|Measure ||Desired Direction||As of this Report |
|Age-adjusted percentage of Ontario men and women, ages 50 to 74, who were overdue for colorectal screening in a calendar year|
| See Methodology and Approach to find out how the ratings are calculated. |
In 2014, approximately 1.6 million Ontarians ages 50 to 74 were overdue for colorectal cancer screening (i.e. they needed to be screened). These people had not received a recent fecal occult blood test (FOBT), flexible sigmoidoscopy or colonoscopy for either screening or diagnostic indications. Overall, 40% of the approximately 4 million people eligible for colorectal cancer screening in 2014 were overdue for screening, an improvement from 2011 (when 44% of eligible Ontarians were overdue for colorectal cancer screening), although there was some variation by region in 2014.
What is colorectal cancer screening?
- 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 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 FOBT, followed by colonoscopy for those with an abnormal (positive) FOBT2.
- For people at increased risk of colorectal cancer due to a family history (i.e. they have a parent, sibling or child 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, which may indicate 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) may also be identified and removed.
- Colorectal cancer screening has been shown to reduce death from colorectal cancer4.
What do the results show?
The percentage of people overdue for colorectal cancer screening (FOBT, flexible sigmoidoscopy or colonoscopy) has improved (Figure 1).
- The percentage of people overdue for colorectal cancer screening identifies the percentage of screen-eligible people who need to be screened at the end of the calendar year. This measure takes into account all colorectal tests that can be used for colorectal cancer screening, including FOBT, flexible sigmoidoscopy and colonoscopy; people who have had a recent flexible sigmoidoscopy or colonoscopy for screening or other indications do not need to be screened for colorectal cancer using an FOBT.
- In 2014, approximately 1.6 million people were overdue for a colorectal cancer screening test (i.e. they needed to be screened).
- In the 4 years reported above (2011 to 2014), the percentage of Ontarians overdue for colorectal cancer screening dropped from 44% to 40%, an improvement of 4 percentage points.
- From 2013 to 2014, the percentage of Ontarians overdue for colorectal cancer screening declined by 1 percentage point, from 41% in 2013 to 40% in 2014.
- In 2014, the Local Health Integration Networks (LHINs) with the smallest percentage of people overdue for colorectal cancer screening were Central and North Simcoe Muskoka (36%). The LHIN with the largest percentage of people overdue for screening was North West (44%).
- The percentage of those overdue for colorectal cancer screening dropped (i.e. it improved) in all LHINs from 2011 to 2014. LHINs that showed the greatest improvement during this period were Central West (6 percentage point improvement) and North West (5 percentage point improvement).
Overdue for colorectal cancer screening (FOBT, flexible sigmoidoscopy or colonoscopy) varies by socio-demographic factor‡.
- The percentage of people overdue for colorectal cancer screening generally dropped (i.e. improved) with increasing age in 2014 (Figure 2). In 2014, 50% of men and women aged 50 to 54 were overdue for colorectal cancer screening, compared to 32% of men and women aged 65 to 69. A similar pattern can be seen in previous years.
- More men were overdue for colorectal cancer screening than women. In 2014, 43% of men aged 50 to 74 were overdue for colorectal cancer screening, compared to 37% of women in the same age range.
- The percentage of people overdue for colorectal cancer screening was higher in rural-remote (42%) and rural-very remote areas (44%) than urban and rural areas (40% for both).
- In urban areas, the percentage of people overdue for colorectal cancer screening dropped steadily as neighbourhood income rose. In 2014, 48% of people living in the lowest income urban areas were overdue for colorectal cancer screening, compared to 34% of people living in the highest income urban areas (a difference of 14 percentage points).
- Forty-three percent (43%) of people in neighbourhoods with the highest percentage of self-reported immigrant residents were overdue for screening, compared to 39% of people living in neighbourhoods with fewer self-reported immigrant residents.
‡ Some data not shown. 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.
Why is this important to Ontarians?
Colorectal cancer burden weighs heavily on Ontario.
- In Ontario, colorectal cancer is the second-most common cancer diagnosed in men and the third-most common cancer diagnosed in women. It is also the second- and third-leading cause of cancer mortality (i.e. death) in Ontario for men and women, respectively5.
- An estimated 9,200 Ontarians were diagnosed with colorectal cancer in 2015 and approximately 3,350 died of the disease that year5.
Regular screening plays a role in improved outcomes.
- A recent meta-analysis showed that regular screening (annual or biennial) using an FOBT for people ages 50 and over—followed by a colonoscopy for those with an abnormal FOBT—can reduce deaths from colorectal cancer by 13%4.
- This reduction in mortality related to screening depends on people returning for screening tests regularly as long as they are eligible.
- Screening with FOBT can lead to the detection of colorectal cancer at an earlier stage6.
- Someone with colorectal cancer has a 90% chance of being cured if the cancer is caught early. The likelihood of curing someone with colorectal cancer decreases to 12% if it is detected at a later stage7. Evidence indicates that screening for colorectal cancer using flexible sigmoidoscopy can reduce colorectal cancer incidence (i.e. new cancer cases) and mortality by 22% and 28%, respectively4.
How does Ontario compare with other jurisdictions?
- Ensuring there are 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 well Ontario is doing compared with other jurisdictions.
- Compared to Manitoba, Ontario has a lower percentage of people overdue for colorectal cancer screening (with 50% of eligible adults in Manitoba overdue for colorectal cancer screening in 2011¬–2012)8.
- For more information on comparisons of colorectal cancer screening participation between jurisdictions, see the Comparison of Screening section of CSQI.
Note: measurement intervals for colorectal tests are different across these jurisdictions, which affects the magnitude of colorectal overdue percentages.
- In fiscal year 2015/2016, Cancer Care Ontario implemented reminder letters for people who do not complete screening after receiving the invitation letter.
- In addition, Cancer Care Ontario is introducing physician-linked invitation and recall letters for patients with a primary care provider who participates in a patient enrolment model (PEM) practice. These letters include an endorsement from a patient’s primary care provider, which has been shown to improve screening percentages in a 2-phased pilot in the ColonCancerCheck program9,10.
- In the spring of 2016, Cancer Care Ontario will be releasing new screening recommendations for the ColonCancerCheck program. These recommendations are being developed through a comprehensive process, which has included a systematic review of the literature conducted by the Program in Evidence-Based Care that evaluated the evidence for all colorectal cancer screening modalities in the context of an organized, population-based screening program.
- 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.
- Annual public awareness campaigns will continue to be conducted in each region.
- In addition, Cancer Care Ontario is examining strategies to improve participation. This includes replacing the current guaiac-based FOBT with the fecal immunochemical test (FIT), which is more sensitive, easier to use11 and has been shown to increase screening participation12–15. The launch of the FIT would occur in conjunction with education and awareness campaigns.
- 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/cms/One.aspx?portalId=1377&pageId=9865 .
- 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.
- Canadian Cancer Society’s Advisory Committee on Cancer Statistics. Canadian cancer statistics 2015. Toronto: Canadian Cancer Society; 2015. Available from: http://www.cancer.ca/~/media/cancer.ca/CW/cancer%20information/cancer%20101/Canadian%20cancer%20statistics/Canadian-Cancer-Statistics-2015-EN.pdf?la=en.
- Steele RJ, Kostourou I, McClements P, Watling C, Libby G, Weller D, et al. Effect of repeated invitations on uptake of colorectal cancer screening using faecal occult blood testing: analysis of prevalence and incidence screening. BMJ. 2010; 241:5531–5525.
- National Cancer Institute [Internet]. Bethesda (MD): National Cancer Institute. SEER stat fact sheets: colon and rectum cancer; [cited 2015 Jan 26]. Available from: http://seer.cancer.gov/statfacts/html/colorect.html.
- CancerCare Manitoba. Colorectal cancer screening report, January 2011–December 2012. Winnipeg: CancerCare Manitoba; 2014.
- Tinmouth J, Baxter NN, Paszat L, Sutradhar R, Rabeneck L, Yun L. Physician-linked mailed invitation to be screened improves uptake in an organized colorectal cancer screening program. BMJ Open. 2014 Mar 12; 4(3):e004494. Available from: http://bmjopen.bmj.com/content/4/3/e004494.full?rss=1.
- Marrett L, Gao, J. Physician-linked correspondence (PLC) evaluation. Cancer Care Ontario internal report. Dec 2012.
- Rabeneck L, Rumble RB, Thompson F, Mills M, Oleschuk C, Whibley A, et al. Fecal immunochemical tests compared with guaiac fecal occult blood tests for population-based colorectal cancer screening. Can J Gastroenterol. 2012 Mar; 26(3):131–47.
- Federici A, Giorgi Rossi P, Borgia P, Bartolozzi F, Farchi S, Gausticchi G. The immunochemical faecal occult blood test leads to higher compliance than the guaiac for colorectal cancer screening programmes: a cluster randomized controlled trial. J Med Screen. 2005; 12(2):83–8.
- Hoffman RM, Steel S, Yee EF, Massie L, Schrader RM, Murata GH. Colorectal cancer screening adherence is higher with fecal immunochemical tests than guaiac-based fecal occult blood tests: a randomized, controlled trial. Prev Med. 2010 May–June; 50(5–6):297–9.
- Hol L, Wilschut JA, van Ballegooijen M, van Vuuren AJ, van der Valk H, Reijerink JC, et al. Screening for colorectal cancer: random comparison of guaiac and immunochemical faecal occult blood testing at different cut-off levels. Br J Cancer. 2009 Apr; 100(7):1103–10.
- van Rossum LG, van Rijn AF, Laheij RJ, van Oijen MG, Fockens P, van Krieken HH, et al. Random comparison of guaiac and immunochemical fecal occult blood tests for colorectal cancer in a screening population. Gastroenterology. 2008 Jul; 135(1):82–90.