Canada’s colorectal cancer (CRC) screening programs, which are run at the provincial or territorial level, meet the International Agency for Research on Cancer’s (IARC) criteria for access to essential service. They vary, however, in areas related to service delivery and quality assurance, according to a new study.
For instance, three programs don’t send patients invitations to participate in CRC screening, and among those that do, four programs don’t include a stool test kit in the invitation. These measures are encouraged worldwide and associated with increased screening participation.
“Because each province or territory runs its own CRC screening program, there is the potential for differences across programs and different screening experiences for Canadians, depending on where they live,” senior author Jill Tinmouth, MD, provincial medical director for cancer control at Cancer Care Ontario and lead scientist for the ColonCancerCheck Program in Toronto, Ontario, Canada, told Medscape Medical News.
“Using a standardized set of criteria to assess the quality of these programs is very important, as it helps us to understand these differences and can help make the case for individual program improvements where needed,” she said. “As we want to provide the best screening care for all Canadians, it is helpful to know what we should be striving to achieve.”
The study was published on May 1 in the Journal of the Canadian Association of Gastroenterology.
Comparing Screening Programs
Tinmouth and colleagues collaborated with the Cancer Screening in Five Continents (CanScreen5) program, which is an initiative of the IARC that collects information about the characteristics and performance of cancer screening programs worldwide. The research team sent standardized CanScreen5 qualitative data forms to representatives of CRC screening programs across Canada’s 10 provinces and three territories in 2020 and 2021.
The CanScreen5 form includes 52 questions about the screening program’s organization, information system and data collection, protocol, invitations for screening and further assessment, and quality assurance. IARC reviewed the forms, and Tinmouth’s research team compared the programs based on 25 questions and general characteristics, such as type of screening performed, target age for screening, and primary screening test used. They also compared Canada’s IARC data with that of 10 countries with a high CRC incidence.
Overall, 10 provinces and two territories submitted data. Although researchers contacted a representative from Nunavut, which doesn’t have a CRC screening program, the person decided not to submit responses.
The first CRC screening programs in Canada were launched in Alberta, Manitoba, and Ontario in 2007. The other provinces followed from 2009 to 2017, and the Northwest Territories launched programs in 2020.
All the screening programs met leadership, governance, and finance criteria, as well as criteria for access to essential services. However, the responses varied with regard to service delivery provisions, information systems, and quality assurance.
None of the provincial programs met all the essential and desirable criteria to be considered an “organized screening program,” as outlined by IARC, the study authors wrote. British Columbia, Newfoundland, and Quebec don’t send invitations to eligible citizens to participate in screening, though British Columbia and Newfoundland have more sophisticated processes for follow-up and quality monitoring than Quebec.
Among the regions that send screening invitations, Alberta, New Brunswick, Ontario, and Prince Edward Island don’t include a stool test kit. Instead, the programs send a letter that encourages residents to talk to their primary care provider about CRC screening.
The greatest variation across programs occurred in information systems and quality assurance. All Canada’s programs collect data about screening-related outcomes, but they differ on the level of detail, such as the cancer stage or treatment. Tracking is more limited in Quebec.
Tinmouth and colleagues proposed collaborations between established screening programs and newer, smaller programs, as well as using multiple communication channels with patients, such as email, texting, and social media.
“While it is important to note that a lot of programs are doing really well, it is interesting that none of the Canadian provincial or territorial programs met all of IARC’s criteria,” said Tinmouth. “To me, that means there is room to do a better job in every program in the country. This work helps to define how to improve, which I hope is helpful and motivating to the programs.”
Improving Program Performance
Across the world, countries vary significantly in their CRC screening programs based on IARC criteria, the study authors noted. So far, 79 countries have submitted information to CanScreen5. Among these countries, only 37 have established CRC screening programs. Even among countries with national programs, approaches differ significantly across invitation protocols, follow-up, information systems, and quality assurance.
“The benefits of CRC screening (both in the short-term, such as reduction in cancer incidence, and in the long-term, such as reduction in mortality) and reduction in costs of advanced cancer treatments and overall outcomes are really beyond question now. CRC screening works,” said Alaa Rostom, MD, a gastroenterologist and regional endoscopy lead for Ontario Health in Ottawa, Ontario, Canada.
Rostom, who wasn’t involved with this study, planned and implemented the CRC screening program in Calgary and previously chaired the gastroenterology division at Ottawa Hospital, Ottawa, Ontario, Canada.
“To achieve optimal benefits, CRC screening needs to be offered to all eligible people, and there have to be systems in place to ensure maximal participation, with prompt follow-up to colonoscopy for those who screen positive,” he said. “These goals are best achieved through organized programs, rather than opportunistic screening.”
During the next phase of research, Tinmouth and colleagues planned to measure the screening performance of Canadian CRC screening programs quantitatively, including the proportion of people who participate in screening by province and territory, the percentage who undergo a follow-up colonoscopy after an abnormal fecal test, and the number of cancers detected through screening.
“This information is extremely valuable to identify gaps and areas of improvement that can help our programs improve, offer greater value to patients and payers, and better incorporate screening under a healthcare system that is under extreme pressure,” Rostom said. “Using this information can help healthcare leaders and provincial programs further streamline and improve access and equity, reduce pressures on primary care, reduce downstream cancer care costs, improve colorectal outcomes, and improve limited healthcare resource utilization.”
The authors reported no funding for the study. Tinmouth serves as the lead scientist of the Ontario Health ColonCancerCheck program and as the Provincial Medical Director of Cancer Control. Rostom declared no relevant financial relationships.
Carolyn Crist is a health and medical journalist who reports on the latest studies for Medscape Medical News, MDedge, and WebMD.
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