Colorectal Cancer Screening Follow-up
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
As of this Report:
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 .
- 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 .
- 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 .
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
As of this Report:
- 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 .
- 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).
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 . 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 .
- 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 .
- 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 . It also reduces patient anxiety .
- Measuring abnormal follow-up helps the ColonCancerCheck program monitor access to colorectal screening and ensures that program participants have timely follow-up.
- 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.