SOUTH WEST PRIMARY

CARE ALLIANCE: OXFORD

NOVEMBER 7TH, 2018

Sub Regional Clinical Lead: Dr. Jitin Sondhi

Primary Care Alliance Co-Chair: Dr. Gerry Rowland

Agenda

• Review of Previous Minutes (completed online)

• Review of SRIT

• Oxford RAAM clinic

• Access to Team Based Care Survey

• Review and Feedback on Priorities

• FIT: Colon Cancer Screening update by CCO

RAAM Clinic in Oxford

• LHIN leadership approved clinic in Oxford

• Located in CHC

• Updates regarding timeline and opening will be posted

• Seeking physician to participate in the clinic• FFS

• No overhead costs

• Stipend weekly for participation in meeting

• Target audience are those with Opioid and Alcohol Use Disorders

• Team will consist of physician, NP and addictions and mental health counsellors on scene

• Goal is for rapid access from clinic and ED

Access to Team Based Care

• Improve access to FHO/FHG physicians

• Complete survey to help with my business plan and

proposal

• Goal is to respect physician autonomy in business

arrangement and not impact on resources available to

patients and providers based on type of practice.

• Survey takes 2 min at most

• Please do this now

• https://www.surveymonkey.com/r/MXC5C65

• Link is available in your newsletter sent October 4th, 2018

https://www.surveymonkey.com/r/MXC5C65

OXFORD SRIT Driver Diagrams

• Based on July meeting

• Drive work from SRIT members

• Please review and provide input directly to Jitin or Gerry.

Broaden access to

inter-professional

resources through

collaboration and

partnership

Availability of inter-professional resources

Collaboration between sectors and providers

Uptake of new models of coordination and planning

Primary Drivers Secondary Drivers Change Ideas

Advise and champion local initiatives -i.e., Clinical

Connect and CSSN Central Intake

Champion initiatives that increase access i.e., Rapid

Access to Addiction Medicine (RAAM) model

Champion uptake of Coordinated Care Plans

Communication with patients and caregivers

Providers are accountable to each other and to patients

Providers are aware of what services are available within

and across sectors

Access Driver Diagram

Providers have access todigital health records

Co-locate staff

Youth Wellness Hub

LHIN Home and Community Care relationship with

Primary Care

Create a shared understanding of

current initiatives and available programs

and resources to improve patient access and flow

Collaboration betweenproviders and sectors

Ease of navigation for online resources

Primary Drivers

Communication between providers

Secondary Drivers Change Ideas

Sector representatives to present to SRIT abouttheir

services

Links on provider websites toother regional services

Make thehealthline.ca more intuitive for patients and

caregiversCommunication with

patients and caregivers

Provider awareness of services available across

sectors

Availability of information online

Communication Driver Diagram

Communication between patients / peer-to-peer

groups

Communication with broader community

Peer-to-peer / community groups’ awareness of

programs and initiatives

Round table updates at each SRIT meeting

Provide information for local social media platforms

Communication with non-healthcare services related to social determinants of

health

SRIT to undertakeservice mapping exercise

Availability of paper-basedinformation

Providers know who to call in other sectors for client /

patient referrals SRIT to engage with City / County representatives when

needed

Broaden access to HealthChat

Presentations to service clubs (Optimists, Legion etc.)

Market health care services in the community (bulletin

boards / newspapers/ flyers)

Improve transitions for complex patients

being discharged from hospital through

system partnerships and collaboration

Communication betweenproviders and patients

Best-practices areimplemented

Provider access to digital health records

Primary Drivers Secondary Drivers Change Ideas

SRIT members champion uptake of Health Links CCPs within sectors

CMHA, CHC & NPLC access toCHRIS

IT support for primary care

Communication between providers

Uptake of Health Links Coordinated Care Plans

Transitions Driver Diagram

Focus on relationshipbuilding among providers

Primary Care Practitioner uptake of Emerg. Dept. notification software

SRIT champion Clinical Connect

SRIT champion CSSN Central Intake

Rounds and Situation Tables tohelp coordinate transitions

Patient experience incorporated into transition

planning / protocols

Proactively seek patient feedback ontransition experience

Share sector education at Care Coordination meetings

Sector updates at each SRIT meeting

SRIT to review IDEAS transitions pilot from Grey Bruce

Successful LHIN and / or provincial projects / pilots

that could be scaled

Discharge planning at admission

Co-location of staff

SRIT champion expansion of BSO Mobile Teams for LTC

Improve access to assisted living and

supportive housing through knowledge

transfer and accountability

Primary Drivers Secondary Drivers Change Ideas

Appropriate Residential Settings Driver Diagram TBD Fall 2018

Presenter Disclosure

12

• Dr. Jan Owen, Primary Care Lead

South West Regional Cancer Program

Dr. Brian Yan, Endoscopy Lead

South West Regional Cancer Program

• Relationships with commercial interests:

o Grants/Research Support: None

o Speakers Bureau/Honoraria: None

o Consulting Fees: None

o Other: Employees of Cancer Care Ontario

• Potential for conflict(s) of interest:

o None

• All information provided in presentation has been provided by Cancer

Care Ontario.

Learning Objectives

13

1. To describe how the colorectal cancer screening

process is changing in Ontario

2. To demonstrate how the fecal immunochemical test

(FIT) results in high yield colonoscopy

3. To discuss how primary care providers (PCPs)

should manage their patients who receive an

abnormal FIT result

Question

14

You have a patient who is 62 years old, with no family

history of colorectal cancer (CRC) and is asymptomatic.

She has recently moved to Canada and has never been

screened for CRC. How would you screen this individual for

CRC, assuming all of these tests were available to you?

a. Colonoscopy

b. gFOBT

c. FIT

d. Flexible sigmoidoscopy

e. No screening

• In 2018, it is estimated that approximately 6,376 men

will be diagnosed with colorectal cancer and

approximately 1,811 will die from it

• Second leading cause of cancer deaths.

• In 2018, it is estimated that approximately 5,219

women will be diagnosed with colorectal cancer and

approximately 1,548 will die from it

• Third leading cause of cancer deaths.

Colorectal cancer is the 2nd most commonly

diagnosed cancer in Ontario

Colorectal Cancer in Ontario

15

Ontario’s ColonCancerCheck (CCC) Program

• Canada’s first organized province-wide colorectal (CRC)

screening program

• CCC sends letters to eligible individuals

• Screening offered to ages 50-74

– Via primary care provider

– Average risk: guaiac fecal occult blood test (gFOBT)*

– Increased risk (≥1 FDR with CRC): colonoscopy

16

*flexible sigmoidoscopy (FS) every 10 years is an acceptable screening test

Sources: Tinmouth et al. Program in Evidence-based Care (PEBC) Evidence

Summary 2015; 15-14

gFOBT vs. No Screening

17

OutcomesRelative effect

(95% CI*)

# of person-years

(# of studies)

CRC mortality

(follow up range: 17-30

years)

RR* 0.87

(0.82 to 0.92)

5,344,100

(4 RCTs*)

CRC incidence

(follow up range: 17-30

years)

RR 0.96

(0.90 to 1.02)

4,866,448

(5 RCTs)

13% reduction in

death

*CI=confidence interval, RR= relative risk, RCT= randomized control trial

Impact of Organized Screening Through the

CCC Program

18

Between 2008 (launch of CCC) and 2014, over 4 million

CCC program gFOBTs have been completed

Estimated detection of 7,460 colorectal cancers

Organized CRC Screening in Canada

19

Fecal immunochemical test (FIT)=

in 8 provinces, 2 territories

20

CCC is planning to

implement FIT as the

recommended test for

people at average risk of

CRC

21

gFOBT vs. FIT Lab Parameters

gFOBT FIT

Measures Heme; non-specific Globin; human

Test technique Guaiac; peroxidase Immunochemical

Lower limit of blood

detection300–600 µg Hb/g* 10–20 µg Hb/g

InterferenceVitamin C, other

sources of HbNone

No dietary or medicine restrictions

Detects much smaller

levels of blood in stool

*Hb=hemoglobin

Source: Tinmouth J, et. al. Gut. 2015 Aug;

64(8):1327-37.

22

gFOBT vs. FIT Lab Parameters

gFOBT FIT

# of samples

required3 1

Lab process Manual Automated

Results Qualitative Qualitative or quantitative

StabilityLess stable at high

temperatures and over time

• Kit delivery and return

• Kit inventory management

23

• At-home stool sample screening test

• 1 sample

• Tube designed for easy sampling

• No dietary or medication restrictions

Easier to use

FIT Usability for Participants

Sources:

1.Lee JK, Liles EG, Bent S, Levin TR, Corley DA. Accuracy of fecal

immunochemical tests for colorectal cancer: systematic review and meta-analysis.

Ann Intern Med 2014;160:171-181.

2. Canadian Task Force on Preventive Health Care. Screening for Colorectal

Cancer [Internet]. Ottawa, Canada: Canadian Task Force on Preventive Health

Care; 2014. Available from: http://canadiantaskforce.ca/guidelines/published-

guidelines/colorectal-cancer/

Accuracy for CRC: One Time Test

24

Sensitivity Specificity

FIT

(n=19 studies)82% 94%

gFOBT

(n=9 studies)47.1% 96.1%

FIT is comparable to mammography & Pap test

*HRA= High risk adenoma

Source: Tinmouth et al. Program in Evidence-based

Care Evidence Summary 2015; 15-14

FIT vs. gFOBT – Clinical Implications

25

OutcomesRelative effect

(95% CI*)

# of person-years

(# of studies)

Participation rateRR 1.16

(1.05 to 1.28)

52,038

(6 RCTs*)

CRC/HRA* detectionRR 2.15

(1.58 to 2.94)

51,634

(5 RCTs)

• 2X more accurate

• Detects CRC and HRA

16% improvement

in participation

Adenoma to Cancer

26

FIT detects

gFOBT detects

CancerHRA

FIT has potential to reduce

the incidence of CRC

When will FIT be Available in Ontario?

Funding Communications

Program

design

Laboratories

ITQuality

assurance

• Until further notice: gFOBT remains the recommended CRC

screening test in Ontario

• We are actively working towards FIT: coming soon!

27

FIT vs. Colonoscopy

28

Quintero: FIT vs. Colonoscopy

29

Large RCT in

Spain

Ages 50-69

Biennial FIT vs.

one-time

colonoscopy

Primary outcome:

CRC- death at 10

years

Reflects only first

round results

Mailed invitation

to participate

Source: Quintero E., et. al., NEJM 2012;366:697-706

Quintero: Patients Prefer FIT

26,599

invited for FIT

1% offered

FIT

opted for

colonoscopy

23% offered

colonoscopy

opted for FIT

26,703

invited for colonoscopy

36% responded 28% responded

30

FIT is preferred by patients when given the option

Quintero: Diagnostic Yield- Intention to Screen

31

Colonoscopy

n=26,703

FIT

n=26,599

P-value

CRC detection 30 33Not

significant

HRA 514 231

Question

32

After you explain the benefits of FIT, your patient still feels

they may want to have a colonoscopy and asks about

potential risks. What are the risks associated with

colonoscopy?

a. Colonoscopy-related perforation

b. Post-polypectomy bleeding

c. Risks related to bowel preparation

d. Risks related to the use of sedation

e. All of the above

Answer

33

e. All of the above

Colonoscopy Associated Complications: Calgary

34

Complication

N=18,456

Total # adverse events: 119

Event rate*

*per 1,000 colonoscopies

Bleeding 2.93

Perforation 0.22

Post-polypectomy syndrome 0.16

Cardiac 0.22

Syncope/hypertension 0.27

GI symptoms (minor and transient) 1.95

Splenic/hepatic hematoma 0.11

Other 0.60

Colonoscopy is not a benign procedure

Screening with Colonoscopy vs FIT

35

FIT: more people screened • same number of

colonoscopies • more cancers detected

Outcome Yield Yield

CRC 400 8,000

HRA 10,000 45,000

Average risk

colonoscopyFIT+ colonoscopy

20x

4.5x

yield

with FIT

1.3 million screened100,000 screened

100,000 scoped 100,000 scoped

FIT Experience in Alberta

36

Colorectal Cancer Screening in Alberta

37

Before fecal immunochemical test FIT roll out:

• Primary care providers preferred colonoscopy over gFOBT

• Only 23.5% gFOBT participation in Calgary zone

Introduction of FIT:

• Rapid uptake of the test

• 31‒35% FIT participation in Calgary zone

• Primary care providers quickly saw value of screening with

FIT

38

0

500

1000

1500

Ref

erra

l Vol

ume

July/13 Oct Jan/14 April July Oct Jan/15 Apr July Oct Jan/16 AprMonth

Urgent Priority Urgent

Moderate Routine

by Triage Priority

CCSC Monthly Referral Volumes

FIT introduced Nov 20130

50

01

000

15

00

Re

ferr

al V

olu

me

Jan/13 Apr Jul Oct Jan/14 April July OctMonth

gFOBT+/FIT+ Average Risk for CRC

Figure 3: 2013-14 Monthly Referral Volumes

FIT Roll Out: Impact on Colonoscopy in Calgary,

Alberta

0

500

1000

1500

Refe

rral V

olume

July/13 Oct Jan/14 April July Oct Jan/15 Apr July Oct Jan/16 AprMonth

Urgent Priority Urgent

Moderate Routine

by Triage Priority

CCSC Monthly Referral Volumes

Introduction of FIT

Source: Alberta Health Services. First Year Experience with the Fecal

Immunochemical Test. June 2015.

Calgary: Lesions Detected at Colonoscopy

39Source: Alberta Health Services. First Year Experience with the Fecal

Immunochemical Test. June 2015.

Benefits of FIT: Summary

40

Better test usability

Increased participation

More follow-up colonoscopies

Higher positivity rate

More cancers and HRAs

detected

Increased sensitivity

Anticipated decrease in CRC

incidence and mortality

FIT vs. Colonoscopy: Summary

41

• Patients prefer FIT

• FIT is safer than colonoscopy

• FIT is as good as colonoscopy at detecting CRC in

average risk people

• FIT-positive colonoscopy is high yield – colonoscopy used

in people most likely to benefit

FIT → better risk–benefit ratio of screening

The CCC program does not recommend screening for

average risk people with colonoscopy

Transition to FIT

42

CCC Eligibility Criteria for FIT

43

Eligibility criteria have not changed

Note: Patients must have a valid Ontario Health Insurance Plan number

Question

44

Your patient is a 56 year old woman who had a colonoscopy

completed in 2016 following an abnormal (positive) gFOBT

result. Her scope revealed one small hyperplastic polyp on

the sigmoid colon. When and how should she next be

screened?

a. Re-screen in 10 years with colonoscopy

b. Re-screen in 10 years with FIT

c. Re-screen in five years with colonoscopy

d. Re-screen in two years with FIT

e. Re-screen in two years with colonoscopy and biennially

thereafter

Answer

45

b. Re-screen in 10 years with FIT

• As per ColonCancerCheck Surveillance Guidelines1,

average risk people with hyperplastic polyps in the rectum

or sigmoid colon should re-screen in ten years with a FIT.

Following a normal colonoscopy, people at average risk of

colorectal cancer do not need to continue to re-screen with

colonoscopy, and the patient should return to screening

with the FIT in ten years.

• As outlined within ColonCancerCheck Screening

Recommendations2, people ages 50-74 without a family

history of colorectal cancer could choose to be screened

with flexible sigmoidoscopy every 10 years instead of FIT.

Confirm mailing

address for FIT kit, patient

address & date of birth*

Explain to patient how to complete

FIT

Submit completed

FIT requisition to central lab

Lab will mail pre-labelled

FIT kit to patient

How to Order FIT for Patients

46

* People who live on a First Nation reserve can request a FIT kit through a health centre or nursing station.

Step 1 Step 2 Step 3 Step 4

Submit completed

FIT requisition to central lab*

Lab will mail pre-

labelled FIT kit to

patient

Requisition Changes

47

Regular lab requisition

cannot be used to

request CCC program

FIT

CCC gFOBT will be

removed from regular

lab requisition

New FIT Requisition

48

• Valid for 6 months

from lab receipt

• Supports patients

who are home

insecure

Ensure Your Patients Get Their FIT

49

Alternate FIT kit delivery

option

Confirm that patient address

information is up-to-date:

• to obtain a FIT kit

• to receive results

Why Centralized Distribution?

50

Program challenges Future State (FIT)

• 11.1% of program gFOBT

require re-testing

• Majority of rejected tests due

to mislabeling

• gFOBT shelf-life: 3 years

• FIT shelf life: 12-18 months

Pre-labeled kits

with patient

identifiers

Inventory

management at

central site

Completing FIT: 3 Steps for Patients

51

Check label accuracy and clearly record

specimen collection date on

FIT tube

Complete FIT

Mail or drop off completed FIT to the lab as soon

as possible*

Step 1 Step 2 Step 3

52

FIT Return

Completed FIT kit should be returned as soon as possible

to the lab

• Mail

o Regular mail

o Expedited mail included for some areas

• Drop off at lab specimen collection centres

• Cancer Care Ontario is working on confirming options to

support FIT return for people living on a First Nation

reserve and in rural and remote areas

53

Supporting Patients

• Patient-friendly FIT

materials are being

developed, including FIT

instructions that use more

visuals than words

• FIT instructions will be

available in 20+ languages

and in accessible format

online

*For people ages 50–74.

FIT Results and Follow-Up by PCP

54

PCP will arrange for

follow-up colonoscopy

to be performed within

8 weeks

Do NOT repeat FIT

Results

Repeat FIT in the next

few weeks– new

requisition required

Normal result

Abnormal result

Invalid result or

rejected deviceLab will send FIT

result to primary

care provider (PCP)

Cancer Care Ontario

will send FIT result

letter to patient

55

Supporting Patients

• Patients will continue to receive CCC program

correspondence

o Invitations/recalls

o Reminders

o Results

• Physician-linked correspondence helps

increase screening rates

The Patient Perspective

56

An abnormal FIT result can be stressful for your

patient and their family

• Explain that an abnormal FIT:

o Needs timely follow-up with colonoscopy within eight

weeks

o Is NOT a cancer diagnosis

o Can identify a polyp before it becomes cancerous

How to Manage Patients

with an Abnormal FIT

57

Follow-Up of Abnormal FIT Results

58

Time to colonoscopy after gFOBT+ result

2 months 4 months 6 months

48% of people receive a

colonoscopy within 8 weeks

of a gFOBT+ result

Approximately 20% of

individuals are lost to

follow-up at 6 months

Benchmark: follow-up within 8 weeks

Importance of Follow-Up

59

Follow-up

No follow-up

Patients with an abnormal FIT who do not undergo colonoscopy are

more likely to die from CRC

Source: Lee et al., Association Between Colorectal Cancer Mortality

and Gradient Fecal Hemoglobin Concentration in Colonoscopy

Noncompliers. J Natl Cancer Inst (2017) 109(5)

60

Importance of Timely Follow-Up

Impact of diagnostic delay is seen within months

- Significantly higher risk of CRC after 6 months

Time to colonoscopy

after FIT+% cases receiving colonoscopy after FIT+

Any CRC Advanced-stage CRC

8-30 days 2.97% 0.81%

2 months 2.78% 0.70%

3 months 3.06% 0.69%

4-6 months 3.14% 0.88%

7-12 months 4.56% 1.49%

>12 months 7.55% 3.13%

Source: Corley et al. JAMA 2017;317(16):1631-41.

Carefully Consider Where Follow-Up Occurs

61

• FIT+ colonoscopies are more complex → require more

expertise, time and resources

Question

62

You have a patient who is 62 years old, with no family

history of colorectal cancer (CRC) and is asymptomatic.

She has recently moved to Canada and has never been

screened for CRC. How would you screen this individual for

CRC, assuming all of these tests were available to you?

a. Colonoscopy

b. gFOBT

c. FIT

d. Flexible sigmoidoscopy

e. No screening

Screening Until FIT is Available

63

Do not delay!

Continue to screen your patients with gFOBT

until FIT is available through the CCC program

Clinical Pearls

64

Use FIT, not colonoscopy

FIT+ colonoscopy needed within 8 weeks

Centralized FIT kit distribution will minimize errors

Screen with gFOBT until FIT is available

Questions?

65

Appendix

66

67

Considerations

• Post polypectomy surveillance recommendations are primarily

intended for endoscopists to ensure appropriateness of

colonoscopy

– When referring for endoscopist surveillance, include prior scope &

path report if available

• How should PCPs manage cases where endoscopist

recommendation does not align with surveillance guidelines?

• Endoscopist recommendation may be influenced by other factors not

accounted for in the surveillance guidelines, such as quality of

colonoscopy:

– Adequate bowel preparation, complete procedure to cecum,

careful examination of colonic mucosa

• Guidelines can be used to assist discussion with endoscopists

68

CRC Mortality in LRA vs General Population

• 25% significant relative risk reduction in CRC mortality of

LRA vs. general population

– Standardized mortality ratio = 0.75 (95% CI: 0.63–0.88)

Loberg et al. N Engl J Med 2014

CRC Mortality in Low Risk Adenoma vs.

General Population

69

Switching to FIT After Average Risk Colonoscopy

Systematic Review: Risk of advanced neoplasia and

death with low risk adenomas

• No evidence to support surveillance in people with LRA

– Lower risk of CRC and CRC mortality compared to

the general population

– Small increase in relative risk for high risk adenoma at

4-10 years compared to those with normal

colonoscopy

Patient Attachment

70

• PCPs can still register to

accept and roster new

patients who require

follow-up

• Code Q043A or Q053A

Evaluation: Physician Linked vs. Unlinked letters

Uptake of FOBT in 6 months

16.9

9.2

0

20

40

60

Summary

Resp

on

den

ts (

%)

PCP linked 2012 Unlinked 2012

%

%