||As of this Report
|Percentage of Ontario screen-eligible people, ages 50 to 74, with an abnormal FOBT result who underwent colonoscopy within 6 months of the abnormal screen date
|Percentage of Ontario screen-eligible people, ages 50 to 74, with an abnormal FOBT result who underwent colonoscopy within 8 weeks of the abnormal screen date
| See Methodology and Approach to find out how the ratings are calculated.
Cancer Care Ontario monitors 2 indicators related to the follow-up of abnormal results for colorectal cancer screening: the proportion of people who receive a follow-up colonoscopy within 6 months of an abnormal fecal occult blood test (FOBT) and the proportion of people who receive a follow-up colonoscopy within 8 weeks of an abnormal FOBT (an indicator of the timeliness of follow-up).
In 2014, approximately 20,000 Ontarians ages 50 to 74 had an abnormal FOBT result that required follow-up with colonoscopy and approximately 15,400 had a colonoscopy within 6 months of the abnormal FOBT result. Seventy-seven percent (77%) received a follow-up colonoscopy within 6 months, compared to 75% in 2011, although there were notable variations by region. Also in 2014, over 9,000 Ontarians (46%) who had an abnormal FOBT result had a follow-up colonoscopy within 8 weeks, compared to 38% in 2011.
What is colorectal cancer screening (FOBT)?
- A screening test identifies people in a healthy, asymptomatic population who may be at risk for disease. It is not a diagnostic test. The purpose of screening is to prevent cancer by identifying pre-cancerous changes or to find cancer at an early stage, when it is easier to treat. Ontario operates organized, population-based screening programs for 3 types of cancer: breast, cervical and colorectal.
- There are different types of colorectal cancer screening tests, ranging from at-home tests (such as the FOBT) to visual inspection of the colon (such as colonoscopy or flexible sigmoidoscopy).
- Based on a 2001 guideline from the Canadian Task Force on Preventive Health Care1, ColonCancerCheck (Ontario’s population-based colorectal cancer screening program) recommends that people ages 50 to 74 without a family history of colorectal cancer (i.e. those at average risk) be screened every 2 years with an FOBT2.
- For people at increased risk of colorectal cancer due to a family history (i.e. they have a parent, sibling or child who was diagnosed with the disease), ColonCancerCheck recommends screening with colonoscopy beginning at age 50, or 10 years earlier than the age at which their relative was diagnosed, whichever occurs first2.
- An FOBT can detect the presence of trace amounts of blood in someone’s stool that may indicate early cancer in the colon or rectum, even when there are no symptoms3.
- An abnormal FOBT does not necessarily mean that someone has cancer, but it does let his or her healthcare provider know that follow-up with a colonoscopy is needed. During colonoscopy, cancer may be detected; polyps (pre-cancerous lesions) also may be identified and removed.
- Colorectal cancer screening has been shown to reduce death from colorectal cancer4.
What do the results show?
Colonoscopy follow-up within 6 months has levelled off (Figure 1).
- In 2014, 77% of Ontarians who had an abnormal FOBT result had a colonoscopy within 6 months, similar to 2013 (78%).
- In 2014, approximately 15,400 Ontarians underwent a follow-up colonoscopy within 6 months of an abnormal FOBT result.
- In 2014, the Local Health Integration Networks (LHINs) with the best 6 month follow-up were Waterloo Wellington and North West (82%).
- The LHIN with the lowest follow-up in the same year was Toronto Central (69%).
Follow-up of abnormal FOBT results within 6 months varies by socio-demographic factor‡.
- There was variation by age groups in follow-up within 6 months of an abnormal FOBT result in 2014. Follow-up was highest in people ages 50 to 54 (78%) and lower for people ages 65 to 69 (76%) and ages 70 to 74 (75%). A similar pattern can be seen in previous years.
- In 2014, 73% of people living in the lowest income neighbourhoods had a follow-up colonoscopy within 6 months of an abnormal FOBT, compared to 79% of people in the highest income neighbourhoods who had a follow-up colonoscopy within 6 months of an abnormal FOBT (a difference of 6 percentage points).
‡ Percentages by socio-demographic factor are available in the data tables (select the desired file type and click “Download”) and presented in the figures by age group.
The percentage of Ontarians receiving follow-up colonoscopies within 8 weeks of an abnormal FOBT has levelled off, although there is notable variation by region (Figure 3).
- Cancer Care Ontario recommends that Ontarians who have an abnormal FOBT receive a colonoscopy within 8 weeks of their abnormal FOBT result. This measure is an indicator of the timeliness of follow-up.
- In 2014, over 9,000 Ontarians underwent a follow-up colonoscopy within 8 weeks of an abnormal FOBT result (46%).
- In 2014, the LHIN with the best colonoscopy wait-time performance (colonoscopy within 8 weeks of an abnormal FOBT result) was Waterloo Wellington (52%). The Toronto Central LHIN had the lowest percentage of colonoscopies performed within 8 weeks of an abnormal FOBT result (36%).
Follow-up within the recommended 8 weeks varies by sociodemographic factor‡
- The percentage of people receiving a colonoscopy within 8 weeks of an abnormal FOBT varied by age group (Figure 4). In 2014, follow up was highest in people ages 50 to 54 and 65 to 69 (47%) and lowest in people ages 70 to 74 (43%). A similar pattern can be seen in previous years.
- While the pattern of 6 month follow-up was similar across geographic regions in 2014, a smaller percentage of people in rural-very remote areas had colonoscopies within 8 weeks compared to those in urban areas (37% vs. 46%).
- In 2014, 42% of people living in the lowest income urban areas received a colonoscopy within 8 weeks of an abnormal FOBT, compared to 48% of people in the highest income urban areas, a difference of 6 percentage points.
- People who live in rural-very remote areas wait longer for colonoscopies than those who live in urban areas (i.e. fewer people in rural-very remote areas receive colonoscopies within the recommended 8 weeks).
- People who live in the lowest income urban areas are less likely to ever have follow-up colonoscopies than those living in the highest income urban areas (i.e. a smaller proportion of people in the lowest income urban areas receive colonoscopies within 6 months of an abnormal FOBT).
‡ Follow-up percentages by socio-demographic factor are available in the data table (select the desired file type and click “Download”) and presented in the figure by age group.
Why is this important to Ontarians?
- While FOBT identifies people at risk of having colorectal cancer, colonoscopy is required to make a definitive diagnosis. This means that in order to realize the benefits of screening with FOBT, people with an abnormal FOBT result should have a follow-up colonoscopy. A meta-analysis showed that regular screening (annual or biennial) using an FOBT for people age 50 and over, followed by a colonoscopy for those with an abnormal FOBT, can reduce deaths from colorectal cancer by 13%4.
- Cancer Care Ontario has explored reasons people may not have a colonoscopy after an abnormal FOBT. While a variety of screening-related factors (including personal preference and contraindications) may contribute, patient care-related factors also play a role. Follow-up after an abnormal FOBT occurs less often when:
- a repeat FOBT is performed rather than a colonoscopy; or
- someone recently had a colonoscopy before the FOBT5.
- The Canadian Association of Gastroenterology (CAG) published a Canadian consensus on medically acceptable wait times in 2006, which included a recommendation that a follow-up colonoscopy should be completed within 2 months of an abnormal FOBT6. ColonCancerCheck has adopted an 8-week benchmark based on the CAG consensus.
- Measuring follow-up helps the ColonCancerCheck program monitor access to colorectal screening and ensures that program participants have timely follow-up.
How does Ontario compare with other jurisdictions?
- Ensuring there is comparable data and measures from multiple jurisdictions is a challenge. It is recommended to use caution when comparing indicators from different jurisdictions due to the different data definitions, methodologies and years that are used in indicators measured outside of and across Canada. Cross-jurisdictional comparison is still useful, however, for providing a rough indication of how Ontario is doing compared with other jurisdictions.
- European colorectal screening quality assurance guidelines recommend that programs actively follow up with people who have had screening abnormalities to ensure timely and appropriate assessment. This is done by using reminders and computerized systems to track and monitor the management of these people7. The standard set by the United Kingdom’s National Health Service is that 85% of people with an abnormal FOBT should have a colonoscopy8, and it was able to achieve 81% to 83% follow-up in recent national pilots9,10.
- Cancer Care Ontario is further evaluating patient and physician reasons for failure to follow-up persons with abnormal FOBT results with a colonoscopy in order to identify strategies to improve follow-up.
- Cancer Care Ontario is investigating potential reasons for the apparent plateau/decline in colonoscopy follow-up.
- Cancer Care Ontario has developed an online Primary Care Screening Activity Report (PC SAR) for all 3 screening programs (cervical, breast and colorectal cancer). This tool (accessed online) allows physicians in a Patient Enrolment Model (PEM) practice to see the complete screening status of each patient, including those who are due for screening and follow-up. Next steps including working with the regional primary care leads to identify barriers to adoption of the tool and to promote and encourage use of the PC SAR.
- Cancer Care Ontario is evaluating different outreach methods to support timely follow-up of abnormal results by PEM physicians, as discussed within the Screening Activity Report.
- In fiscal year 2015/2016, Cancer Care Ontario implemented reminder letters for people who had not had a colonoscopy following an abnormal FOBT result.
- McLeod RS, Canadian Task Force on Preventive Health Care. Screening strategies for colorectal cancer: a systematic review of the evidence. Can J Gastroenterol. 2001 Oct; 15(10):647–60.
- Cancer Care Ontario [Internet]. Toronto: Cancer Care Ontario. About ColonCancerCheck; 2015 Jul 16 [cited 2015 Dec 18]. Available from: https://cancercare.on.ca/pcs/screening/coloscreening/cccworks/.
- Greegor DH. Diagnosis of large-bowel cancer in the asymptomatic patient. JAMA. 1967; 201:943–5.
- Tinmouth J, Vella E, Baxter NN, Dubé C, Gould M, Hey A, et al. Colorectal cancer screening in average risk populations: evidence summary. Toronto: Cancer Care Ontario; 2015.
- Correia A, Rabeneck L, Baxter NN, Paszat LF, Stradhar R, Yun L, Tinmouth J. Lack of follow-up colonoscopy after positive FOBT in an organized colorectal cancer screening program is associated with modifiable health care practices. Prev Med. 2015 Jul; 76:115¬–22.
- 6. Paterson WG, Depew WT, Paré P, Petrunia D, Switzer C, Veldhuyzen van Zanten SJ, et al. Canadian consensus on medically acceptable wait times for digestive health care. Can J Gastroenterol. 2006 Jun; 20(6):411–23.
- Malila N, Senore C, Armoroli P. Organisation. In: Segnan N, Patnick J, von Karsa L, editors. European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition. Luxembourg: Publications Office of the European Union; 2010. p. 33–69.
- Chilton A, Rutter M. Quality assurance guidelines for colonoscopy. NHS BCSP Publication No. 6. Sheffield: National Health Service Bowel Cancer Screening Programme (BCSP); 2011.
- Alexander F and Weller D. Evaluation of the UK colorectal cancer screening pilot: final report. Edinburgh: The UK CRC Screening Pilot Evaluation Team; 2003.
- Weller D, Coleman D, Robertson R, Butler P, Melia J, Campbell C, et al. The UK colorectal cancer screening pilot: results of the second round of screening in England. Br J Cancer. 2007 Dec 17; 97(12):1601–5.