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Colorectal Cancer Screening Participation

Key findings

In 2016, approximately 1.6 million Ontarians age 50 to 74 were overdue for colorectal (bowel) cancer screening (i.e., they needed to get screened). These people had not received a recent fecal occult blood test (FOBT), flexible sigmoidoscopy or colonoscopy for either screening or diagnostic reasons. Out of a colorectal cancer screen-eligible population of more than 4 million, 38% were overdue for screening in 2016. The percentage of Ontarians overdue for screening has decreased (i.e., improved) annually since 2013.

Measure: Participation:  age-adjusted percentage of Ontarians, age 50 to 74, who were overdue for colorectal screening in a calendar year

 

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.

 

 


What is colorectal cancer screening?

  • Cancer screening is testing 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 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 their 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 they do not have any symptoms [3].
  • 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 test. During a colonoscopy, cancer may be found. Polyps (pre-cancerous lesions) may also be identified and removed during colonoscopy.
  • ColonCancerCheck recommends that people at increased risk of colorectal cancer due to a 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].

Figure 1. Age-adjusted percentage of Ontarians, age 50 to 74, who were overdue for colorectal cancer screening, 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. Individuals are considered "overdue" if they have not had an FOBT in 2 years, colonoscopy in 10 years, or flexible sigmoidoscopy in 10 years.
  2. ⱡRate is adjusted for age

Figure 2. Percentage of Ontarians, age 50 to 74, who were overdue for colorectal cancer screening in a calendar year, by age group, 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. Individuals are considered "overdue" if they have not had an FOBT in 2 years, colonoscopy in 10 years, or flexible sigmoidoscopy in 10 years.
  2. ⱡRate is adjusted for age

Data Table 1. Age-adjusted percentage of Ontarians, age 50 to 74, who were overdue for colorectal cancer screening, 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 41.5 1,613,031 3,891,541 41.4 41.5 39.9 1,601,879 4,018,806 39.9 40.0 38.7 1,597,500 4,138,063 38.7 38.8 38.1 1,612,084 4,254,286 38.1 38.2
Erie St. Clair 42.3 83,203 198,248 42.0 42.5 40.2 80,982 203,168 40.0 40.5 38.9 79,815 207,574 38.7 39.1 37.9 78,938 211,806 37.7 38.1
South West 43.9 129,750 297,805 43.7 44.1 42.7 128,408 304,364 42.5 42.8 41.5 126,868 310,496 41.3 41.6 40.6 125,562 315,791 40.4 40.7
Waterloo Wellington 41.4 83,170 200,264 41.2 41.6 40.7 84,687 207,389 40.5 40.9 39.6 85,099 214,498 39.4 39.8 39.1 86,138 220,889 38.8 39.3
Hmltn-Ngr-Hldmnd-Brnt 43.4 187,642 435,213 43.3 43.5 42.2 186,559 446,535 42.0 42.3 41.1 185,385 456,572 40.9 41.2 40.4 185,525 465,945 40.2 40.5
Central West 44.7 99,131 221,258 44.5 44.9 42.0 97,780 231,766 41.8 42.2 40.3 97,735 241,803 40.1 40.5 39.5 99,968 252,287 39.3 39.7
Mississauga Halton 41.2 126,077 302,921 41.1 41.4 39.4 125,979 316,777 39.2 39.6 38.2 127,300 330,486 38.0 38.4 37.8 130,995 344,268 37.6 38.0
Toronto Central 43.1 134,419 311,015 42.9 43.2 41.3 133,242 321,703 41.1 41.5 40.2 133,936 332,487 40.0 40.3 39.9 137,291 344,093 39.7 40.0
Central 38.1 186,769 487,630 38.0 38.2 36.5 186,589 508,210 36.4 36.6 35.6 188,626 527,647 35.5 35.7 35.4 194,604 548,191 35.3 35.5
Central East 39.7 185,484 466,291 39.6 39.9 38.2 184,116 481,861 38.1 38.4 37.4 184,878 495,713 37.3 37.5 37.1 187,561 509,082 36.9 37.2
South East 43.4 74,065 173,047 43.2 43.6 42.6 73,828 176,627 42.3 42.8 41.4 72,797 179,847 41.1 41.6 40.3 71,342 182,054 40.1 40.5
Champlain 40.4 152,501 377,785 40.2 40.5 38.8 151,600 390,897 38.7 39.0 37.2 149,631 403,658 37.1 37.4 36.5 150,591 415,945 36.3 36.6
North Simcoe Muskoka 37.4 56,731 152,702 37.2 37.7 36.0 55,913 156,795 35.8 36.2 34.9 55,258 160,341 34.7 35.1 34.3 55,038 163,313 34.0 34.5
North East 41.6 79,637 192,739 41.4 41.9 40.5 78,539 196,290 40.2 40.7 39.3 76,980 199,111 39.0 39.5 38.2 75,352 201,488 37.9 38.4
North West 46.2 34,452 74,623 45.8 46.5 44.2 33,657 76,424 43.9 44.6 43.0 33,192 77,830 42.7 43.3 42.5 33,179 79,134 42.1 42.8

Report date: December 2017

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

Prepared by: Analytics, Cancer Screening,  P&CC

Note:

  1. Individuals are considered "overdue" if they have not had an FOBT in 2 years, colonoscopy in 10 years, or flexible sigmoidoscopy in 10 years.
  2. ⱡRate is adjusted for age

 

Data Table 2. Percentage of Ontarians, age 50 to 74, who were overdue for colorectal cancer screening in a calendar year, 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 (adj) 41.5 1,613,031.0 3,891,541.0 41.4 41.5 39.9 1,601,879.0 4,018,806.0 39.9 40.0 38.7 1,597,500.0 4,138,063.0 38.7 38.8 38.1 1,612,084.0 4,254,286.0 38.1 38.2
50 to 54 50.6 545,314.0 1,076,809.0 50.5 50.7 49.8 548,922.0 1,102,347.0 49.7 49.9 48.4 542,092.0 1,119,723.0 48.3 48.5 48.1 539,684.0 1,122,318.0 48.0 48.2 Ref.
55 to 59 42.5 396,922.0 934,208.0 42.4 42.6 41.0 394,956.0 962,706.0 40.9 41.1 39.7 392,707.0 988,105.0 39.6 39.8 38.9 396,921.0 1,020,248.0 38.8 39.0 <0.001
60 to 64 37.6 294,835.0 783,602.0 37.5 37.7 35.9 288,262.0 803,094.0 35.8 36.0 34.9 288,546.0 827,064.0 34.8 35.0 34.3 293,950.0 857,046.0 34.2 34.4 <0.001
65 to 69 33.8 214,780.0 635,547.0 33.7 33.9 31.9 214,060.0 670,633.0 31.8 32.0 30.9 217,621.0 703,186.0 30.8 31.1 30.3 223,489.0 737,748.0 30.2 30.4 <0.001
70 to 74 34.9 161,180.0 461,375.0 34.8 35.1 32.4 155,679.0 480,026.0 32.3 32.6 31.3 156,534.0 499,985.0 31.2 31.4 30.6 158,040.0 516,926.0 30.4 30.7 <0.001

Report date: December 2017

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

Prepared by: Analytics, Cancer Screening,  P&CC

Note:

  1. Individuals are considered "overdue" if they have not had an FOBT in 2 years, colonoscopy in 10 years, or flexible sigmoidoscopy in 10 years.
  2. ⱡRate is adjusted for age

 

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 Ontarians who have not been screened by 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 flexible sigmoidoscopy or colonoscopy within the past 10 years (for screening or other reasons) do not need to get screened for colorectal cancer.  
  • In 2016, approximately 1.6 million Ontarians were overdue for colorectal cancer screening (i.e., they needed to get screened).
  • From 2013 through 2016, the percentage of Ontarians overdue for colorectal cancer screening decreased from 42% to 38%. The percentage of Ontarians overdue for screening has decreased consistently since 2008, the year that the ColonCancerCheck program began (data not shown).
  • In 2016, the Local Health Integration Network (LHIN) with the lowest percentage of people overdue for colorectal cancer screening was North Simcoe Muskoka (34%). The LHIN with the highest percentage of people overdue for screening was North West (43%).
  • The percentage of people overdue for colorectal cancer screening decreased (i.e., improved) in all LHINs from 2013 through 2016.

The percentage of people overdue for colorectal cancer screening (FOBT, flexible sigmoidoscopy or colonoscopy) varies by demographic factors.*

  • In 2016, the percentage of people overdue for colorectal cancer screening in Ontario generally decreased (improved) with increasing age (Figure 2). The percentage overdue for colorectal cancer screening was lowest in the older age group (people age 65 to 74) at 30%, and it was highest in the youngest age group (people age 50 to 54) at 48%. A similar pattern can be seen in previous years. 
  • More men were overdue for colorectal cancer screening than women. In 2015, 41% of screen-eligible men were overdue for colorectal cancer screening compared to 36% of screen-eligible women.

* Some data are not shown. Percentages by 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 commonly diagnosed cancer in men and the third-most commonly diagnosed cancer in women. It is also the second-leading cause of cancer mortality (i.e., deaths) in Ontario for men and the third-leading cause for women [4]. It is estimated that 11,595 Ontarians will be diagnosed with colorectal cancer in 2018 and approximately 3,359 will die of the disease [4].

Regular screening plays a role in improved outcomes.

  • A 2016 meta-analysis showed that deaths from colorectal cancer in people age 50 and older can be reduced by 13% with regular screening (annually or every other year) using an FOBT, followed by a colonoscopy if the FOBT is abnormal [3].
  • This screening-related reduction in mortality depends on people regularly returning for screening tests for as long as they are eligible.
  • Screening with FOBT can help find colorectal cancer at an earlier stage [5].
  • The evidence also shows that screening for colorectal cancer using flexible sigmoidoscopy can reduce colorectal cancer incidence (i.e., new cancer cases) by 22% and mortality by 28% [3].  However, only about 14% of people with colorectal cancer who are diagnosed at a later stage will be cured [5].

How does Ontario compare with other jurisdictions?

  • Ensuring that the data and measures from other jurisdictions are comparable to those in Ontario is a challenge. Caution should be used when comparing Ontario’s indicator results to those from other jurisdictions due to potential differences in data definitions, methodologies and time periods. Cross-jurisdictional comparison, however, may still be useful for providing a rough indication of how Ontario is doing compared to other jurisdictions.
  • In 2016, 38% of screen-eligible Ontarians were overdue for colorectal cancer screening. In Manitoba, 50% of screen-eligible adults were overdue for colorectal cancer screening for the 24-month period of 2011­ to 2012 (2011-2012). Caution needs to be exercised when comparing participation across these jurisdictions because of the differences in reporting periods (2016 in Ontario vs. 2011-2012 in Manitoba).
    • Manitoba has seen improvement in participation since 2010, when the participation rate was 45%. It is expected that Manitoba has improved further since the 2011–2012 report.
    • Also, while Manitoba’s rate includes colonoscopy and flexible sigmoidoscopy in the last 5 years (and FOBT in the last 2 years), Ontario’s overdue for screening rate includes colonoscopy and flexible sigmoidoscopy in the last 10 years [6].
  • For more information on comparisons of colorectal cancer screening participation among jurisdictions, see the Cancer System Quality Index’s (CSQI’s) screening comparison section.

Next steps

  • In recent years, Cancer Care Ontario has improved its suite of correspondence letters to help maximize participation. In 2016, Cancer Care Ontario implemented reminder letters for people who did not complete colorectal cancer screening after receiving an invitation letter.
  • Also in 2016, Cancer Care Ontario offered primary care providers who participate in a patient enrolment model practice the opportunity to participate in physician-linked correspondence for invitation and recall letters. These letters include an endorsement from a patient’s primary care provider, an approach that a 2-phase pilot project through the ColonCancerCheck program showed improved screening participation [7, 8]. Primary care providers have to opt-in to physician-linked correspondence, so Cancer Care Ontario has conducted an evaluation of the expansion to identify barriers for physician opt-in. To date, the opt-in rate is 37%. 
  • In fiscal year 2018/2019, Cancer Care Ontario will be implementing male-specific invitation letters in the ColonCancerCheck program. These invitations include specific messaging about colorectal cancer symptoms. A randomized controlled trial conducted by Cancer Care Ontario showed that male-specific letters with targeted messaging resulted in a significant increase in colon cancer screening participation [9].
  • 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 a physician in patient enrolment model practice 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. Cancer Care Ontario has also 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.
  • In addition, Cancer Care Ontario is examining other strategies to improve colorectal cancer screening participation. For instance, Cancer Care Ontario is working to replace the guaiac-based FOBT with the fecal immunochemical test (FIT). FIT is more user-friendly and better at detecting colon cancer and pre-cancer [10, 11]. It has also been shown to increase colorectal cancer screening participation [11–15]. The launch of FIT will include education and awareness campaigns.

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. Colorectal Cancer Screening Recommendations Summary [Internet]. Toronto: Cancer Care Ontario [cited 2018 Jan 3]. Available from here.
  3. Greegor DH. Diagnosis of large-bowel cancer in the asymptomatic patient. JAMA. 1967;201:943–5.
  4. Cancer Care Ontario. Ontario cancer statistics 2018. Toronto: Cancer Care Ontario; 2018 [cited 2018 Feb 7]. Available from here.
  5. Cancer Stat Facts: Colorectal Cancer [Internet]. Bethesda (MD): National Cancer Institute [cited 2015 Jan 26]. Available from here.
  6. CancerCare Manitoba [Internet]. Colorectal Cancer Screening Report January 2011 – December 2012 [cited 2018 February 9]. Available from here.
  7. 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.
  8. Marrett L, Gao J. Physician-linked correspondence (PLC) evaluation. Cancer Care Ontario internal report. Dec 2012.
  9. Tinmouth J, Llovet D, Lee A, Hader J, Kone A, Sutradhar R, et al. Tailored versus non-tailored invitations for colorectal cancer screening in Ontario’s ColonCancerCheck program: two randomized controlled trials. Gastroenterology. 2015;148(4):s161–162.
  10. 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.
  11. Tinmouth J, Vella E, Baxter NN, Dubé C, Gould M, Hey A, et al. Colorectal cancer screening in average risk populations: evidence summary. Toronto (ON): Cancer Care Ontario; 2015 November 11.
  12. 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.
  13. 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.
  14. 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.
  15. 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.