifferencesinthelattergroupmaybedueto thedifferentbrandsoffecaltestsbeingused,thenumberofsamplestaken,thenumberofsamplesusedtodefinepositivity,anddifferentcut-offpointsforapositivetestresult.ThetablebeneathFigure14showsthedifferentcharacteristicsofthefecalteststhatwereinuseduringthereporttimeframe.Higherpositivityratesamongmales,andinfirstversussubsequentscreens,areconsistentwiththe literature (Figures15–17).24,25PositivityratesincreasewithageforthosewhounderwentFTi(notwithstandingthepositivitycut-offlevelsused)buttherewasnosimilartrendforthosewhounderwentFTg(Figure17).


Quality Indicators

FIGURE 14

Positivity rates for fecal tests, by province, 2013 and 2014 screening years combined

0

5

10

15

20

25

Percent (%)

FTiFTgProvince

MB

3.4

ON

4.0

AB

9.7

SK

8.3

NS

8.6

PE

15.0

NL

16.1

MB ON SK NS AB PE NL

Individuals with positive fecal tests 1,596 19,731 11,603 5,823 24,864 1,236 734

Individuals with successful fecal tests 47,062 495,560 139,886 67,536 257,576 8,226 4,564

Cut-off value for abnormal result (FTi only)

≥100ng/ml ≥100ng/ml ≥75ng/ml ≥100ng/ml ≥100ng/ml

Number of samples2samplesperstoolfrom3

stools

2samplesperstoolfrom3

stools1 2 1 2 2

Fecal test brand Hemoccult II SENSA Hema-screen Polymedco Hemoccult ICT Polymedco Alere Alere

FTg=guaiacfecaltest;FTi=immunochemicalfecaltest. AB,ON:Dataarefor2014only.Datasource:Provincialcanceragenciesandprograms.


Quality Indicators

FemaleMale

FIGURE 15

Positivity rates for fecal tests, by province and sex, 2013 and 2014 screening years combined

0

5

10

15

20

25

Percent (%)

FTg FTiProvince

MB

4.42.6

ON

4.83.3

AB

11.9

7.4

SK

10.2

6.6

NS

10.7

7.1

PE

18.7

12.0

NL

21.2

13.0

Province

Both sexes Male FemaleIndividuals

having positive fecal

tests

Individuals having

successful fecal tests Rate(%)

Individuals having

positive fecal tests

Individuals having

successful fecal tests Rate (%)

Individuals having

positive fecal tests

Individuals having

successful fecal tests Rate (%)

MB 1,596 47,062 3.4 900 20,480 4.4 696 26,582 2.6

ON 19,731 495,560 4.0 10,582 220,954 4.8 9,149 274,606 3.3

SK 11,603 139,886 8.3 6,768 66,277 10.2 4,835 73,609 6.6

NS 5,823 67,536 8.6 3,130 29,376 10.7 2,693 38,160 7.1

AB 24,864 257,576 9.7 15,129 126,754 11.9 9,735 130,822 7.4

PE 1,236 8,226 15.0 701 3,756 18.7 535 4,470 12.0

NL 734 4,564 16.1 364 1,717 21.2 370 2,847 13.0



Quality Indicators


70–7465–6960–6455–5950–54Agegroup:

FIGURE 16

Positivity rates for fecal tests, by province and screening round, 2013 and 2014 screening years combined

0

5

10

15

20

25

Percent (%)

FTg FTiProvince

MB

3.5 3.3

AB

10.1 9.3

SK

8.67.1

NS

10.08.0

PE

15.7

13.4

NL

16.5

11.5

FTg=guaiacfecaltest;FTi=immunochemicalfecaltest.—:Datanotavailable. AB:Dataarefor2014only.NL:Datarepresentlastfivemonthsofthereportingperiod.Datasource:Provincialcanceragenciesandprograms.

FIGURE 17

Positivity rates for fecal tests, by province and age group, 2013 and 2014 screening years combined

0

5

10

15

20

25Percent (%)

FTg FTiProvince

MB ON PE

3.3

3.2

3.3

3.4 4.

0 4.2

3.9

3.8

3.9 4.2

AB

7.1

8.5

9.9 11

.5

13.2

SK

5.6

7.1 8.

0

10.4 11

.6

NS

6.1

7.5 8.

7 9.7 10

.6 11.8 12

.4

14.5

17.9

17.8



Quality Indicators

Follow-upcolonoscopyuptakeFollow-upcolonoscopyuptakerateisdefinedasthepercentageofindividualswhohadafollow-upcolonoscopyperformedwithin180daysofanabnormalfecaltestresultinthemeasurementtimeframe. Target:≥85% Theeffectivenessofascreeningprogramrequiresthatindividuals with an abnormal test result complete the appropriatediagnosticfollow-upwithcolonoscopy.Monitoringthisindicatorprovidesimportantinformationtoplanstrategiestoimprovefollow-up.Thisindicatorincludesfollow-upcolonoscopiesperformedwithin180daysoftheabnormaltestresult.Whilethisintervalis usedformonitoringandevaluationpurposesonly,notas arecommendedtarget,screeningprogramsmayuse thesedatatoinformstrategiestodecreasewaittimes.

In2013–14,follow-upcolonoscopyuptakevariedfrom62.9%inAlbertato82.8%inManitoba(Figure18),wherepositivityrateswere13.8%and3.4%,respectively.Whilenoprovincereachedthetargetof85%,Manitobawasclose(82.8%).Follow-upcolonoscopyuptakewashigherinsubsequentscreensthanfirstscreensinallprovinces(Figure19).Alowerfollow-upcolonoscopyuptakerateassociatedwithahigherpositivityratecouldindicatetheneedtoimprovenotificationandfollow-upofpositivefecaltestresults,torevisecut-offlevelsforfecaltestingand/ortoinvestinendoscopicresources.Follow-upcolonoscopyuptakemustbeinterpretedinrelationtopositivepredictivevaluesandprogramadenomaandcancerdetectionrates(seeTable2forasummary).


Quality Indicators

FIGURE 18

Follow-up colonoscopy uptake among individuals with abnormal fecal test results, both sexes combined, by province, 2013 and 2014 screening years combined

0

20

40

60

80

100

Percent (%)

Province

AB

62.9

SK

65.1

MB

82.8

ON

77.1

NS

66.6

PE

70.7

NL

73.7

Target ≥85%

AB SK NS PE NL ON MB

Individuals having follow-up colonoscopy within 180 days 19,717 7,559 3,877 874 541 15,395 1,322

Individuals with abnormal fecal test results 31,332 11,603 5,823 1,236 734 19,962 1,596

Follow-upcolonoscopyuptakerateamongthosewhohadafollow-upcolonoscopyperformedwithin180daysofanabnormalfecaltestresult. AB:Follow-upcolonoscopyuptakeisunderestimatedowingtoincompletecolonoscopydata.Thereisadelaybetweencolonoscopydateandreportingdate.Multipledatasourceshavebeenusedtocapturefollow-upcolonoscopies(NationalAmbulatoryCareReportingSystem[NACRS],DischargeAbstractDatabase[DAD]andphysicianclaimdatabase[billingdata]).ForNACRSandDAD,reportingdelaysmaybesixweeksormore.AvailablephysicianclaimsdatainthedatarepositorycoverproceduresuptoMarch31,2015.Thepopulationforfollow-upcolonoscopyuptakeisdifferentfromthenumeratorforthepositivityrate,wheredatawereforFTionly.SK:Follow-upcolonoscopyuptakeisunderestimatedowingtoincompletecolonoscopydata.Notallcolonoscopydatahasbeenretrievedforthismeasurementtimeframe. NS:OwingtoachangeinthesensitivityoftheparticularFTibeingusedandasubsequentincreaseinpositiveresults,therewasanincreaseinthenumberofcolonoscopiesrequired.Thisledtolongerwaittimesthananticipated.Additionally,10%ofprogramparticipantschosefollow-upoutsidetheprogram.Nodataareavailableontheseindividuals.ON:Dataarefor2014only.MB:IncludesdataonindividualswhowerereferredbyColonCheckandbyprimarycareproviders.Eightmorepeoplehadoneormoreotherfollow-upprocedures(computedtomographiccolonography,flexiblesigmoidoscopy);117peoplehadnocolonoscopyformedicalreasons,patientrefusalorotherreasonsnotcontrolledbythescreeningprogram.Datasource:Provincialcanceragenciesandprograms.


Quality Indicators


FIGURE 19

Follow-up colonoscopy uptake among individuals with abnormal fecal test results, by province and screening round, 2013 and 2014 screening years combined

0

20

40

60

80

100

Percent (%)

ProvinceAB

61.064.5

SK

64.668.1

MB

80.885.4

NS

62.968.7

PE

69.973.0

Target ≥85%

Follow-upcolonoscopyuptakerateamongthosewhohadafollow-upcolonoscopyperformedwithin180daysofanabnormalfecaltestresult. AB:Follow-upcolonoscopyuptakeisunderestimatedowingtoincompletecolonoscopydata.Thereisadelaybetweencolonoscopydateandreportingdate.Multipledatasourceshavebeenusedtocapturefollow-upcolonoscopies(NationalAmbulatoryCareReportingSystem[NACRS],DischargeAbstractDatabase[DAD]andphysicianclaimdatabase[billingdata]).ForNACRSandDAD,reportingdelaysmaybesixweeksormore.AvailablephysicianclaimsdatainthedatarepositorycoverproceduresuptoMarch31,2015.Thepopulationforfollow-upcolonoscopyuptakeisdifferentfromthenumeratorforthepositivityrate,wheredatawereforFTionly. NS:OwingtoachangeinthesensitivityoftheparticularFTibeingusedandasubsequentincreaseinpositiveresults,therewasanincreaseinthenumberofcolonoscopiesrequired.Thisledtolongerwaittimesthananticipated.Additionally,10%ofprogramparticipantschosefollow-upoutsidetheprogram.Nodataareavailableontheseindividuals. SK:Follow-upcolonoscopyuptakeisunderestimatedowingtoincompletecolonoscopydata.Notallcolonoscopydatahasbeenretrievedforthismeasurementtimeframe. MB:IncludesdataonindividualswhowerereferredbyColonCheckandbyprimarycareproviders.Eightmorepeoplehadoneormoreotherfollow-upprocedures(computedtomographiccolonography,flexiblesigmoidoscopy);117peoplehadnocolonoscopyformedicalreasons,patientrefusalorotherreasonsnotcontrolledbythescreeningprogram.Datasource:Provincialcanceragenciesandprograms.


Quality Indicators

90thpercentilewaittimeMedianwaittime

Waittimetofollow-upcolonoscopyWaittimetofollow-upcolonoscopyisdefinedasthetimeintervalfromanabnormalfecaltestresulttofollow-upcolonoscopyinthemeasurementtimeframe. Target: ≥90%within60daysofanabnormalfecaltestresult Thewaittimetofollow-upcolonoscopyprovidesinformationontheeffectivenessofthereferralsystemandtheavailabilityofthediagnosticprocedure.Waittimetofollow-upcolonoscopyispresentedasthemedianand90thpercentilenumberofcalendardaysfromanabnormalfecaltestresulttoafollow-upcolonoscopywithin180daysoftheabnormalfecaltest.Colonoscopiesperformedmorethan180daysaftertheabnormalfecaltestarenotincluded.Thedateoftheabnormalfecaltestisthedatethe result is reported by the laboratory for each individual test;ifthereismorethanoneabnormalfecaltest,thedateofthefirsttestisused.

Amongprovincesthatprovideddatainboththe2011–12and2013–14colorectalcancerscreeningmonitoringand

evaluationreports,the90thpercentileforwaittimestofollow-upcolonoscopyhavedecreasedinsomeprovinces,butincreasedinothers.Amongindividualswhohadafollow-upcolonoscopywithin180daysofanabnormalfecaltestresultin2013–14,waittimeswerewithinornearthetargetof60daysforhalfoftheindividuals(median)infourprovinces:NewfoundlandandLabrador,Manitoba,SaskatchewanandAlberta.However,noprovincemetthetargetand90thpercentilewaittimesinthesevenreportingprovinces indicate that many individuals had to wait twice therecommendednumberofdaysfortheirfollow-upcolonoscopy,rangingfrom104to151days(Figure20).Forallbutoneprovince,90thpercentilewaittimeswereshorterin2013–14thanin2011–12(Figure21).Medianwaittimetofollow-upcolonoscopyislikelytobeaffectedbythefollow-upcolonoscopyuptakerate,orthepercentageofpatientswhoundergocolonoscopywithin180days(Figure18),whichrangedfrom61.9%to82.8%.

FIGURE 20

Median and 90th percentile wait times from abnormal fecal test result to follow-up colonoscopy, by province, 2013 and 2014 screening years combined

0 20 40 60 80 100 120 140 160 180 200

Province

Days

Target ≤60

65AB 139

56MB 119

61SK 119

83NS 147

88PE 151

37NL 104

Waittimetofollow-upcolonoscopyiscalculatedamongthosewhocompletedacolonoscopywithin180daysofanabnormalfecaltest. AB:Follow-upcolonoscopyuptakeisunderestimatedowingtoincompletecolonoscopydata.Thereisadelaybetweencolonoscopydateandreportingdate.Multipledatasourceshavebeenusedtocapturefollow-upcolonoscopies(NationalAmbulatoryCareReportingSystem[NACRS],DischargeAbstractDatabase[DAD]andphysicianclaimdatabase[billingdata]).ForNACRSandDAD,reportingdelaysmaybesixweeksormore.AvailablephysicianclaimsdatainthedatarepositorycoverproceduresuptoMarch31,2015.Thepopulationforwaittimetofollow-upcolonoscopyisdifferentfromthenumeratorforthepositivityrate,wheredatawereforFTionly.MB:IncludesdataonindividualswhowerereferredbyColonCheckandbyprimarycareproviders.Eightmorepeoplehadoneormoreotherfollow-upprocedures(computedtomographiccolonography,flexiblesigmoidoscopy);117peoplehadnocolonoscopyformedicalreasons,patientrefusalorotherreasonsnotcontrolledbythescreeningprogram.NS:OwingtoachangeinthesensitivityoftheparticularFTibeingusedandasubsequentincreaseinpositiveresults,therewasanincreaseinthenumberofcolonoscopiesrequired.Thisledtolongerwaittimesthananticipated.Additionally,10%ofprogramparticipantschosefollow-upoutsidetheprogram.Nodataareavailableontheseindividuals. Datasource:Provincialcanceragenciesandprograms.


Quality Indicators

2013–142011–12

FIGURE 21

90th percentile wait times from abnormal fecal test result to follow-up colonoscopy, by province, 2011–12 and 2013–14 screening years

0 20 40 60 80 100 120 140 160 180 200

Province

Days

Target ≤60

NL104

159

PE151

155

NS147

113

MB119

140

SK119

149

AB139

—

—:Datanotavailable. Waittimetofollow-upcolonoscopyiscalculatedamongthosewhocompletedacolonoscopywithin180daysofanabnormalfecaltest.AB:In2013–14,follow-upcolonoscopyuptakeisunderestimatedowingtoincompletecolonoscopydata.Thereisadelaybetweencolonoscopydateandreportingdate.Multipledatasourceshavebeenusedtocapturefollow-upcolonoscopies(NationalAmbulatoryCareReportingSystem[NACRS],DischargeAbstractDatabase[DAD]andphysicianclaimdatabase[billingdata]).ForNACRSandDAD,reportingdelaysmaybesixweeksormore.AvailablephysicianclaimsdatainthedatarepositorycoverproceduresuptoMarch31,2015.Thepopulationforwaittimetofollow-upcolonoscopyisdifferentfromthenumeratorforthepositivityrate,wheredatawereforFTionly.NS:For2013–14,owingtoachangeinthesensitivityoftheparticularFTibeingusedandasubsequentincreaseinpositiveresults,therewasanincreaseinthenumberofcolonoscopiesrequired.Thisledtolongerwaittimesthananticipated.Additionally,10%ofprogramparticipantschosefollow-upoutsidetheprogram.Nodataareavailableontheseindividuals.MB:IncludesdataonindividualswhowerereferredbyColonCheckandbyprimarycareproviders.For2013–14,eightmorepeoplehadoneormoreotherfollow-upprocedures(computedtomographiccolonography,flexiblesigmoidoscopy);117peoplehadnocolonoscopyformedicalreasons,patientrefusalorotherreasonsnotcontrolledbythescreeningprogram.SK:2011–12FTiincludesdatafromonlyonehealthregion. PE:Earlyin2012,FTiwasimplemented.InJune2012,FTgwasdiscontinued.NL:2011–12dataareforthefinalfivemonthsofthereportingperiod,inonehealthregion.Datasource:Provincialcanceragenciesandprograms.


Quality Indicators

90thpercentilewaittimeMedianwaittime

Waittimefromfollow-upcolonoscopytodefinitivepathological diagnosisWaittimefromfollow-upcolonoscopytodefinitivepathologicaldiagnosisisdefinedasthetimefromafollow-upcolonoscopyproceduretodefinitivepathologicaldiagnosis. Target: Notyetdetermined Whilethereisnonationaltargetforthisindicator,theEuropeanGuidelinesforQualityAssuranceinColorectalCancerScreeningandDiagnosis(2010)suggestthatthe

diagnosisshouldbeavailablewithin15daysofthecolonoscopy.26Dependingontheprovince,somepatientswaitlongerthanotherstoreceiveadiagnosisaftercolonoscopy,90thpercentilewaittimevariesfromsixdaysinPrinceEdwardIslandto24daysinSaskatchewan(Figure22).Butthesuggestedinternationaltargetof15dayswasachieved,ornearlyachieved,for90%ofindividualsinthreeofthefiveprovincesthatprovideddataandwasachievedforhalfoftheindividuals(median)inthefiveprovinces.

FIGURE 22

Median and 90th percentile wait times from follow-up colonoscopy to definitive pathological diagnosis, by province, 2013 and 2014 screening years combined

0 5 10 15 20 25 30

Province

Days

SK 8 24

PE 3 6

NS 7 15

MB 12 19

NL 6 16

Waittimefromfollow-upcolonoscopytodefinitivepathologicaldiagnosisiscalculatedamongthosewhocompletedacolonoscopywithin180daysofanabnormalfecaltest. Datasource:Provincialcanceragenciesandprograms.


Quality Indicators

Positivepredictivevalueadenoma(s)ThePPVadenomaisdefinedandmeasuredintwoways.

a)theProgrammaticPPVoftheFTforAdenoma:•thisistheproportionofpeoplewithabnormalfecaltestswhoareconfirmedtohaveanadenoma

•ahighPPVadenomaofafecaltestreflectsaminimizationoftheharmsofscreeningexperiencedthroughabnormalscreeningtestresultswhichdonotresultinadiagnosis ofadenoma

•resultsareshowninfigure23forallfecaltestsandfigure24forfirstandsubsequentfecaltests

b)thePPVoftheFTforAdenoma(s)AmongthoseWhoCompletedFollow-up:

•thisistheproportionofpeoplewithabnormalfecaltestsandcompletedcolonoscopyfollow-up(within180daysofthefecaltest)whoareconfirmedtohaveanadenoma

•thisdefinitionismorefocusedonthelikelihoodthatafollow-upcolonoscopyresultsinadiagnosisofadenoma,andcanbeconsideredamarkerofboththetechnicalqualityofthecolonoscopyandtheefficiencyofthescreeningstrategy28

•resultsareshowninfigure25forallfollow-upcolonoscopiescompletedwithin180daysofanabnormalscreeningresultandfigure26forfollow-upcolonoscopiesstratifiedbyscreeninground

Target: ≥50%forFTiand≥35%forFTg

Notethatthetargetforthisindicatoriscurrently underreview.

Positivepredictivevalue(PPV)isanindicatorofthepredictivevalidityofascreeningtest.Itreflectstheprobabilitythatapositivetestresultisassociatedwiththepresenceoftheunderlyingconditiontargetedbyscreening.

Thepositivepredictivevalueadenoma(PPVadenoma)hasbeenselectedforreportingasaproxyindicatorofthetargetdisease,colorectalcancer.Whilelessthantenpercentofadenomasprogresstocolorectalcancer,nearly95percentofcolorectalcancersdevelopfromadenomasand individuals with a history of adenomas are at increased riskofdevelopingcolorectalcancer.27Thedetectionandremoval of adenomas may prevent progression to colorectalcancer.

ThePPVforadenomadependsonthesensitivityofthescreeningtest,thepositivityrate,thepositivitycut-offfortheFT,thequalityofthecolonoscopy,follow-upcomplianceandunderlyingprevalenceofdiseaseinthescreeningpopulation.TheprogrammaticPPVoftheFTforadenomasandthePPVoftheFTforadenomasamongthosewhocompletedfollow-upshowquiteavariationacrossprovinces.

Fourofthefiveprovincesprovidingdataforthisindicatorachieved the target for PPV for adenoma calculated for PPV offollow-upcolonoscopy(Figure25).Itappearsthatinthisfirsttimereportingofresultsbyscreeninground,thePPV’sareeithersimilarbetweentheinitialandsubsequentFTscreens,orslightlyhigherinfirsteverFTs.Monitoringovertimewillprovideconfirmationofthetrendbetweenthescreeningrounds.


Quality Indicators

FIGURE 23

Positive predictive value of a fecal test for detection of adenomas, by province, both sexes combined, 2013 and 2014 screening years combined

0

20

40

60

80

100

Percent (%)

Province

MB

28.9

SK

33.2

NS

42.7

PE

29.3

NL

49.7FTi target ≥50%

FTiFTg

FTg target ≥35%

MB PE SK NS NL

Number of individuals with an abnormal fecal test (denominator for Figures 23–24) 1,596 1,236 11,603 5,823 734

Number of individuals with adenoma(s) 461 362 3,855 2,487 365

FTg=guaiacfecaltest;FTi=immunochemicalfecaltest. Dataforthenumberofindividualswithadenomawerederivedfromthetotalnumberofindividualswithneoplasia(adenomas,advancedadenomas, invasivecolorectalcancer,neoplasia,advancedneoplasia)minusthetotalnumberofindividualswithinvasivecolorectalcancer. ThenumeratorforPPVadenoma(s)referstothoseinwhomoneormoreadenomaswereconfirmedbypathologyatfollow-upcolonoscopyperformedwithin180daysoftheabnormalFT.PPVoffecaltestisunderestimatedowingtoincompletecolonoscopydata.Notallcolonoscopydatahasbeenretrievedforthismeasurementtimeframe.NS:10%ofparticipantswithanabnormalfecaltestresultforwhomcolonoscopywasrecommendedwerefollowedupoutsidetheprogram;nodataareavailable ontheseindividuals.Thepositivepredictivevalueofthefecaltestisunderestimatedowingtoincompletecolonoscopydata.Notallcolonoscopydatahasbeenretriedforthismeasurementtimeframe. Datasource:Provincialcanceragenciesandprograms.


Quality Indicators


FIGURE 24

Positive predictive value of a fecal test for detection of adenomas, by province and screening round, both sexes combined, 2013 and 2014 screening years combined

0

20

40

60

80

100

FTg

FTg target ≥35%

FTi target ≥50%

FTiProvince

MB

29.7 27.8

SK

33.1 34.0

NS

43.2 42.4

PE

28.7 31.0

Percent (%)

FTg=guaiacfecaltest;FTi=immunochemicalfecaltest. Dataforthenumberofindividualswithadenomawerederivedfromthetotalnumberofindividualswithneoplasia(adenomas,advancedadenomas,invasivecolorectalcancer,neoplasia,advancedneoplasia)minusthetotalnumberofindividualswithinvasivecolorectalcancer.ThenumeratorforPPVadenoma(s)referstothoseinwhomoneormoreadenomaswereconfirmedbypathologyatfollow-upcolonoscopyperformedwithin180daysoftheabnormalFT.NS:10%ofparticipantswithanabnormaltestresultforwhomcolonoscopywasrecommendedwerefollowedupoutsidetheprogram;nodataareavailableontheseindividuals.Datasource:Provincialcolorectalcancerscreeningagenciesandprograms.

FIGURE 25

Positive predictive value of follow-up colonoscopy for detection of adenomas, by province, 2013 and 2014 screening years combined

0

20

40

60

80

100Percent (%)

FTg

FTg target ≥35%

FTi target ≥50%

FTiProvince

MB

34.9

SK

51.0

NS

64.1

PE

41.4

NL

67.5

FTg=guaiacfecaltest;FTi=immunochemicalfecaltest. Dataforthenumberofindividualswithadenomawerederivedfromthetotalnumberofindividualswithneoplasia(adenomas,advancedadenomas,invasivecolorectalcancer,neoplasia,advancedneoplasia)minusthetotalnumberofindividualswithinvasivecolorectalcancer.ThenumeratorforPPVadenoma(s)referstothoseinwhomoneormoreadenomaswereconfirmedbypathologyatfollow-upcolonoscopyperformedwithin180daysoftheabnormalFT.NS:10%ofparticipantswithanabnormaltestresultforwhomcolonoscopywasrecommendedwerefollowedupoutsidetheprogram;nodataareavailableontheseindividuals.Datasource:Provincialcanceragenciesandprograms.


Quality Indicators


FIGURE 26

Positive predictive value of follow-up colonoscopy for detection of adenomas, by province and screening round, 2013 and 2014 screening years combined

0

20

40

60

80

100

FTg

FTg target ≥35%

FTi target ≥50%

FTiProvince

MB NS

68.761.8

PE

41.0 42.5

SK

51.2 49.9

36.732.6

Percent (%)

FTg=guaiacfecaltest;FTi=immunochemicalfecaltest.Dataforthenumberofindividualswithadenomawerederivedfromthetotalnumberofindividualswithneoplasia(adenomas,advancedadenomas,invasivecolorectalcancer,neoplasia,advancedneoplasia)minusthetotalnumberofindividualswithinvasivecolorectalcancer.ThenumeratorforPPVadenoma(s)referstothoseinwhomoneormoreadenomaswereconfirmedbypathologyatfollow-upcolonoscopyperformedwithin180days oftheabnormalFT.NS:10%ofparticipantswithanabnormaltestresultforwhomcolonoscopywasrecommendedwerefollowedupoutsidetheprogram;nodataareavailableontheseindividuals.Datasource:Provincialcanceragenciesandprograms.


Quality Indicators

ProgramadenomadetectionrateProgramadenomadetectionrateisdefinedasthenumberofindividualsper1,000screenedwithoneormoreadenomasconfirmedbypathologyfromafollow-upcolonoscopyperformedwithin180daysoftheabnormalfecaltestresult. Target: Notyetdetermined

Thisindicatorreflectsthetechnicalqualityofthecolonoscopyprocedureandtheefficacyoftheentirescreeningprogramstrategy.28Adenomadetectionrateswereverydifferentacrossprovinces,rangingfrom9.8to80.0per1,000individualsscreenedwithafecaltest(Figure27).Asexpectedbasedontheliterature,therateishigherinmalesthaninfemalesand,toalesserextent,infirstasopposedtosubsequentscreens(Figures28 and 29).21,24

FIGURE 27

Program adenoma detection rate, by province, 2013 and 2014 screening years combined

0

30

60

90

120

150

FTg FTiProvince

MB SK NS PE NL

9.827.6

36.844.0

80.0

Per 1,000 people screened

FTg=guaiacfecaltest;FTi=immunochemicalfecaltest. Dataforthenumberofindividualswithadenomawerederivedfromthetotalnumberofindividualswithneoplasia(adenomas,advancedadenomas,invasivecolorectalcancer,neoplasia,advancedneoplasia)minusthetotalnumberofindividualswithinvasivecolorectalcancer. NS:10%ofparticipantswithanabnormalfecaltestresultforwhomcolonoscopywasrecommendedwerefollowedupoutsidetheprogram;nodataareavailableontheseindividuals.Datasource:Provincialcanceragenciesandprograms.


Quality Indicators


Male Female

FIGURE 28

Program adenoma detection rate, by province and sex, 2013 and 2014 screening years combined

0

30

60

90

120

150


FTg FTiProvince

MB SK NS NL

6.0

51.9

25.2

124.1

53.4

38.5

17.714.7

FTg=guaiacfecaltest;FTi=immunochemicalfecaltest. Dataforthenumberofindividualswithadenomawerederivedfromthetotalnumberofindividualswithneoplasia(adenomas,advancedadenomas,invasivecolorectalcancer,neoplasia,advancedneoplasia)minusthetotalnumberofindividualswithinvasivecolorectalcancer.NS:10%ofparticipantswithanabnormalfecaltestresultforwhomcolonoscopywasrecommendedwerefollowed-upoutsidetheprogram;nodataareavailableontheseindividuals.Datasource:Provincialcanceragenciesandprograms.

FIGURE 29

Program adenoma detection rate, by province and screening round, 2013 and 2014 screening years combined

0

30

60

90

120

150

FTg FTiProvince

MB SK NS PE

9.1

43.234.0

45.0 41.628.3 24.110.4


FTg=guaiacfecaltest;FTi=immunochemicalfecaltest. Dataforthenumberofindividualswithadenomawerederivedfromthetotalnumberofindividualswithneoplasia(adenomas,advancedadenomas,invasivecolorectalcancer,neoplasia,advancedneoplasia)minusthetotalnumberofindividualswithinvasivecolorectalcancer. NL:Didnotprovidedatabyscreeninground.Datasource:Provincialcanceragenciesandprograms.


Quality Indicators

PrograminvasivecolorectalcancerdetectionratePrograminvasivecolorectalcancerdetectionrateisdefinedasthenumberofindividualsper1,000screenedwithinvasivecolorectalcanceronpathologyfromafollow-upcolonoscopyperformedwithin180daysoftheabnormalfecaltestresult. Target:≥2colorectalcancercasesper1,000peoplescreened Measuringthecancerdetectionrateattheprogramlevelmayhelptoassesstheeffectivenessofascreeningprogramovertime.Detectionratesdependonmanyfactors,includingthesensitivityofthescreeningtestandtheabilitytoprovidetimely,high-qualityfollow-upprocedurestoallindividualswithabnormalscreeningresults. In2013–14,thecolorectalcancerdetectionratevariedgreatlyamongprovinces,from1.0per1,000peoplescreenedinManitobato7.7per1,000screenedinNewfoundlandandLabrador(Figure30).Thetypeoffecaltest,brand,testthresholds,screeningprogramstageandtheprevalenceofcolorectalcancerinspecificprovincesmustbetakenintoaccountwheninterpretingresultsforthisindicator(seeFigure1).Indicatorresultsmustalsobecorrelatedwithprogramadenomadetectionrates(Table2)andwiththestagedistributionofscreen-detectedcancers (Figures33 and 34). The target of two or more colorectal cancers detected per 1,000individualsscreenedwasachievedinfourofthesixprovincesprovidingdataforthisindicator.Colorectalcancerdetectionratesarehigherinmalesthaninfemales,andinfirst-everratherthansubsequentscreens(exceptinPrinceEdwardIsland,whereratesarebasedonsmallnumbers,andAlbertawhichtransitionedfromFTgtoFTiduringthereport period) (Figures30 and 31).

Table2presentsthepositivity,follow-upcompliance,positivepredictivevalueandadenomaandinvasivecolorectalcancerdetectionratesfortheprovincesforwhichdatawereavailablefor2013–14.ThePPVisinfluencedbythepositivityrate,thecancerdetectionrate,follow-upuptakeanddiseaseprevalence.Whenahighpositivityrateisduetoahighnumberoffalse-positivefecaltestresults,thePPVforadenomawillbelower.Whenalowpositivityrateistheresultofahighnumberoffalse-negativefecaltestresults,theadenomadetectionratewillbelower.ThePPVforadenoma is lower and less variable across provinces when calculated among all abnormal fecal test results (from 28.9%to49.7%,Figure23) than when calculated among individuals with abnormal fecal test results who also underwentfollow-upcolonoscopywithin180days(from34.9%to67.5%,Figure25).Theformerincludesinthedenominatorscreeningparticipantswhohadanabnormalfecal test result but did not proceed to colonoscopy within 180days,whichis,inpart,afunctionofprovincialcolonoscopyresourceavailability. Theinterrelationshipbetweentheseindicatorsisalsoaffectedbyfactorssuchasthecolorectalcancerprevalence,thequalityofthecolonoscopy,andthebrandandcut-offratesofthefecaltest.Further,whenlookingatthecancerdetectionrates,anydifferenceacrossCanadamaynotbestatisticallysignificantbecauseoftherelativelysmallnumberofcasesinsomeprovinces.Asaresult,whileconsidering these indicators jointly may provide more contextualinformationontheeffectivenessofscreening,robustcomparisonacrossprovincesmaynotbepossible.


Quality Indicators

FemaleMaleBothsexes

TABLE 2

Relationship between key indicators for colorectal cancer screening, 2013 and 2014 screening years combined

Province Test typePositivity

rate (%)

Follow-up colonoscopy uptake rate

(%)

PPV for adenoma(s)Program adenoma

detection rateProgram invasive

colorectal cancer rateColonoscopy

(%) Fecal test (%) per 1,000 screened per 1,000 screened

MB FTg 3.4 82.8 34.9 28.9 9.8 1.0

ON FTg 4.0 77.1 — — — 1.4

SK FTi 8.3 65.1 51.0 33.2 27.6 2.3

NS FTi 8.6 66.6 64.1 42.7 36.8 1.4

AB FTi 9.7 62.9 — — — 2.0

PE FTi 15.0 70.7 41.4 29.3 44.0 5.1

NL FTi 16.1 73.7 67.5 49.7 80.0 7.7

PPV=positivepredictivevalue;FTg=guaiacfecaltest;FTi=immunochemicalfecaltest.Dataforthenumberofindividualswithadenomawerederivedfromthetotalnumberofindividualswithneoplasia(adenomas,advancedadenomas,invasivecolorectalcancer,neoplasia,advancedneoplasia)minusthetotalnumberofindividualswithinvasivecolorectalcancer. '—':Datanotavailable. ON:Dataforpositivityrateandfollow-upcolonoscopyratearefor2014only.Dataforprograminvasivecolorectalcancerratearefor2013only. Datasource:Provincialcanceragenciesandprograms.

FIGURE 30

Program invasive colorectal cancer detection rate, by province and sex, 2013 and 2014 screening years combined

0

3

6

9

12

15

FTiProvince

MB AB NS

1.01.4 0.8

7.7

11.6

5.35.1

— —1.4 1.6 1.32.3

3.1

1.52.0 2.5 1.51.4 1.9 0.9

FTgON SK NLPE

Target ≥2


FTg=guaiacfecaltest;FTi=immunochemicalfecaltest. —:Datanotavailable. Theprograminvasivecolorectalcancerdetectionratedoesnotincludecanceroftheappendix.MB:Numeratorincludeseightpeoplewithcolorectalcancerconfirmedbypathologyfromotherprocedureswithin180daysofabnormalfecaltestresult.NS:CancerregistrationiscompletetoDecember31,2013(anyavailablecasesfrom2014areincluded).However,180daysafterasuccessfulFTionDecember31,2014,meansadiagnosisdateofaslateasJune30,2015.Thus,thisindicatordoesnotallowforadequatefollow-uptime.Projectedcaseswouldreach2.0per1,000successfulFTitests.10%ofparticipantswithanabnormalfecaltestresultforwhomcolonoscopywasrecommendedwerefollowedupoutsidetheprogram;nodataareavailableontheseindividuals.ON:2013only.


Quality Indicators


FIGURE 31

Program invasive colorectal cancer detection rate, by province and screening round, 2013 and 2014 screening years combined

0

3

6

9

12

15

FTg FTiProvince

MB

Target ≥2

AB

1.1 1.0 1.8

NL

4.4

6.7

SK* *

2.3

PE

1.32.5

NS

1.12.1


FTg=guaiacfecaltest;FTi=immunochemicalfecaltest. *Suppressedowingtosmallnumbers.Theprograminvasivecancerdetectionratedoesnotincludecanceroftheappendix. MB:Numeratorincludeseightpeoplewithcolorectalcancerconfirmedbypathologyfromotherprocedureswithin180daysofabnormalfecaltestresult.AB:FTireplacedFTgastheprimaryscreeningtestinNovember2013.NS:CancerregistrationiscompletetoDecember31,2013(anyavailablecasesfrom2014areincluded).However,180daysafterasuccessfulFTionDecember31,2014,meansadiagnosisdateofaslateasJune30,2015.Thus,thisindicatordoesnotallowforadequatefollow-uptime.Projectedcaseswouldreach2.0per1,000successfulFTitests.10%ofparticipantswithanabnormalfecaltestresultforwhomcolonoscopywasrecommendedwerefollowedupoutsidetheprogram;nodataareavailableontheseindividuals.PE:Thegreaterinvasivecolorectalcancerdetectionrateinsubsequentversusfirstscreensmaybeduetothelownumberofindividualswithasubsequentscreen.


Quality Indicators

Stage IIIStage I Stage IVStage II

InvasivecolorectalcancerstagedistributionInvasivecolorectalcancerstagedistributionisdefinedasthedistributionofscreen-detectedinvasivecolorectalcancersbytumour,nodeandmetastases(TNM)stage. Target: Notapplicable Colorectal cancer screening aims to detect cancer at an earlystage,whichallowsformoresuccessfultreatment,leadingtoareductionincolorectalcancermortality.Figure32showsage-standardizedincidenceratesin2011to2013diagnosisyearscombinedbyprovince.

Figure33showsthatthecombinationofStageIandIIinthedistributionofinvasivecolorectalcancervariesfrom53.7%inPrinceEdwardIslandto76.8%inNovaScotia.Figure34showsthatsubsequentscreensdetectedasmallerproportionofStageIIIandIVinvasivecolorectalcancerthanfirstscreens,whichisexpected. Although it may be too soon to see a measurable impact from colorectal cancer screening in Canada on stage at diagnosis,theincidenceofcolorectalcancerdiagnosedatlaterstages(StagesIIIandIV)inthegeneralpopulationshoulddeclineasscreeningprogramsachievehigheruptake.

FIGURE 32

Incidence rates for colorectal cancer, by stage at diagnosis and by province, 2011–13 diagnosis years combined

0

10

20

30

40

50

ProvinceAB SK MB QC ON NB NS PE NL

18.0 22

.024.026

.0

22.0

20.0

26.0

24.0

16.0

16.018

.020.0

— — — — — — — — — — — —

19.0

17.0

26.0

21.0

22.0

18.022

.023

.0

15.1 17

.020.9

17.5


—:Datanotavailable.Incidencerateswereagestandardizedtothe2011Canadianpopulation.Territorieswereexcludedowingtosmallnumbers.Theincidenceratesdonotincludecanceroftheappendix.Datasource:Provincialcanceragenciesandprograms.


Quality Indicators

Stages I and II Stages III and IV

FIGURE 33

Distribution of invasive colorectal cancer cases from follow-up colonoscopies after abnormal fecal test results, by stage and province, 2013 and 2014 screening years combined

0

20

40

60

80

100

ProvincePE

46.3

53.7

NS

23.2

76.8

MB

43.8

56.3

SK

35.2

64.8

AB

44.1

55.9

Proportion (%)

Province Total cases Stage I/II Proportion (%) Stage III/IV Proportion (%)

PE 41 22 53.7 19 46.3

AB 701 392 55.9 309 44.1

MB 48 27 56.3 21 43.8

SK 267 173 64.8 94 35.2

NS 95 73 76.8 22 23.2

StagesI/IIandIII/IVcombinedowingtosmallnumbers. Invasivecolorectalcancerstagedistributioniscalculatedamongthosewhocompletedafollow-upcolonoscopywithin180daysofanabnormalfecaltest.AB:ColorectalcancercaseswerestagedusingAJCC6thandAJCC7th.NS:10%ofparticipantswithanabnormalfecaltestresultforwhomcolonoscopywasrecommendedwerefollowedupoutsidetheprogram;nodataareavailableontheseindividuals. Datasource:Provincialcanceragenciesandprograms.


Quality Indicators

Stages I and II Stages III and IV

FIGURE 34

Distribution of colorectal cancer cases from follow-up colonoscopies after abnormal fecal test results, by stage and screening sequence, 2013 and 2014 screening years combined

0

20

40

60

80

100

First ever FT Subsequent FT First ever FT Subsequent FT

NSABProvince

48.3 39.7 29.5 17.6

51.760.3

First ever FT Subsequent FT

SK

35.4 33.3

64.6 66.7

First ever FT Subsequent FT

MB

48.1 38.1

51.9

61.970.5

82.4

Proportion (%)

ProvinceScreening

round Total cases

Stage I/II Stage III/IV

Cases Proportion (%) Cases Proportion (%)

ABFirsteverFT 356 184 51.7 172 48.3

SubsequentFT 345 208 60.3 137 39.7

MBFirsteverFT 27 14 51.9 13 48.1

SubsequentFT 21 13 61.9 8 38.1

SKFirsteverFT 240 155 64.6 85 35.4


NSFirsteverFT 44 31 70.5 13 29.5


FT=fecaltest. StagesI/IIandIII/IVcombinedowingtosmallnumbers. Invasivecolorectalcancerstagedistributioniscalculatedamongthosewhocompletedafollow-upcolonoscopywithin180daysofanabnormalfecaltest. AB:ColorectalcancercaseswerestagedusingAJCC6thandAJCC7th.NS:10%ofparticipantswithanabnormalfecaltestresultforwhomcolonoscopywasrecommendedwerefollowedupoutsidetheprogram;nodataareavailableontheseindividuals.Datasource:Provincialcanceragenciesandprograms.


QualityIndicators

Interval colorectal cancerIntervalcolorectalcancerrateisdefinedasthenumberofindividualsper1,000screenedwithascreeningepisodenegativeforcolorectalcancer(i.e.,negativefecaltestorpositivefecaltestfollowedbynegativecolonoscopy)whoweresubsequentlydiagnosedwithcolorectalcancerbeforetheirnextscheduledscreeningtest. Target: Notyetdetermined Monitoring of interval cancers is a crucial part of evaluatingcolorectalcancerscreeningprogramsbecauseit provides a mechanism to evaluate the likely impact of

screening programs on colorectal cancer mortality in the targetpopulation.29Fiveplausiblereasonshavebeensuggestedtoexplainsomeoftheintervalcancers:afecaltestwithafalse-negativeresult,missedpolypsorcolorectalcancerduringendoscopy,incompletelyresectedpolyps,rapidprogressionofnewpolypsandfailure of biopsy to diagnose a colorectal cancer that was present.30Thenumberofprovincesreportingonintervalcolorectal cancers increased in this report compared with the2011–12colorectalcancerscreeningreport.Intervalcancerratesrangedfrom0.3to1.9per1,000peoplescreenedforindividualsscreenedin2011–12(Figure35).

FIGURE 35

Interval colorectal cancer rate, by province, 2011 and 2012 screening years combined

0

1

2

3

4

5

ProvinceMB

1.4

ON

1.3

AB

1.9

SK

0.3

NS

0.6

PE*


*Suppressedowingtosmallnumbers.ON:2012dataonly.AB:Useoftheimmunochemicalfecaltest(FTi)wasimplementedprovince-wideNovember2013,replacingguaiacfecaltests(FTg)asprimaryscreeningtestforcolorectalcancer.Intervalcancerrateper1,000individualsscreenedisFTg-based.Intervalcancercasesexcludescreen-detectedcancerduring2013–14.Example:anindividualhadanFTgMay17,2012,withanegativeresult,anFTiFebruary6,2014,withapositiveresultandcolonoscopyApril17,2014,withacancerdiagnosis.Accordingtotheprogram’sinvasivecolorectalcancerdetectionrateindicator,thisisdefinedasscreen-detectedcancer.However,basedonthedefinitionoftheintervalcancerindicator,thiscaseisalsodefinedasintervalcancer.Notallsimilarcancercaseswerecountedasintervalcancer. Datasource:Provincialcanceragenciesandprograms.


FutureDirections

Thisreportrevealsthatsignificantvariationsremainacrossprovincesintermsofscreeningprogramimplementation,uptakeandachievementoftargetsforqualityindicators.MoreprovinceswereabletoprovidedatatodescribeprogrammaticcolorectalcancerscreeninginCanadainthisreportthanforthepreviouscolorectalcancerscreeningmonitoringandevaluationreportfor2011–12.

Thisreportdifferedfromthepreviousreportinthatitcomparedindicatorresultsforfirst-timescreeningparticipantsandforindividualswhowereundergoingasubsequentscreen.Thetwogroupsdifferinthenumberofunderlyingcancersandadenomasthatexistatthetimeofthescreen.First-timescreeningparticipantstendtohave more underlying disease that has been developing over yearsandnotbeenpreviouslydetected.Thusitwouldbeexpectedthattherewouldbehigherpositivityratesandhighercancerandadenomadetectionratesinthisgroupthanamongthescreeningparticipantsundergoingasubsequentscreen.31–33

Thedatadoshow,however,thattheeffectissmallonthisfirstroundofanalysisofthetwogroups.Itmaybethatasadditionaldataaccumulateforindividualsgoingthroughrepeatedroutinescreening,thedifferenceswillbelargerbetweenfirstandsubsequentscreeningparticipants.Infuture,itmaybepossibletosettargetsforsomeoftheindicatorsthatarespecificforeachofthesetwogroups.

Thereportalsoassessedtheinterrelationshipsbetweensomeofthequalityindicators,thoughmakingmoreformalcomparisons across provinces and territories remains a challengebecauseofdifferencesintestsused,thenumberofsamplesrequiredandthresholdsforpositivity,amongotherconsiderations.

It has been demonstrated that screening delivered through organizedprogramshasagreaterpotentialtoreducecancerincidenceandmortality,ismorecosteffectiveandismorelikelytoreducepotentialharmsfromscreeningthanisnon-programmaticscreening.10However,increasedstandardizationofdataelements,datacollectionanddatasubmissionisrequiredinordertobetterassesstheimpactofcolorectalcancerscreeningatthenationallevel.Researchisalsoneededonthereasonsindividualscontinuetobescreenedoutsideorganizedprogramsordonotparticipateinscreening.

Infuture,ascolorectalcancerscreeningprogramsmature,ongoingnationalmonitoringandevaluationwillprovidetheopportunitytoidentifybestpracticesinordertocontinuallyimprovecolorectalcancerscreeningservicesforCanadians.


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Appendix

AppendixAColorectal Cancer Screening Quality Indicator DefinitionsIndicator definition & target Calculation

Participation

Participation Rate

Definition:ThepercentageofthetargetpopulationthatsuccessfullycompletedatleastoneFTintheprogramwithinthemeasurementtimeframeof30months

Target: ≥60%ofthetargetpopulationwithinthe specifiedperiod

Numerator:NumberofindividualswhosuccessfullycompletedatleastoneFTintheprogramwithina 30-monthperiod

Denominator:Numberofindividualstowhomtheprogramwasavailableinadefined24-monthperiod(Jan1,2013,toDec31,2014)

Fecal Test Utilization

Definition:ThepercentageofthetargetpopulationthatcompletedatleastoneFT,eitherprogrammaticornon-programmatic,withinthemeasurementtimeframe


Numerator: NumberofindividualswithinthetargetpopulationwithatleastoneFTwithinthemeasurementtimeframe(programmaticornon-programmatic)

Denominator:Numberofindividualsinthetargetpopulationwithinthemeasurementtimeframe(2013,2014)

Retention Rate

Definition: Thepercentageofthetargetpopulationaged50to72yearsofagerescreenedwithin30monthsafteranormalFTinthemeasurementtimeframe


Numerator:NumberofindividualswithsuccessfulFTsinthemeasurementtimeframewhohadatleastonesubsequentsuccessfulFTintheprogramwithin30months

Denominator:Numberofindividualsaged50–72withnormalFTresultswithinthemeasurementtimeframe (Jan1,2011–Dec31,2012)

Entry-Level Screening Test

Fecal Test Inadequacy Rate

Definition:ThepercentageofindividualswhoseFTwasinadequateandwhohavenotrepeatedthetesttogetasuccessfulFTresultwithinthemeasurementtimeframe

Target: ≤5%ofallFTs

Numerator:NumberofindividualshavinganinadequateFTwhohavenotrepeatedthetesttoobtainasuccessfulFTlaboratoryresultwithinthemeasurementtimeframe

Denominator: NumberofindividualshavingaFTwithinthemeasurementtimeframe(Jan1,2013–Dec31,2014)

Positivity Rate

Definition: The percentage of individuals with an abnormalFTresultinthemeasurementtimeframe

Target:Notyetdetermined

Numerator:NumberofindividualswithanabnormalFTresult

Denominator:NumberofindividualshavinghadatleastonesuccessfulFTprocessedbyalaboratorywithinthemeasurementtimeframe(Jan1,2013–Dec31,2014)

FT=fecaltest;PPV=positivepredictivevalue;FTg=guaiacfecaltest;FTi=immunochemicalfecaltest; CRC=colorectalcancer;TNM=tumour,node,metastases.


Appendix

Indicator definition & target Calculation

Follow-up Colonoscopy

Follow-up Colonoscopy Uptake Rate

Definition: The percentage of individuals who had a follow-upcolonoscopyperformedwithin180daysofanabnormalFTresultinthemeasurementtimeframe

Target: ≥85%

Numerator:Numberofindividualswhohada follow-upcolonoscopyperformedwithin180daysofanabnormalFTresult

Denominator:Numberofindividualswithanabnormal FTlabresultwithinthemeasurementtimeframe (Jan1,2013–Dec31,2014)

Wait Time to Follow-up Colonoscopy

Definition:ThetimefromanabnormalFTresultto follow-upcolonoscopy

Target: ≥90%within60daysofanabnormalFTresult

Medianand90thpercentilenumberofcalendardaysfromanabnormalFTresultinthemeasuretimeframe(Jan1,2013–Dec31,2014)toafollow-upcolonoscopywithinwithin180days

Diagnosis and Initiation of Treatment

Positive Predictive Value (PPV) for Adenoma

Definition: a)PercentageofindividualswithanabnormalFTinwhomoneormoreadenomaswereconfirmedbypathology

b) PercentageofindividualswithanabnormalFTwhoalsocompletedafollow-upcolonoscopy(within180daysoftheFT)inwhomoneormoreadenomaswereconfirmedbypathology

Target: ≥50%forFTi ≥35%forFTg

Numerator:Numberofindividualswithoneormoreadenoma(excludinginvasiveCRC)onpathologyfromcolonoscopywithin180daysofanabnormalFTresultobtainedwithinthemeasurementtimeframe

Denominator: a) NumberofindividualswithanabnormalFTwithin themeasurementtimeframe(Jan1,2013–Dec31,2014)

b)NumberofindividualswithanabnormalFTwithinthemeasurementtimeframe(Jan1,2013–Dec31,2014)whohadafollow-upcolonoscopywithin180days

Wait Time from Follow-up Colonoscopy to Definitive Pathological Diagnosis

Definition: Timefromafollow-upcolonoscopytodefinitivepathological diagnosis


Medianand90thpercentilenumberofcalendardaysbetweencolonoscopy(within180daysoftheabnormalFT)anddefinitivepathologicaldiagnosis

Colorectal Cancer Screening Program Outcomes

Program Adenoma Detection Rate

Definition:Thenumberofindividualsper1,000screenedwithoneormoreadenomasconfirmedbypathologyfromafollow-upcolonoscopyperformedwithin180daysofanabnormalFTresultinthemeasurementtimeframe


Numerator:Numberofindividualswithoneormoreadenomasconfirmedbypathologyfromafollow-upcolonoscopyperformedwithin180daysofanabnormalFTresultobtainedwithinthemeasurementtimeframe




Appendix

Indicator definition & target Calculation

Colorectal Cancer Screening Program Outcomes

Program Invasive Colorectal Cancer Detection Rate

Definition:Thenumberofindividualsper1,000screenedwithinvasiveCRCconfirmedbypathologyfromafollow-upcolonoscopyperformedwithin180daysofanabnormalFTresultinthemeasurementtimeframe

Target: ≥2CRCsper1,000peoplescreened

Numerator:NumberofindividualswithinvasiveCRConpathologyfromafollow-upcolonoscopyperformedwithin180daysofthedateofanabnormalFTresultobtainedwithinthemeasurementtimeframe

InvasiveCRCinICD-10includes C18.0,C18.2-C18.9,C19,C20,C26.0withbehaviour3,butthefollowinghistologytypesexcluded:colonlymphoma,sarcoma and carcinoid

GroupstageswereclassifiedusingAmericanJointCommitteeonCancer(AJCC)7thedition


Invasive Colorectal Cancer Stage Distribution

Definition:Thedistributionofscreen-detectedinvasiveCRCbyTNMstage


Numerator:NumberofindividualswithinvasiveCRCStageI,II,IIIorIV;unknownstage;andunstageddiagnosedbythescreeningprogramfromafollow-upcolonoscopywithin180daysafteranabnormalFTresultwithinthemeasurementtimeframe

InvasiveCRCinICD-10includesC18.0,C18.2-C18.9,C19,C20,C26.0withbehaviour3,butthefollowinghistologytypesexcluded:colonlymphoma,sarcomaandcarcinoid

GroupstageswereclassifiedusingAmericanJointCommitteeonCancer(AJCC)7thedition

Denominator:NumberofindividualswithinvasiveCRC(includingofunknownstage)confirmedbypathologyatfollow-upcolonoscopywithin180daysafteranabnormalFTresultwithinthemeasurementtimeframe(Jan1,2013–Dec31,2014)

Interval Colorectal Cancer

Definition:Thenumberofindividualsper1,000screenedwhoweresubsequentlydiagnosedwithCRCwithin24monthsofanegativeresultforCRCinthemeasurementtimeframe


Numerator:NumberofindividualssubsequentlydiagnosedwithCRCwithin24monthsofanFTresultthatwasnegativeforCRCinthemeasurementtimeframe

InvasiveCRCinICD-10includesC18.0,C18.2-C18.9,C19,C20,C26.0withbehaviour3,butthefollowinghistologytypesexcluded:colonlymphoma,sarcomaandcarcinoid

Denominator:NumberofindividualswithFTscreeningresultnegativeforCRCinthemeasurementtimeframe (Jan1,2011–Dec31,2012)


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