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Introducing an educational module on cancer screening of LGBTQ patients

Author: Alicia St.Hill Champlain Regional Cancer Program

Lesbian, Gay, Bisexual, Trans, Queer (LGBTQ) patients have lower screening rates.

You can do a great deal to improve screening rates by:

  • creating a welcoming and inclusive environment
  • learning about cancer screening information and considerations for your LGBTQ clients
  • learning NEW information about transgender screening

This module, created by the Canadian Cancer Society in collaboration with the Toronto Central Regional Cancer Program, is designed for you to explore LGBTQ screening issues and barriers, and to provide culturally and clinically competent cancer screening services to your patients.

This module is eligible for 0.5 (half hour) Mainpro-M2 credit.

To access the module, please click on the below.

http://www.rainbowhealthontario.ca/wp-content/uploads/2015/01/CME-LGBTQCancerScreening-English-final.pdf

PLEASE NOTE:

The presentation references Canadian Cancer Society screening guidelines. Ontario guidelines differ for the following slides:

  • Slide 27, the cervical screening age-eligible population is 21-69, not 70.

Slide 28, the Ontario Breast Screening Program age-eligible population is age 50-74.  At age 75, not 70, a conversation a doctor about future screening is recommended.

Image Source: Canadian Cancer Society www.cancer.ca

Image Source: Canadian Cancer Society http://www.cancer.ca

Colonoscopy Quality: What Is It And Why It Matters

Colonoscopy is an essential component of colorectal cancer (CRC) screening. Colonoscopy is generally a very safe procedure but growing demands for screening-related colonoscopy challenges us to provide high-quality colonoscopy at minimal risk to patients.

CRC screening has clear benefits in terms of reducing the mortality and incidence of CRC. However, every patient undergoing a screening colonoscopy is at risk of potential complications. These could be direct procedural-related complications such as perforation or bleeding. Or they could be bowel preparation- related complications, or any number of secondary complications such as cardiac ischemia, or the consequences of missed lesions. In contrast symptomatic patients undergoing the same investigation have a more balanced benefit-to-risk ratio.

Quality of Colonoscopy

Broadly speaking there are two key components of colonoscopy: 1) examining the colon to the cecum completely, safely, and comfortably; and 2) the detection of adenomas and more advanced lesions and their subsequent complete removal.

There are several validated indicators of colonoscopy quality. Cecal intubation rate (CIR) is the percentage of cases the colonoscope is advanced beyond the ileocecal valve into the cecal pole and/or the terminal ileum. The target CIR is 95%. Having a high CIR ensures adequate visualization and reduces the need for repeat procedures and additional investigations. High CIR with maintained high patient comfort rates, and low perforations rates, are auditable measures of the skill of endoscopy technique.

High levels of polyp, and more importantly adenoma detection rates (ADR), are defined as the proportion of patients that have at least one adenoma identified and removed during colonoscopy. For screening colonoscopies, the ADR should be at least 20%. High ADR’s correlate with low levels of missed and interval cancers.

Ontario has adopted a minimal number of colonoscopies per year (200) as a surrogate of the other measured outcomes.

Complications of colonoscopy

Complications of colonoscopy include bleeding, perforation, sedation-related complications, and bowel prep-induced complications (dehydration, metabolic disturbances, seizures and falls). The generally accepted rate of perforation is less than 1 in 2000 screening colonoscopies (<0.05%). Some consider this rate to be high, and aim for 1 perforation per 5000 colonoscopies. Bleeding is more common, occurring in 1 in 500 colonoscopies with polypectomy. Sedation-related complications are more commonly seen when reversal agents are given. US studies indicate that the use of propofol for colonoscopy is associated with a risk of aspiration pneumonia of as high as 1 in 500.

Quality of the patient experience

It is important to consider the patient journey through endoscopy services, including the pre-procedural interventions, the level of empathy and respect shown by all staff, and the post-procedural aspects. The care of patients following an endoscopy is critical for a good patient experience and for safety and quality reasons. This includes the immediate post- procedure recovery and discharge, with post-procedure patient education. A clear plan should exist for the follow-up of pathology, and that evidence-based guidelines are followed for recall colonoscopies that are based on the polyp size and pathology. This information also needs to be clearly communicated to the primary care physician.

Summary

Quality is a critical component of the CRC screening pathway. While there is often a concentration on scoping procedural quality, the pre and post- procedural components also need to be of high quality. Lastly, effective communication of post-procedural care and follow-up to primary care physicians is critical for the appropriate re-entry of patients into the screening or surveillance cycles.

Article written by: Dr. Alaa Rostom, Regional Colorectal Screening GI and Endoscopy Lead

Colorectal Cancer Screening in Ontario Explained

Colorectal cancer (CRC) is the second most common cancer in men and the third most common cancer in women.

Ontario has a colorectal cancer screening program called ColonCancerCheck (CCC). The program recommends that those between the ages of 50 and 74 with no personal or family history of CRC be screened using the fecal occult blood test (FOBT) every two years. For individuals at increased risk due to one or more first degree relative(s) with CRC, it recommends colonoscopy starting at the age of 50, or 10 years earlier than the age at which their relative was diagnosed, whichever comes first.

The overall participation to CRC screening in Ontario remains low. In 2012, 57.8% of at-risk Ontarians were up-to-date with CRC screening (FOBT, colonoscopy and flexible sigmoidoscopy) – 58.7% in the Champlain LHIN.

Different screening modalities

There is strong evidence (level one) that screening with FOBT every 1-2 years reduces CRC mortality by 16%. In 2011-2012, 29.9% of eligible Ontarians completed at least one FOBT during the two-year period; the Champlain LHIN had the highest rate of FOBT screening (35.5%).

The FOBT is relatively simple, cheap and accessible. However, the FOBT has been criticized for its low sensitivity. This limitation has prompted many CRC screening programs in Canada and in Europe to use the fecal immunochemical test (FIT) as entry-level CRC screening test instead of the FOBT.

The FIT is an immunoassay that detects the presence of human blood in stools. It can detect much lower amounts of blood than the FOBT does, it is not affected by dietary changes, and it is more specific for colonic sources of blood.

In 2010, Cancer Care Ontario (CCO) and Program in Evidence-Based Care (PEBC) formed the FIT Guidelines Expert Panel to review and evaluate the evidence for FIT CRC screening. The panel concluded that FIT has a greater sensitivity for detecting cancer, a much greater sensitivity for detecting advanced adenoma, and that it achieves higher screening participation rates.

CCO is working with the Ministry of Health and Long-Term Care to develop a plan to fund and implement FIT in the CCC program as the recommended screening test for those at average-risk of developing CRC.

There is also strong evidence to support the use of flexible sigmoidoscopy (FS) in persons at average risk for CRC.

FS every 5 years or once in a lifetime has been shown to decrease CRC incidence by about 20% and CRC mortality by 25%. The anticipated harms associated with FS (including follow-up colonoscopy for those with positive tests) are small and are outweighed by the benefits. CCO has piloted the Registered Nurse Flexible Sigmoidoscopy (RNFS) program, with sites in several regions, including the Montfort Hospital and The Ottawa Hospital.

Colonoscopy remains the gold standard intervention for follow- up of individuals with abnormal screening tests. However, there are no randomized controlled trials of the effectiveness and safety of colonoscopy for average risk screening.

CT colonography use for population-based screening has not been studied, although a Canadian economic evaluation revealed its use, for population-based screening, would be more resource intensive than an endoscopy-based or FOBT- based screening program. By comparison with colonoscopy, it is as good at detecting polyps that are greater than 1 cm in size, but less sensitive for smaller polyps.

Serologic blood tests for CRC screening, such as the Cologic test, are being promoted by some laboratories. The scientific evidence is insufficient to recommend or endorse their use, and as such, CCO is not able to offer a recommendation on follow-up of abnormal results.

Summary

In summary, CRC is one of the leading causes of cancer- related morbidity and mortality in Ontario. Screening can effectively reduce the risk of these harms. Although there are multiple tests available for CRC screening, there is strong evidence in support of only a few such tests in the context of an organized, population-based, screening program. CCC currently recommends that average-risk individuals aged 50 to74 be screened with FOBT every 2 years.

Article written by: Dr. Catherine Dubé, Provincial Clinical Lead, ColonCancerCheck

Think about family history. It’s the first genetic test.

While most cases of cancer are sporadic, there are subsets of cancers that can be attributed to a hereditary etiology. Family history is still the gold standard in initial assessment for heritable conditions.

In general, suspicion of a hereditary cancer syndrome should be raised if:

  • There are multiple family members with cancer
  • Cancers occur on the same side of family
  • Cancer diagnoses occur at a younger than expected age
  • Several generations are affected (demonstrating an autosomal dominant pattern – typical of most hereditary cancer syndromes)
  • Clustering of certain types of cancers is present
  • Multiple primary cancers are diagnosed in the same individual

5-10% of cases of colorectal cancer (CRC) are hereditary. Lynch syndrome (LS), also known as Hereditary Non-Polyposis Colorectal Cancer (HNPCC), is the most common hereditary CRC predisposition syndrome. It is an autosomal dominant condition that causes a significant increased lifetime risk of CRC and endometrial cancer in addition to other cancers. Individuals suspected of having LS should be referred for a genetic consultation and consideration of genetic testing.

Screening, surveillance and management of CRC and other cancers should be guided by genetic test results and/or family/personal history. Studies show that conversations between patients and their health care providers are the strongest drivers of screening participation.

Are you asking the right questions and identifying your patients who may be at risk of hereditary cancer? Do you know how and where to refer those patients who may benefit from referral to genetics?

Genetics Education Canada – Knowledge Organization (GEC-KO) is a genetics education program funded by the Children’s Hospital of Eastern Ontario (CHEO) with in-kind support from Mount Sinai Hospital in Toronto. GEC-KO is dedicated to the development, collection, dissemination and evaluation of genetics educational materials for health care providers, especially primary care providers.

The GEC-KO website at www.geneticseducation.ca contains educational resources and point of care tools designed for primary care providers. These are intended to facilitate integration of genomic medicine into practice. Additionally, the website helps you to identify your nearest genetics centre and find the information you need to connect with your local genetics specialist and laboratory.

Article written by: Shawna Morrison, Certified Genetic Counsellor – CHEO, Program Manager for GEC-KO