Cancer diagnostic assessment programs: standards for the organization of care in Ontario

Background

Improving access to better, more efficient, and rapid cancer diagnosis is a necessary component of a high-quality cancer system. How diagnostic services ought to be organized, structured, and evaluated is less understood and studied. Our objective was to address this gap.

Methods

As a quality initiative of Cancer Care Ontario’s Program in Evidence-Based Care, the Diagnostic Assessment Standards Panel, with representation from clinical oncology experts, institutional and clinical administrative leaders, health service researchers, and methodologists, conducted a systematic review and a targeted environmental scan of the unpublished literature. Standards were developed based on expert consensus opinion informed by the identified evidence. Through external review, clinicians and administrators across Ontario were given the opportunity to provide feedback.

Results

The body of evidence consists of thirty-five published studies and fifteen unpublished guidance documents. The evidence and consensus opinion consistently favoured an organized, centralized system with multidisciplinary team membership as the optimal approach for the delivery of diagnostic cancer assessment services. Independent external stakeholders agreed (with higher mean values, maximum 5, indicating stronger agreement) that dap standards are needed (mean: 4.6), that standards should be formally approved (mean: 4.3), and importantly, that standards reflect an effective approach that will lead to quality improvements in the cancer system (mean: 4.5) and in patient care (mean: 4.3).

Interpretation

Based on the best available evidence, standards for the organization of daps are offered. There is clear need to integrate formal and comprehensive evaluation strategies with the implementation of the standards to advance this field.

Pay-for-performance incentives for preventive care: views of family physicians before and after participation in a reminder and recall project (P-PROMPT)

OBJECTIVE

The Provider and Patient Reminders in Ontario: Multi-Strategy Prevention Tools (P-PROMPT) project was designed to increase the rates of delivery of 4 targeted preventive care services to eligible patients in primary care network and family health network practices eligible for pay-for-performance incentives.

DESIGN

Self-administered fax-back surveys completed before and after participation in the P-PROMPT project.

SETTING

Southwestern Ontario.

PARTICIPANTS

A total of 246 physicians from 24 primary care network or family health network practices across 110 different sites.

INTERVENTIONS

The P-PROMPT project provided several tools and services, including physician and patient reminders, office management tools, and administrative database integration.

MAIN OUTCOME MEASURES

Physicians' views about the delivery of preventive health services and pay-for-performance incentives before and after participation in the P-PROMPT project.

RESULTS

The preintervention survey was completed by 86.2% (212 of 246) of physicians and the postintervention survey was completed by 53.3% (131 of 246) of physicians; 46.7% (114 of 246) of the physicians completed both surveys. Overall, 80.5% of physicians indicated that the P-PROMPT project was useful (scores of 5 or higher on a 7-point Likert scale). Patient reminder letters (89.1%), physician approval lists of eligible patients (75.6%), administrative assistance with management fees (79.8%), and annual bonus calculations (75.2%) were rated as the most useful features of the program. Compared with the preintervention survey, there were statistically significant increases in the mean agreement scores that the established target levels and bonuses provided appropriate financial incentive to substantially increase the uptake of mammography (P=.012) and Papanicolaou tests (P=.003) but not to increase uptake of annual influenza vaccination or childhood immunizations. There were statistically significant changes in the mean ratings of relying on an opportunistic approach (P<.001), increased agreement about the effectiveness of the current approach to delivery of preventive care (P<.001), and increased use of preventive management fees to recall patients (P<.001).

CONCLUSION

The preventive care management program and P-PROMPT were viewed favourably by most respondents and were perceived to be useful in improving delivery of preventive health care services.

Promoting cancer screening among Ontario Chinese women

OBJECTIVES

Cancer screening participation is typically low among newcomers to Canada. Consequently, mortality and morbidity rates are higher in ethno/cultural populations. There are inherent challenges in reaching these population groups to increase awareness and participation in cancer screening. Many reports have cited the need for culturally appropriate materials and multi-pronged strategies for effective outreach in the Chinese community. This paper outlines the consultation/development process and evaluation strategy for promoting cancer screening among Chinese women with limited English language skills.

PARTICIPANTS

As Chinese is the third most commonly spoken language in Canada, this community education project focused on health promoters providing services to Chinese women 50 years and older.

SETTING

Ontario communities.

INTERVENTION

Partners and stakeholders were consulted and engaged to define the best approach to develop and distribute culturally sensitive public education resources to assist communities in realizing greater awareness of and participation in cancer screening.

OUTCOMES

Customized resource kits were developed and distributed to the target population over the course of two phases of this project. An evaluation strategy was designed and implemented to assess the impact of the project.

CONCLUSION

The process to develop culturally sensitive and evidence-based materials for Chinese is detailed in this article. This multi-year project designed and distributed customized resource kits, through consultation with partners and stakeholders. Project outcomes will be further assessed one year after distribution of the kits. This project template may be useful for adaptation and use in other ethnocultural groups within and outside Ontario.

A Fall-off in Cervical Screening Coverage of Younger Women in Developed Countries

Objectives

To analyse cervical screening coverage data by age over time in a number of developed countries throughout the world, with specific emphasis on trends for younger women and on age differentials between younger and older women.

Methods

Routinely collected cervical screening statistics and survey data were collected on the proportion of women who have undergone cervical screening with cytology in seven countries in the period 1995 to 2005.

Results

Data for the 25-29 age group were examined. Coverage fell in most countries, in three by more than 5 percentage points. In two countries while overall coverage rose in the period, the rise was not as steep in the youngest group of women. Data for each available 5-year age group for the different countries shows a similar gradient in most, regardless of the absolute level of coverage. Although the trend is not uniform in every country, it appears that generally the gap between coverage of younger women and coverage of older women increased, sometimes dramatically, between the mid-1990s and the mid-2000s.

Conclusions

There is a general trend in developed countries towards lower coverage in young women (25-29 years old). No common underlying cause has been clearly identified and there is a need for further studies to investigate the possible reasons for this phenomenon.

Breast cancer screening program in Canada: successes and challenges

This paper describes breast screening program development in Canada and the current status of screening in Canada. Programs have been implemented in most of Canada, beginning in the late 1980's. Certain components are common to all the programs, but others, such as personal invitation letters for recruitment and clinical breast examination vary across the country. Key successes in organized breast screening in Canada include the development of a comprehensive set of screening performance indicators, which are reported on regularly, and the downward trend in mortality rates observed over the past 20 years. Challenges include the continued prevalence of opportunistic screening; the need to better manage follow-up; dealing with changing evidence; and supporting informed decision-making about screening. Approaches to breast screening are dependent on the health care services available in countries, but regardless of the approach, good evaluation is necessary.

Defining a strategy to evaluate cervical cancer prevention and early detection in the era of HPV vaccination

OBJECTIVE

The purpose of this paper is to outline the short-, medium- and long-term requirements of a strategy to evaluate the impact of HPV immunization and to define a framework to facilitate planning and evaluation.

METHOD

This strategy was developed in Ontario from January to August 2008. Literature review was completed to assess existing material relevant to vaccine evaluation, and HPV vaccine specifically. Scientists and epidemiologists within our organization attended meetings to brainstorm and identify key requirements for vaccine evaluation. Other selected internal and external experts were consulted to review preliminary lists of potential indicators and questions for inclusion in an evaluation strategy.

RESULTS

Results are reported in three sections--literature review, proposed evaluation framework and data requirements.

CONCLUSION

The first vaccine evaluation strategy that integrates primary and secondary prevention of cervical cancer is presented. Among women who are neither screened nor immunized, customized interventions will be required to ensure that they are aware of potential risks and benefits. This evaluation strategy may serve as a useful outline for jurisdictions in Canada and elsewhere. This new paradigm of combined primary and secondary intervention will encourage cooperation for effective evaluation of an integrated approach for control of cervical cancer and other HPV-related disease.

Predisposing factors associated with compliance to biennial breast screening among centers with and without nurses

BACKGROUND

Previous research suggests that predisposing factors such as previous screening experience, participation in preventive health behaviors, and knowledge/beliefs about breast cancer and screening influence a woman's decision to make a timely return for a second screen.

METHODS

A stratified random sample of compliers and noncompliers to biennial screening were selected from a cohort of 51,242 women ages 50 to 65 years who had their initial screen at the Ontario Breast Screening Program. In total, 1,901 women were telephone-interviewed. The associations between predisposing factors and compliance were estimated separately for centers with and without nurses using logistic regression analyses adjusted for demographics and smoking status.

RESULTS

Women screened at nurse centers were less likely to comply if they thought women should stop having mammograms before age 70 years [odds ratio (OR), 0.39; 95% confidence interval (95% CI), 0.19-0.79], did not consider mammograms very likely to find cancer (OR, 0.73; 95% CI, 0.56-0.95), felt their likeliness of getting breast cancer was below average (OR, 0.69; 95% CI, 0.54-0.89), or believed a high-fat diet was not an important risk factor for breast cancer (OR, 0.59; 95% CI, 0.36-0.97). Women attending nurse centers were significantly more likely to comply if they sometimes had thoughts or worries about developing breast cancer (OR, 1.40; 95% CI, 1.10-1.80).

CONCLUSIONS

Nurses at screening centers may reinforce a woman's knowledge or beliefs about breast cancer or screening and as a result increase their compliance to biennial breast screening.

Factorial validity and invariance of a survey measuring psychosocial correlates of colorectal cancer screening in Ontario, Canada--a replication study

Psychosocial constructs have been used to predict colorectal cancer screening and are frequently targeted as intermediate outcomes in behavioral intervention studies. Few studies have conducted analyses to adequately test construct validity. The psychometric analyses undertaken with U.S. populations of 16 theory-based, colorectal cancer screening items designed to measure five factors (salience-coherence, cancer worries, perceived susceptibility, response efficacy, and social influence) are an exception. The current investigation replicates previous work by examining factor validity and invariance in a random sample of Ontario, Canada residents. A survey instrument was administered to 1,013 Ontario male (49%) and female (51%) residents randomly selected by the Canada Survey Sample. Single-group confirmatory factor analyses (CFA) assessed data fit to the proposed five-factor model for males and females separately, and then a multigroup CFA evaluated if the factor structure was invariant for men and women. The five-factor model provided good fit for both males and females. Tests for factorial invariance between sexes, however, found mixed results. chi2 difference test was significant (P = 0.025); however, DeltaRMSEA = 0.0001. Factor loadings were similar by sex except for two social influence items, with item frequency distributions suggesting an extreme response style, in females, on these items. Overall, the single-group and multigroup CFA results support factorial validity and partial invariance of the five-factor model first identified in the U.S. populations. The items can be used to evaluate and compare psychosocial correlates across U.S. and Canadian samples. Additional research is needed to show invariance for other ethnocultural and national subgroups.

Fecal occult blood testing: people in Ontario are unaware of it and not ready for it

OBJECTIVE

To determine factors that influence awareness of, and readiness to undergo, fecal occult blood testing (FOBT) for colorectal cancer (CRC) screening.

DESIGN

Validated survey designed to ascertain respondents' stages of decision making regarding CRC screening using FOBT.

SETTING

Ontario.

PARTICIPANTS

A total of 1013 people 50 years old and older drawn from all regions of the province using a random-digit dialing telephone protocol.

MAIN OUTCOME MEASURES

Awareness of FOBT and readiness to undergo it for screening for CRC.

RESULTS

Response rate was 69%. Results indicated that 54% of women and 45% of men had "heard of" FOBT, and 26% of women and 17% of men had heard of it but were still "not considering" FOBT screening. Only 17% of all respondents had "decided to have" FOBT screening. Demographic factors associated with having heard of FOBT were female sex, completion of college or higher education, and being married or living as married. Demographic factors associated with active consideration of FOBT among those who reported awareness of it were male sex and being married or living as married.

CONCLUSION

Many people seemed uninformed about FOBT and not ready to undertake this type of screening. Results of this survey could help guide strategies and develop programs to make eligible people aware of CRC screening using FOBT and to motivate them to undergo testing.

Discussions about self-obtained samples for HPV testing as an alternative for cervical cancer prevention

OBJECTIVES

Patient-collected samples for human papillomavirus (HPV) testing have shown promise, thus opening up a new possibility for cervical cancer screening. The purpose of this study was to explore women's beliefs about collecting their own samples for HPV testing instead of participating in conventional Pap testing.

METHODS

Three focus groups were conducted in diverse cities in Ontario, Canada. One group included women from a small under-serviced northern city, one included culturally diverse women from a large urban city, and one included culturally diverse women from a medium sized under-serviced city. Transcripts were coded using open and axial coding as well as focused coding procedures and were organized using qualitative software. The Health Belief Model (HMB) was used as a framework for designing the focus group guide and interpreting the results.

RESULTS

Six overriding themes were identified in the analysis: (1) need (and desire) for information about cervical cancer and HPV, (2) concerns about self-sampling, (3) perceived potential of self-sampling, (4) logistics remain unanswered, (5) need for education and promotion of self-sampling, and (6) need for options.

CONCLUSION

The six themes were connected to some or all of the HBM components. In particular, self-sampling provides a different benefits-minus-barriers equation, which might make it a preferred screening option for some women.

Attitudes toward HPV testing: interview findings from a random sample of women in Ontario, Canada

As most women diagnosed with cervical carcinoma have been "inadequately screened," improvements in screening are critical. After abnormal Pap test findings (through liquid-based cytology), residual specimens now can be tested simultaneously for oncogenic types of Human Papilloma virus (HPV). If these "reflex" HPV tests are negative, Pap tests need not be repeated for 12 months. Women with positive oncogenic HPV tests, however, can be referred immediately for colposcopy. There has been concern that "stigma" issues could be associated with positive HPV status (because of its sexual transmission) that might cause women to avoid this reflex HPV testing. We addressed this concern by assessing whether stigma issues surface in relation to HPV testing. We randomly selected 20 women and administered to them semistructured telephone interviews that included responses to a scenario of reflex HPV-DNA testing. Interview transcripts were analyzed qualitatively. Highly limited knowledge levels were found about HPV, but, following education about screening options, there was no rejection of HPV testing. In conclusion, it appears that women favor reflex HPV testing due to its "convenience" and perceptions that it is "the least intrusive option more definitive than Pap testing."

Chronic disease prevention and management: implications for health human resources in 2020

Through improved screening, detection, better and more targeted therapies and the uptake of evidence-based treatment guidelines, cancers are becoming chronic diseases. However, this good-news story has implications for human resource planning and resource allocation. Population-based chronic disease management is a necessary approach to deal with the growing burden of chronic disease in Canada. In this model, an interdisciplinary team works with and educates the patient to monitor symptoms, modify behaviours and self-manage the disease between acute episodes. In addition, the community as a whole is more attuned to disease prevention and risk factor management. Trusted, high-quality evidence-based protocols and healthy public policies that have an impact on the entire population are needed to minimize the harmful effects of chronic disease. Assuming we can overcome the challenges in recruitment, training and new role development, enlightened healthcare teams and community members will work together to maintain the population's health and wellness and to reduce the incidence and burden of chronic disease in Ontario.

Cancer Care Ontario Colonoscopy Standards: standards and evidentiary base

Colorectal cancer (CRC) is the most common cause of non-tobacco-related cancer deaths in Canadian men and women, accounting for 10% of all cancer deaths. An estimated 7800 men and women will be diagnosed with CRC, and 3250 will die from the disease in Ontario in 2007. Given that CRC incidence and mortality rates in Ontario are among the highest in the world, the best opportunity to reduce this burden of disease would be through screening. The present report describes the findings and recommendations of Cancer Care Ontario's Colonoscopy Standards Expert Panel, which was convened in March 2006 by the Program in Evidence-Based Care. The recommendations will form the basis of the quality assurance program for colonoscopy delivered in support of Ontario's CRC screening program.

Endoscopic follow-up of positive fecal occult blood testing in the Ontario FOBT Project

BACKGROUND

The Ontario FOBT Project is a pilot study of fecal occult blood testing (FOBT) for colorectal cancer screening conducted among age-eligible volunteers (50 to 75 years) in 12 of 37 public health regions in Ontario.

METHODS

Volunteers responded to invitations from primary care practitioners (PCPs) in six regions, and from public health programs in the remaining regions. FOBT collection kits were distributed from routine laboratory specimen collection sites, to which completed kits were returned. Results were sent to PCPs in all 12 regions, with copies sent to the study office at Cancer Care Ontario (Toronto, Ontario). Follow-up of positive results was at the discretion of the PCPs. The study files contained the unique Ontario Health Insurance Numbers, the date of the analyses, the number of satisfactory slides and the results for each slide. The Ontario Health Insurance Numbers were encrypted for each participant, and along with the study file, were linked to medical billing claims, hospital records and aggregate demographic data.

RESULTS

Among participants with positive results (men 3.5% and women 2.2%), the median time from date of FOBT analysis to date of colonoscopy was 121 days among men and 202 days among women. At the end of follow-up, after positive FOBT (six to 17 months), 73% of men and 56% of women had proceeded to colonoscopy.

CONCLUSION

Although colonoscopy appeared to be acceptable to the majority of participants with positive FOBT, accessibility problems was the likely explanation for lengthy intervals between the date of positive FOBT and its performance. Differences between the experiences of men and women require further investigation.

Self-Collected Samples for Testing of Oncogenic Human Papillomavirus: A Systematic Review

BACKGROUND

To investigate the role of self-sampling for human papillomavirus (HPV) testing as an alternative to cervical cancer screening by clinicians (i.e., Papanicolaou [Pap] test).

METHODS

A systematic search of MEDLINE, EMBASE, Cochrane Library, and other sources for evidence related to the efficacy and feasibility of HPV DNA self-collection.

RESULTS

A total of 25 studies were identified. In 22 comparisons across 19 studies, the concordance between samples collected by patients and those obtained by clinicians was reasonably high in the majority of cases. Women in many countries across wide age ranges were successful in collecting samples for HPV DNA testing. In four studies, the quality of the cytology from patient samples was as good as clinician samples, with more than 95% of samples yielding HPV DNA results. The studies that examined acceptability found that women were generally very positive about collecting their own samples, although some concerns were noted. No study evaluated the effect of HPV DNA self-sampling on screening participation rates, early detection, survival, or quality of life.

CONCLUSIONS

Self-sampling for HPV DNA testing is a viable screening option, but there is insufficient evidence to conclude that self-sampling for HPV DNA testing is an alternative to the Pap test. Although HPV DNA testing using self-collected samples holds promise for use in under-resourced areas or for women who are reluctant to participate in Pap testing programs, the evidence supporting it is limited. Further definitive research is needed to provide a solid evidence base to inform the use of self-sampling for HPV DNA testing for the purpose of increasing screening rates, especially in women who are never or seldom screened.

The effects of a high-fruit and -vegetable, high-fiber, low-fat dietary intervention on serum concentrations of insulin, glucose, IGF-I and IGFBP-3

OBJECTIVE

To determine the effects of dietary change on serum concentrations of insulin, glucose, IGF-I and IGFBP-3.

SUBJECTS

From among participants in a randomized clinical trial of men and women without a history of diabetes who were 35 years old or older and who had at least one histologically confirmed colorectal adenoma removed during a qualifying colonoscopy within the 6 months before randomization, 750 subjects were selected for this analysis.

METHODS

The authors analyzed fasting serum from 375 subjects with and 375 subjects without a recurrent polyp among participants in a randomized trial of a low-fat (20% of energy), high-fiber (18 g per 1000 kcals of energy intake) and high-fruit and -vegetable (5-8 servings per day) dietary intervention.

RESULTS

After 4 years of follow-up, IGF-I concentration in the intervention group (N=248) declined by 8.86 ng/ml (initial mean of 133 ng/ml) and 7.74 ng/ml (initial mean value of 139 ng/ml) in the non-intervention group (N=502). Based on an unpaired t-test, these declines were both statistically significant, but the difference between groups for the decline in IGF-I (1.12 ng/ml ((95% confidence interval, -3.24 to 5.48)) was not. After 4 years, concentrations of IGFBP-3, insulin and glucose were not statistically different from values at baseline, and there were no differences in these serum measures between the intervention and control groups. In analysis restricted to lean (body mass index <25 kg/m(2)) subjects only, however, glucose concentrations in the intervention group decreased by 0.28 mmol/l, while they increased in the control group by 0.01 mmol/l (t-test for mean differences P=0.0003) over 4 years.

CONCLUSIONS

A low-fat, high-fiber, high-fruit and -vegetable dietary intervention had minimal impact on serum concentrations of insulin, glucose, IGF-I and IGFBP-3 overall, but in lean subjects the intervention resulted in a significant reduction in serum glucose concentration.

Ontario Cervical Cancer Screening Clinical Practice Guidelines

OBJECTIVE

To develop clinical practice guidelines for cervical screening and the primary management of abnormal cytology in Ontario, using an established methodological process.

DATA SOURCES

Primary data sources were relevant articles listed in the Medline (1998 to July 2004), Embase (1998 to July 2004), and Cochrane Library (2004, Issue 2) databases.

STUDY SELECTION

Studies addressing quality or the optimization of cervical screening were considered eligible in the systematic review of the evidence. Specifically, clinical practice guidelines, technology assessments, systematic reviews, and randomized controlled trials were of primary interest. Given the variability of the data, other information sources were considered eligible if there was a demonstrated gap in the published literature.

DATA EXTRACTION

Data were identified and extracted by a methodologist and reviewed by four authors. Results were reviewed and discussed by members of an expert working group consisting of a diverse group of health professionals with expertise in cervical cancer. Data audits were conducted by independent reviewers.

DATA SYNTHESIS

recommendations with evidence ratings were developed through a review of the evidence with expert consensus and were approved by more than 80% of 40 external practitioners who reviewed the document and responded to a standardized survey.

CONCLUSION

The development of comprehensive recommendations on cervical screening in Ontario was feasible using a rigorous methodological process. Recommendations for practice are provided.

The effect of haem in red and processed meat on the endogenous formation of N-nitroso compounds in the upper gastrointestinal tract

Red and processed meat (PM) consumption increases the risk of large bowel cancer and it has been demonstrated that haem in red meat (RM) stimulates the endogenous production of N-nitroso compounds (NOCs) within the human intestine. To investigate whether N-nitrosation occurs in the upper gastrointestinal tract, 27 ileostomists were fed diets containing no meat, or 240 g RM or 240 g PM in a randomly assigned crossover intervention design carried out in a volunteer suite. Endogenous NOC were assessed as apparent total N-nitroso compounds (ATNC) in the ileostomy output. ATNC concentration in the diets was 22 microg ATNC/kg (RM) and 37 microg ATNC/kg (PM), and 9 microg ATNC/kg in the no meat diet. Levels significantly increased to 1175 microg ATNC/kg SEM = 226 microg ATNC/kg) following the RM (P=0.001) and 1832 microg ATNC/kg (SEM=294 microg ATNC/kg) following PM (P<0.001) compared to the no meat diet (283 microg ATNC/kg, SEM=74 microg ATNC/kg). ATNC concentrations in the ileal output were equivalent to those measured in faeces in similarly designed feeding studies. Supplementation with either 1 g ascorbic acid or 400 IU alpha-tocopherol had no effect on the concentration of ATNC detected in the ileal output. In in vitro experiments, N-nitrosomorpholine (NMor) was formed in the presence of nitrosated haemoglobin, at pH 6.8 but not in the absence of nitrosated haemoglobin. These findings demonstrate that haem may facilitate the formation of NOC in the absence of colonic flora in the upper human gastrointestinal tract.

The management of ductal carcinoma in situ of the breast: a screened population-based analysis

BACKGROUND

A recent SEER study identified significant variations in the care of women with DCIS, yet several potential confounding variables were not included. We report a patterns of care study of women with DCIS to better understand the gap between evidence-based knowledge and the management of DCIS.

METHODS

We studied all cases of DCIS diagnosed through the Ontario Breast Screening Program from 1991 to 2000. Data was obtained by database linkage and chart abstraction. A logistic regression model using generalized estimating equations to adjust for clustering was used.

RESULTS

About 320,236 women were screened and 727 individuals were diagnosed with DCIS. The rate of mastectomy was 30% and was associated with multifocality (OR: 3.5 [1.7, 7.1], P = 0.0005), tumor size (OR: >2 cm vs. <or=1 cm: 2.7 [1.3, 5.9], P = 0.01), high nuclear grade (OR: 2.4 [1.1, 5.2], P = 0.03) and surgeon's practice pattern. The rate of axillary dissection (AND) decreased from 36% in 1991-1993 to 20% in 1998-2000. AND was associated with mastectomy, year of surgery and hospital volume (OR: 2.7 [1.3, 5.6], P = 0.01). The use of radiation (XRT) following breast-conserving surgery increased from 39% in 1991 to 51% in 2000. XRT was associated with age<70 years, high nuclear grade (OR: 2.7 [1.2, 6.3], P = 0.02) and tumor size > 1 cm (OR: 2.4 [1.3, 4.4], P = 0.006). Half of cases with margins <1 cm did not receive XRT.

CONCLUSIONS

Our study corroborates previous reports on the persistent rates of mastectomy and axillary nodal dissection and the limited use of XRT in the treatment of DCIS.

Effect of screening result on waiting times to assessment and breast cancer diagnosis: results from the Ontario Breast Screening Program

BACKGROUND

The effect of severity of screening result on delays to diagnosis has primarily been examined for mammographic abnormalities. This study will examine delays to assessment and diagnosis for women with an abnormal mammogram compared to women with an abnormal clinical breast examination (CBE) or abnormal CBE and mammogram.

METHODS

Using data routinely collected by Ontario Breast Screening Program (OBSP), 12,675 women aged 50 to 69 with an abnormal screening result between January 1, 2000 and December 31, 2000 were followed prospectively to the completion of their assessment process. Median waiting times from abnormal screen to first assessment procedure and diagnosis were compared by modality of referral and among women with a breast cancer diagnosis by prognostic features.

RESULTS

The median waiting time to first assessment and to diagnosis was significantly longer for women with only a clinical abnormality compared to women with a mammographic abnormality. In addition, women diagnosed with cancers of larger size had longer delays when the abnormality was detected only clinically. However, women referred by both modalities had significantly shorter waiting times to first assessment procedure and to diagnosis of poor prognosis cancers compared to women referred by mammography alone.

INTERPRETATION

Women with an abnormal CBE and mammogram are assessed more promptly and have shorter diagnostic times. However, women with only a CBE abnormality had delays to diagnosis as a result of longer waiting times to first assessment procedure. Integration of the OBSP with assessment centres should improve times to diagnosis irrespective of modality of referral.