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Colorectal Cancer Screening Follow-up

Key findings

Measure:  Six-month follow-up: percentage of screen-eligible Ontarians, age 50 to 74, with a positive fecal occult blood test result who did not undergo colonoscopy within 6 months of the positive fecal occult blood test date

 

Desired Direction:

 

An image of an arrow pointing downwards. This indicates that desired direction for this action is downwards.

 

As of this Report:

 

An image of an arrow pointing downwards in a yellow box. This indicates that there has been an increase in performance over the previous years identified and this action is below but approaching target or has notable regional variation.

In 2016, over 21,000 Ontarians age 50 to 74 had an abnormal fecal occult blood test (FOBT) result that required follow-up with colonoscopy. Of these people, 4,375 (20%) did not have a colonoscopy within 6 months of their abnormal FOBT result. This is down from 23% in 2012. Notable variations were present by region.

Also in 2016, over 10,000 Ontarians (48%) with an abnormal FOBT results had a follow-up colonoscopy within 8 weeks, compared to 46% in 2013.

What is colorectal cancer screening?

  • Cancer screening is for people who may be at risk of getting cancer, but who have no symptoms and generally feel fine. It is not meant to diagnose cancer. Instead, it helps determine which people are more likely to develop cancer in the future. Cancer Care Ontario operates organized, population-based screening programs for 3 types of cancer: breast, cervical and colorectal.
  • The purpose of colorectal (bowel) cancer screening with FOBT is to find cancer at an early stage, when it is easier to treat. Colorectal cancer screening has been shown to reduce deaths from colorectal cancer [1].
  • 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).
  • ColonCancerCheck (Ontario’s population-based colorectal cancer screening program) recommends that people age 50 to 74 without a family history of colorectal cancer (i.e., those at average risk) get screened every 2 years with an FOBT, followed by colonoscopy if the FOBT is abnormal [2].
  • The FOBT can find very small amounts of blood in someone’s stool (poop) that may be caused by cancer in the colon or rectum, even when a person does not have any symptoms [3].

Measure:  Eight-week follow-up: percentage of screen-eligible Ontarians, age 50 to 74, with an abnormal fecal occult blood test result who underwent colonoscopy within 8 weeks of the abnormal screen date

 

Desired Direction:

 

An image of an arrow pointing upwards. This indicates that desired direction for this action is upwards.

 

As of this Report:

 

An image of an arrow pointing upwards in a red box. This indicates that there has been an increase in performance over the previous periods identified and this action is well below targets.

  • An abnormal FOBT does not necessarily mean that someone has cancer, but it does mean that further testing is needed. A colonoscopy is the recommended follow-up test. During colonoscopy, cancer may be found. Polyps (pre-cancerous lesions) also may be removed during colonoscopy.
  • ColonCancerCheck recommends that people at increased risk of colorectal cancer due to family history in a first-degree relative (i.e., they have a parent, sibling or child who has been diagnosed with the disease) screen with colonoscopy beginning at age 50 or 10 years earlier than the age at which their relative was diagnosed, whichever occurs first [2].
  • Cancer Care Ontario monitors 2 indicators for colorectal cancer screening related to the follow-up of abnormal FOBT results: (1) the percentage of people with no follow-up colonoscopy within 6 months of an abnormal FOBT (an indicator of those who have been lost to follow-up) and (2) the percentage of people who receive a follow-up colonoscopy within 8 weeks of an abnormal FOBT (an indicator of the timeliness of follow-up).  

Figure 1. Percentage of screen-eligible Ontarians with an abnormal fecal occult blood test (FOBT) result, age 50 to 74, who did not undergo colonoscopy within 6 months, by Local Health Integration Network (LHIN), 2013 to 2016

More information regarding the methodology is available.

Report date: December 2017

Data source: OHIP CHDB, LRT, CIRT, OCR, RPDB, PCCF+ version 6D

Prepared by: Analytics, Cancer Screening,  P&CC

Note:

  1. Please refer to technical documentation.

Figure 2. Percentage of screen-eligible Ontarians with an abnormal fecal occult blood test (FOBT) result, age 50 to 74, who did not undergo colonoscopy within 6 months, by age group, 2013 to 2016

More information regarding the methodology is available.

Report date: December 2017

Data source: OHIP CHDB, CytoBase, OCR, RPDB, PCCF+ version 6D

Prepared by: Analytics, Cancer Screening,  P&CC

Note:

  1. Please refer to technical documentation.

Figure 3. Percentage of screen-eligible Ontarians with an abnormal fecal occult blood test (FOBT) result, age 50 to 74, who underwent colonoscopy within 8 weeks of the abnormal screen date, by Local Health Integration Network (LHIN), 2013 to 2016

More information regarding the methodology is available.

Report date: December 2017

Data source: OHIP CHDB, LRT, CIRT, GI Endo DSP, OCR, RPDB, PCCF+ version 6D

Prepared by: Analytics, Cancer Screening,  P&CC

Note:

  1. Please refer to technical documentation.

Figure 4. Percentage of screen-eligible Ontarians with an abnormal fecal occult blood test (FOBT) result, age 50 to 74, who underwent colonoscopy within 8 weeks of the abnormal screen date, by age group, 2013 to 2016

More information regarding the methodology is available.

Report date: December 2017

Data source: OHIP CHDB, LRT, CIRT, GI Endo DSP, OCR, RPDB, PCCF+ version 6D

Prepared by: Analytics, Cancer Screening,  P&CC

Note:

  1. Please refer to technical documentation.

Data Table 1. Percentage of screen-eligible Ontarians with an abnormal fecal occult blood test (FOBT) result, age 50 to 74, who did not undergo colonoscopy within 6 months, by Local Health Integration Network (LHIN), 2013 to 2016

LHIN Rate (%) in 2013 Numerator in 2013 Denominator in 2013 Lower confidence interval in 2013 Upper confidence interval in 2013 Rate (%) in 2014 Numerator in 2014 Denominator in 2014 Lower confidence interval in 2014 Upper confidence interval in 2014 Rate (%) in 2015 Numerator in 2015 Denominator in 2015 Lower confidence interval in 2015 Upper confidence interval in 2015 Rate (%) in 2016 Numerator in 2016 Denominator in 2016 Lower confidence interval in 2016 Upper confidence interval in 2016  
Ontario 22.5 4,298 19,128 21.9 23.1 22.9 4,591 20,052 22.3 23.5 21.6 4,358 20,138 21.1 22.2 20.2 4,375 21,609 19.7 20.8
Erie St. Clair 20.9 223 1,068 18.4 23.4 21.6 237 1,098 19.1 24.1 19.7 218 1,108 17.3 22.1 18.0 214 1,189 15.8 20.2
South West 19.2 286 1,486 17.2 21.3 18.9 287 1,516 16.9 20.9 19.4 287 1,476 17.4 21.5 18.2 288 1,585 16.2 20.1
Waterloo Wellington 17.6 174 988 15.2 20.0 18.5 173 934 16.0 21.1 19.4 195 1,003 16.9 21.9 19.0 197 1,039 16.5 21.4
Hmltn-Ngr-Hldmnd-Brnt 18.6 419 2,251 17.0 20.2 20.6 437 2,123 18.8 22.3 17.7 375 2,114 16.1 19.4 18.2 417 2,290 16.6 19.8
Central West 24.9 242 973 22.1 27.6 23.0 260 1,131 20.5 25.5 24.0 277 1,156 21.5 26.5 22.2 274 1,233 19.9 24.6
Mississauga Halton 24.5 323 1,317 22.2 26.9 23.3 343 1,469 21.2 25.5 22.2 317 1,430 20.0 24.4 20.6 321 1,558 18.6 22.6
Toronto Central 34.0 436 1,281 31.4 36.7 30.9 433 1,401 28.5 33.4 30.7 464 1,510 28.4 33.1 26.4 421 1,594 24.2 28.6
Central 24.8 643 2,589 23.2 26.5 27.1 758 2,795 25.5 28.8 24.3 678 2,791 22.7 25.9 22.4 703 3,133 21.0 23.9
Central East 22.7 527 2,320 21.0 24.4 23.9 628 2,631 22.2 25.5 21.6 552 2,555 20.0 23.2 21.2 600 2,833 19.7 22.7
South East 20.0 186 930 17.4 22.6 20.0 184 919 17.4 22.7 18.6 174 938 16.0 21.1 17.5 169 963 15.1 20.0
Champlain 21.8 437 2,002 20.0 23.7 20.6 447 2,174 18.8 22.3 21.0 457 2,177 19.3 22.7 19.1 417 2,180 17.5 20.8
North Simcoe Muskoka 17.8 103 580 14.6 21.0 19.9 121 608 16.6 23.2 19.4 115 594 16.1 22.6 17.4 116 666 14.5 20.4
North East 23.7 227 959 20.9 26.4 24.2 219 905 21.4 27.0 17.7 160 906 15.1 20.2 17.3 167 965 14.9 19.7
North West 18.8 72 384 14.7 22.8 18.4 64 348 14.2 22.6 23.4 89 380 19.0 27.8 18.6 71 381 14.6 22.7

Report date: December 2017

Data source: OHIP CHDB, LRT, CIRT, OCR, RPDB, PCCF+ version 6D

Prepared by: Analytics, Cancer Screening,  P&CC

Note:

  1. Please refer to technical documentation.

Data Table 2. Percentage of screen-eligible Ontarians with an abnormal fecal occult blood test (FOBT) result, age 50 to 74, who did not undergo colonoscopy within 6 months, by age group, 2013 to 2016

Age group Rate (%) in 2013 Numerator in 2013 Denominator in 2013 Lower confidence interval in 2013 Upper confidence interval in 2013 Rate (%) in 2014 Numerator in 2014 Denominator in 2014 Lower confidence interval in 2014 Upper confidence interval in 2014 Rate (%) in 2015 Numerator in 2015 Denominator in 2015 Lower confidence interval in 2015 Upper confidence interval in 2015 Rate (%) in 2016 Numerator in 2016 Denominator in 2016 Lower confidence interval in 2016 Upper confidence interval in 2016 p-value
50 to 74 22.5 4,298 19,128 21.9 23.1 22.9 4,591 20,052 22.3 23.5 21.6 4,358 20,138 21.1 22.2 20.2 4,375 21,609 19.7 20.8
50 to 54 20.9 1,027 4,916 19.7 22.0 22.0 1,109 5,035 20.9 23.2 18.8 999 5,306 17.8 19.9 18.7 960 5,124 17.7 19.8 Ref.
55 to 59 21.7 874 4,025 20.4 23.0 22.0 936 4,248 20.8 23.3 21.5 935 4,354 20.2 22.7 19.9 882 4,431 18.7 21.1 0.148
60 to 64 21.7 798 3,685 20.3 23.0 22.5 892 3,971 21.2 23.8 21.6 834 3,854 20.3 23.0 20.2 878 4,356 19.0 21.4 0.081
65 to 69 24.4 891 3,655 23.0 25.8 24.0 912 3,800 22.6 25.4 23.5 879 3,742 22.1 24.9 20.3 883 4,359 19.1 21.5 0.062
70 to 74 24.9 708 2,847 23.3 26.5 24.7 742 2,998 23.2 26.3 24.7 711 2,882 23.1 26.3 23.1 772 3,339 21.7 24.6 <0.001

Report date: December 2017

Data source: OHIP CHDB, CytoBase, OCR, RPDB, PCCF+ version 6D

Prepared by: Analytics, Cancer Screening,  P&CC

Note:

  1. Please refer to technical documentation.

Data Table 3. Percentage of screen-eligible Ontarians with an abnormal fecal occult blood test (FOBT) result, age 50 to 74, who underwent colonoscopy within 8 weeks of the abnormal screen date, by Local Health Integration Network (LHIN), 2013 to 2016

LHIN Rate (%) in 2013 Numerator in 2013 Denominator in 2013 Lower confidence interval in 2013 Upper confidence interval in 2013 Rate (%) in 2014 Numerator in 2014 Denominator in 2014 Lower confidence interval in 2014 Upper confidence interval in 2014 Rate (%) in 2015 Numerator in 2015 Denominator in 2015 Lower confidence interval in 2015 Upper confidence interval in 2015 Rate (%) in 2016 Numerator in 2016 Denominator in 2016 Lower confidence interval in 2016 Upper confidence interval in 2016
Ontario 46.4 8,877 19,128 45.7 47.1 45.5 9,117 20,052 44.8 46.2 43.9 8,837 20,138 43.2 44.6 48.0 10,365 21,609 47.3 48.6
Erie St. Clair 41.8 446 1,067 38.8 44.8 42.1 462 1,098 39.1 45.0 43.4 480 1,107 40.4 46.3 45.7 543 1,187 42.9 48.6
South West 45.1 673 1,492 42.5 47.7 44.8 680 1,517 42.3 47.4 43.9 648 1,475 41.4 46.5 48.7 776 1,594 46.2 51.2
Waterloo Wellington 49.6 493 993 46.5 52.8 51.0 476 933 47.8 54.3 46.8 468 1,001 43.6 49.9 50.0 520 1,039 47.0 53.1
Hmltn-Ngr-Hldmnd-Brnt 49.7 1,112 2,239 47.6 51.8 45.9 974 2,124 43.7 48.0 46.8 991 2,117 44.7 49.0 49.6 1,129 2,274 47.6 51.7
Central West 48.4 472 975 45.2 51.6 50.2 568 1,132 47.2 53.1 47.3 550 1,162 44.4 50.2 49.1 605 1,231 46.3 52.0
Mississauga Halton 48.3 636 1,318 45.5 51.0 48.4 711 1,470 45.8 51.0 46.0 658 1,429 43.4 48.7 49.0 767 1,565 46.5 51.5
Toronto Central 41.6 533 1,282 38.8 44.3 36.3 508 1,401 33.7 38.8 37.8 570 1,509 35.3 40.3 44.8 715 1,597 42.3 47.2
Central 52.9 1,367 2,585 50.9 54.8 48.3 1,351 2,798 46.4 50.2 46.9 1,307 2,787 45.0 48.8 49.0 1,535 3,133 47.2 50.8
Central East 46.9 1,088 2,319 44.9 49.0 45.5 1,198 2,631 43.6 47.5 42.1 1,075 2,555 40.1 44.0 42.5 1,203 2,829 40.7 44.4
South East 42.9 400 933 39.6 46.1 41.9 386 922 38.6 45.1 37.0 347 938 33.9 40.1 48.2 465 964 45.0 51.4
Champlain 40.1 802 2,001 37.9 42.3 45.0 976 2,168 42.9 47.1 41.8 911 2,179 39.7 43.9 48.8 1,067 2,185 46.7 51.0
North Simcoe Muskoka 51.4 299 582 47.2 55.5 45.0 272 605 40.9 49.0 45.9 272 593 41.8 50.0 56.4 374 663 52.6 60.3
North East 40.3 386 958 37.1 43.5 45.2 409 905 41.9 48.5 46.0 417 906 42.7 49.3 52.5 509 969 49.3 55.7
North West 44.3 170 384 39.2 49.4 42.0 146 348 36.6 47.3 37.6 143 380 32.6 42.6 41.4 157 379 36.3 46.5

Report date: December 2017

Data source: OHIP CHDB, LRT, CIRT, GI Endo DSP, OCR, RPDB, PCCF+ version 6D

Prepared by: Analytics, Cancer Screening,  P&CC

Note:

  1. Please refer to technical documentation.

Data Table 4. Percentage of screen-eligible Ontarians with an abnormal fecal occult blood test (FOBT) result, age 50 to 74, who underwent colonoscopy within 8 weeks of the abnormal screen date, by age group, 2013 to 2016

Age group Rate (%) in 2013 Numerator in 2013 Denominator in 2013 Lower confidence interval in 2013 Upper confidence interval in 2013 Rate (%) in 2014 Numerator in 2014 Denominator in 2014 Lower confidence interval in 2014 Upper confidence interval in 2014 Rate (%) in 2015 Numerator in 2015 Denominator in 2015 Lower confidence interval in 2015 Upper confidence interval in 2015 Rate (%) in 2016 Numerator in 2016 Denominator in 2016 Lower confidence interval in 2016 Upper confidence interval in 2016 p-value
50 to 74 46.4 8,877 19,128 45.7 47.1 45.5 9,117 20,052 44.8 46.2 43.9 8,837 20,138 43.2 44.6 48.0 10,365 21,609 47.3 48.6
50 to 54 48.5 2,386 4,916 47.1 49.9 46.7 2,352 5,035 45.3 48.1 46.8 2,482 5,306 45.4 48.1 50.1 2,565 5,124 48.7 51.4 Ref.
55 to 59 46.4 1,868 4,025 44.9 48.0 45.3 1,926 4,248 43.8 46.8 43.4 1,890 4,354 41.9 44.9 47.7 2,114 4,431 46.2 49.2 0.022
60 to 64 47.9 1,765 3,685 46.3 49.5 44.3 1,760 3,971 42.8 45.9 44.2 1,702 3,854 42.6 45.7 48.3 2,106 4,356 46.9 49.8 0.097
65 to 69 44.6 1,631 3,655 43.0 46.2 46.9 1,784 3,800 45.3 48.5 41.5 1,554 3,742 39.9 43.1 47.6 2,074 4,359 46.1 49.1 0.016
70 to 74 43.1 1,227 2,847 41.3 44.9 43.2 1,295 2,998 41.4 45.0 42.0 1,209 2,882 40.1 43.8 45.1 1,506 3,339 43.4 46.8 <0.001

Report date: December 2017

Data source: OHIP CHDB, LRT, CIRT, GI Endo DSP, OCR, RPDB, PCCF+ version 6D

Prepared by: Analytics, Cancer Screening,  P&CC

Note:

  1. Please refer to technical documentation.

What do the results show?

The percentage of abnormal FOBT with no follow-up colonoscopy within 6 months has improved (Figure 1).

  • In 2016, the percentage of Ontarians who had an abnormal FOBT with no follow-up colonoscopy in 6 months improved (i.e., it decreased), falling to 20% (compared to 23% in 2013).
  • In 2016, the North Simcoe Muskoka and the North East Local Health Integration Networks (LHINs) had the lowest percentage of people with an abnormal FOBT and no follow-up colonoscopy in 6 months (17%).
  • In the same year, the Toronto Central LHIN had the highest percentage of people with an abnormal FOBT and no follow-up colonoscopy in 6 months (26%).
  • From 2015 to 2016, the rate of Ontarians who had an abnormal FOBT with no follow-up colonoscopy within 6 months improved or was maintained across all LHINs. The North West LHIN showed the greatest improvement, with a decrease of 4 percentage points (from 23% in 2015 to 19% in 2016).

Improvements in abnormal FOBT with no follow-up colonoscopy within 6 months vary by demographic factors.

  • In 2016, there was variation by age group in the percentage of people with an abnormal FOBT and no follow-up colonoscopy within 6 months (Figure 2). This percentage was lowest (19%) in people age 50 to 54 (the youngest age group) and highest (23%) in people age 70 to 74 (the oldest age group). A similar pattern can be seen in previous years.

The percentage of Ontarians who received follow-up colonoscopies within 8 weeks of an abnormal FOBT has increased (Figure 3).

  • Cancer Care Ontario recommends that Ontarians with an abnormal FOBT result receive a colonoscopy within 8 weeks of that result [5]. This measure is an indicator of the timeliness of follow-up.
  • In 2016, over 10,000 Ontarians had a follow-up colonoscopy within 8 weeks of an abnormal FOBT result (48%), an improvement from 44% in 2015.
  • In 2016, the LHIN where the most people had a follow-up colonoscopy within the wait-time target of 8 weeks was North Simcoe Muskoka (56%). Conversely, the LHIN where the fewest people received a colonoscopy within 8 weeks of an abnormal FOBT result was North West (41%).
  • In 2016, all of the LHINs showed improvement in timeliness of follow-up compared to 2015 (when there was a decrease in timeliness). The North Simcoe Muskoka and South East LHINs showed the greatest improvement, each rising 11 percentage points from their 2015 rate.

Follow-up colonoscopy within the recommended 8 weeks varies by demographic factors.

  • The percentage of people receiving a colonoscopy within 8 weeks of an abnormal FOBT result was highest (50%) among people age 50 to 54 (the youngest age group) and lowest (45%) among people age 70 to 74 (the oldest age group). A similar pattern can be seen in previous years.
  • People living in very remote rural geographic areas were less likely than people living in other geographic areas (i.e., urban, rural and remote rural areas) to have a colonoscopy within 8 weeks of an abnormal FOBT result in 2016 (40% for very remote rural vs. 47% other areas).

Why is this important to Ontarians?

  • While FOBT identifies people at risk of having colorectal cancer, a colonoscopy is required to make a definitive diagnosis.
  • A recent meta-analysis showed that deaths from colorectal cancer in people age 50 and older can be reduced by 13% when people are screened regularly (annually or every other year) with an FOBT, followed by a colonoscopy if the FOBT is abnormal [3].
  • The reasons Ontarians may not have a colonoscopy after an abnormal FOBT are varied. They include things such as personal preference and contraindications (i.e., symptoms or conditions that might prevent someone from having a procedure). System factors also play a role in the follow-up process.For instance, follow-up after an abnormal FOBT occurs less often when an FOBT is repeated (instead of performing a colonoscopy) or when an FOBT is performed within 2 years of a previous colonoscopy [4].
  • The Canadian Association of Gastroenterology (CAG) published a Canadian consensus on medically acceptable wait times in 2006, which included a recommendation that follow-up colonoscopy be completed within 8 weeks of an abnormal FOBT [5, 6]. ColonCancerCheck has adopted an 8-week benchmark based on the CAG consensus.
  • Timely access to colonoscopy is important because it increases the chance of detecting cancer before it becomes more advanced [7]. It also reduces patient anxiety [8].
  • Measuring abnormal follow-up helps the ColonCancerCheck program monitor access to colorectal screening and ensures that program participants have timely follow-up.

Next steps

  • To identify strategies to improve abnormal follow-up, Cancer Care Ontario is continuing to evaluate the reasons for lack of follow-up at the physician and patient levels.
  • Cancer Care Ontario, with funding from the Ontario Institute for Cancer Research, is currently conducting a pilot project to explore the use of centralized navigation to improve overall follow-up and the timeliness of follow-up with colonoscopy in people who have abnormal FOBT results.
  • Cancer Care Ontario has developed an online Primary Care Screening Activity Report (PC SAR) for all 3 screening programs (breast, cervical and colorectal cancer). This online tool allows physicians in patient enrolment model practices to see the complete screening status of each of their enrolled age-eligible patients, including those who are overdue or due for screening and those who require follow-up. In addition, Cancer Care Ontario has partnered with a rural First Nations community to improve its colorectal cancer screening rates by issuing a SAR to primary care providers serving the community.
  • Cancer Care Ontario works closely with Regional Cancer Programs to monitor and improve colonoscopy wait times for people with an abnormal FOBT.

Notes

  1. 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.
  2. About ColonCancerCheck [Internet]. Toronto: Cancer Care Ontario; 2015 Jul 16 [cited 2015 Dec 18]. Available from: here.
  3. Greegor DH. Diagnosis of large-bowel cancer in the asymptomatic patient. JAMA. 1967;201:943–5.
  4. Correia A, Rabeneck L, Baxter NN, Paszat LF, Stradhar R, Yun L, et al. 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.
  5. 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.
  6. Canadian Partnership Against Cancer. Quality determinants and indicators for measuring colorectal cancer screening program performance in Canada. Toronto: Canadian Partnership Against Cancer; 2012.
  7. Corley DA, Jensen CD, Quinn VP, Doubeni CA, Zauber AG, Lee JK, et al. Association between time to colonoscopy after a positive fecal test result and risk of colorectal cancer and cancer stage at diagnosis. JAMA. 2017;317(16):1631–1641.
  8. Canadian Partnership Against Cancer. Living the cancer journey: a report on the patient experience [Internet]. Toronto: Canadian Partnership Against Cancer; 2017 [cited 2018 Jan 29] Available from: here.