Are you Average Risk or High Risk?

Average Risk
- People 50-74 years of age, with no first-degree relative who has been diagnosed with colorectal cancer.
- No personal history of pre-cancerous colorectal polyps or inflammatory bowel disease (Crohn's Disease or Ulcerative Colitis)

High Risk
People with a family history of colorectal cancer in one or more first-degree relatives.
People with diagnosis of Crohn's Disease or Ulcerative Colitis

Colon Cancer Screening Recommendations

Average Risk

• Screen with a Fecal Immunochemical Test (FIT) every 2 years for asymptomatic people aged 50-74 without a family history of colorectal cancer.
• Abnormal FIT results should be followed up by a colonoscopy within 8 weeks.
• Flexible sigmoidoscopy can be used every 10 years for patients aged 50-74 without a family history of colorectal cancer.

High Risk

• Screen with colonoscopy at age 50, or 10 years earlier than the age their relative was diagnosed, whichever occurs first.
• If the first colonoscopy is normal, re-screen in 5 years in patients with a first-degree relative who was diagnosed with colorectal cancer before age 60.
• If the first colonoscopy is normal, re-screen in 10 years in patients with a first-degree relative who was diagnosed with colorectal cancer at age 60 or older.
• If the first colonoscopy is abnormal, your specialist, considering your family history as well as the results of your initial colonoscopy, will make a specific screening recommendation.

If at any time a patient becomes symptomatic (at average or high risk), they should be referred for specialist evaluation. There is no role for FIT in symptomatic patients.

References: https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=358486 this chart which summarizes it nicely.

Reference: Cancer Care Ontario

Information on Abnormal Colonoscopy and Appropriate Re-Screening

If the first colonoscopy is abnormal, a surveillance protocol will be given based on family history and results of first colonoscopy.

A patient is considered at increased risk for development of colorectal cancer if one or more of the following is found on colonoscopy:
- 3 or more adenomas
- High-grade dysplasia
- Villous features
- Adenoma 1cm or greater in size

Recommendation: 3 year follow up colonoscopy

*If a patient has >10 adenomas found on 1 examination, colonoscopy should be completed in <3 years.
* If a patient is found to have a sessile adenoma, removed piecemeal, follow up evaluation should be completed at short intervals, 2-6 months to verify complete removal.
*More intensive surveillance may be indicated when there is a family history of Hereditary Non-Polyposis Colorectal Cancer (HNPCC)/Lynch Syndrome.

A patient is considered at lower risk for development of colorectal cancer if one or more of the following is found on colonoscopy:
- 1 or 2 small (<1cm) adenomas
- Tubular adenoma
- No high-grade dysplasia

Recommendation: 5-10 year follow up colonoscopy

A patient is considered low risk or average risk for development of colorectal cancer if a hyperplastic polyp is found.

Recommendation: 10 year follow up colonoscopy

Reference: Guidelines for Colonoscopy Surveillance After Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society.

Cervical Cancer Screening Recommendations

• It is recommended that Cervical Screening with Pap Test (cervical cytology) is initiated at age 21 years of age for women who are or have been sexually active.
• Routine Cervical Cancer Screening should be completed at 3 year intervals if cytology is reported as normal.
• Screening may be discontinued at age 70, if the previous 3 Pap Tests were normal.

Recommendations for Follow-Up of Abnormal Cytology

Repeat Cytology in 12 months if any of the following are reported on Pap Smear Cervical Cytology:
- Atypical Squamous Cells of Undetermined Significance (If patient is <30 years, however if patient is >30 years, proceed to HPV testing)
- Low Grade Squamous Intraepithelial Lesion (LSIL)

Colposcopy should be completed if any of the following are reported on Pap Smear Cervical Cytology:
- Atypical Squamous Cells, Cannot Exclude HSIL
- Atypical Glandular Cells, Atypical Endocervical Cells, Atypical Endometrial Cells
- Low Grade Squamous Intraepithelial Lesion (LSIL)
- High Grade Squamous Intraepithial Lesion (HSIL)
- Squamous carcinoma, Adenocarcinoma, Other Malignant Neoplasms

Endometrial Sampling should be considered if any of the following are reported on Pap Smear Cervical Cytology:
- Atypical Glandular Cells, Atypical Endocervical Cells, Atypical Endometrial Cells
- Benign Endometrial Cells (if the patient is post-menopausal, or if the patient is presenting with abnormal vaginal bleeding)

If Pap Smear Cervical Cytology is reported as "Unsatisfactory for Evaluation", repeat in 3 months.
If Pap Smear Cervical Cytology is reported as "Satisfactory for Evaluation, No Transformation Zone Present", proceed with routine screening in 3 years.

Please see the link below for further details regarding abnormal cytology results.
https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=13104

References: Cancer Care Ontario

Are you Average Risk or High Risk?

Average Risk

• Women 50-74 years of age
• No acute breast symptoms
• No personal history of breast cancer
• No current breast implants
• Has not had a screening mammogram within the last 11 months

High Risk

• Women 30-69 years of age
• Known to be a carrier of the BRCA1 or BRCA2 gene mutation
• First degree relative of a carrier of the BRCA1 or BRCA2 gene mutation and has not had genetic counseling or genetic testing
• First degree relative of a mutation carrier, has had genetic counseling, and has declined genetic testing
• Previously assessed by a genetic clinic as having a >25% personal lifetime risk of breast cancer based on family history
• Received radiation therapy to the chest before age 30 and at least 8 years ago
• Personal or family history of breast or ovarian cancer suggestive of a hereditary breast cancer syndrome

Breast Cancer Screening Recommendations

Average Risk
Mammogram every 2 years

An average risk woman may be required to have a mammogram in one year if;

• Documented pathology of high risk lesions
• Personal history of ovarian cancer
• Two or more first-degree relatives with breast cancer at any age
• One first degree female relative with breast cancer under age 50
• One first degree relative with ovarian cancer at any age
• One male relative with breast cancer at any age
• Breast density >75% at time of initial screening
• Recommended by radiologist at time of screening

High Risk
Mammogram and breast MRI (or ultrasound) every year.

Does every "high risk" woman get an MRI?
The recommendations state that women in the following categories should receive an MRI of the breasts in conjunction with mammogram on an annual basis:
- Known mutation in BRCA1 or BRCA2 or another gene predisposing to a markedly elevated breast cancer risk
- Untested first-degree relative of a carrier of such a gene mutation
- Family history consistent with a hereditary breast cancer syndrome, and estimated personal lifetime cancer risk of >25%.

There is currently insufficient evidence to make a recommendation regarding MRI imaging for women in the following two categories:
- High risk marker on prior biopsy (atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ)
- Radiation therapy to chest (before age 30, at least 8 years ago)
If you fall into the above two categories, a discussion with your family physician is recommended regarding the need for MRI imaging.

References: CCO
A Quality Initiative of the Program in Evidence-Based Care (PEBC), Cancer Care Ontario (CCO). Magnetic Resonance Imaging Screening of Women at High Risk for Breast Cancer. E. Warner, H. Messersmith, P. Causer, A. Eisen, R. Shumak, and D. Plewes

In Ontario, there are no evidence-based guidelines or standardized of care for Routine Lung Cancer Screening. However, due to the prevalence of lung cancer in Ontario, Cancer Care Ontario is working towards producing Lung Cancer Screening Clinical Practice Guidelines for high-risk populations and a Pilot Project to be initiated.

Current Recommendation
Screening for lung cancer with low-dose CT scan of the chest is recommended in high risk patient populations, defined as persons age 55-74 years of age with a minimum smoking history of >30 pack years who currently smoke, or have quit within the past 15 years, who are disease free at time of screening.

What is a Positive Result and How Do We Follow Up?

• A positive result on low-dose CT is considered a solid nodule size of >5mm or a non-solid nodule >8mm. This should be followed with a repeat CT scan in 3 months.
• If a nodule is >15mm on initial low-dose CT, the patient should undergo immediate further diagnostic work up to rule out malignancy.

What is an Appropriate Screening Interval?

• After a baseline low-dose CT scan is completed and is negative, annual low-dose CT scans should be completed for 2 years, then extend the interval of low-dose CT scans to be completed every 2 years.
• As stated above, if initial low-dose CT is positive, continue with a follow up CT in 3 months. If this second low-dose CT reveals a stable or smaller nodule, proceed with a CT scan annually for 2 years. If this second low-dose CT reveals growth, proceed to a further diagnostic work up.

Reference: A Quality Initiative of the Program in Evidence-Based Care (PEBC), Cancer Care Ontario (CCO). Screening High-Risk Populations for Lung Cancer: Guideline Recommendations. H. Roberts, C. Walker-Dilks, K. Sivjee, Y. Ung, K. Yasufuku, A. Hey, N. Lewis, and the Lung Cancer Screening Guideline Development Group

Currently, Ontario does not support a standardized screening program for prostate cancer.

However, men who are concerned about their risk of prostate cancer are encouraged to make individualized decisions to screen for prostate cancer with PSA testing with their primary care provider. It is important to consider the possible benefits of screening (a small reduction in prostate cancer mortality), against the potential harms of screening (over-diagnosis and over-treatment).

Considerations for Prostate Cancer Screening
Screening for Prostate Cancer can be offered to all men 50 years of age with at least a 10-year life expectancy. It is strongly recommended by the Canadian Urological Association that Prostate Cancer screening be discontinued at age 75 years of age or older. Although there is no standard of care with respect to screening interval, both the Canadian Urological Association, as well as the U.S. Preventative Services Task force suggests lengthening the interval of PSA testing from annually, to 2-4 years. The frequency of PSA testing should ultimately be decided upon by the patient and their primary care physician.

High Risk Patient Population

• Men with a family history of prostate cancer, with prostate cancer in multiple generations, or one or more first-degree relatives who were diagnosed with prostate cancer.
• African American men

The Canadian Urological Association recommends that patients in this category should be offered prostate cancer screening at age 40.

References: CCO,
CUA Guideline – Prostate Cancer screening: Canadian Guidelines 2011 Jonathan I. Izawa, MD, FRCSC; Laurence Klotz, MD, FRCSC; D. Robert Siemens, MD, FRCSC; Wassim Kassouf, MD, FRCSC;‡ Alan So, MD, FRCSC;± John Jordan, CCFP, FCFP, MSc;¥ Michael Chetner, MD, FRCSC; Alla E. Iansavichene, MD

United State Preventative Services Task Force, Moyer VA, et al. Screening for Prostate Cancer: U.S. Preventative Services Task Force Recommendation Statement. Ann Intern Med. 2012; 157: 120-134.

In Ontario, there is insufficient evidence at this time for or against skin cancer screening of the general population who are average or low risk for developing skin cancer. Because of this, there is no current recommendation for annual total body skin examination by a health care practitioner for those who are average or low risk patients.

However, if patients fall into any of the below categories, it may be reasonable to following the considerations listed below.

Very High Risk
If you have any of the following risk factors, you are at very high risk for skin cancer, 10 times the general population:

- Receiving immunosuppressive therapy post organ transplant
- Personal history of skin cancer
- Two or more first-degree relatives with melanoma
- More than 100 nevi in total, or >5 atypical nevi
- Received radiation therapy for cancer as a child
- Received >250 PUVA (psoralen ultraviolet A radiation) treatments for psoriasis

High Risk
If you have two or more of the following risk factors, you are at a high risk for skin cancer, 5 times the general population:

- First-degree relative with melanoma
- 50-100 nevi
- One or more atypical (dysplastic) nevi
- Naturally red or blonde hair
- A tendency to freckle
- Skin that burns easily and tans poorly, or not at all

Considerations for Skin Cancer Screening

Very High Risk Patients
Patients who fall into this category should be offered total body skin examination on an annual basis performed by a dermatologist or other healthcare provider with expertise in skin examination
- They should be educated about self-skin examination as well as skin cancer prevention.

High Risk Patients
Patients who fall into this category should be educated about self-skin examination as well as skin cancer prevention. These patients should have annual appointments with their primary care physician.

References:
Screening for Skin Cancer: A Clinical Practice Guideline. L. From, L. Marrett, C. Rosen, C. Zwaal, M. Johnston, K. Bak, G. Sibbald, J. Fong, and V. Mai. A Quality Initiative of the Program in Evidence-based Care (PEBC), Cancer Care Ontario (CCO)