The head of the province's cancer screening programs is encouraging Ontarians to go for breast, cervical or colorectal cancer screening tests as the province sees a "gradual phased resumption" of these services.
This follows a significant decrease in screening tests during the COVID-19 pandemic, with nearly 451,000 fewer tests performed across three Ontario screening programs during a 78-day period compared to a year prior. One surgical oncologist says these tests can "save thousands of lives" and wants to see an "aggressive" ramping up of cancer screening.
"We would encourage them to go," said Dr. Linda Rabeneck, left, vice-president of prevention and cancer control at Ontario Health, which now includes Cancer Care Ontario. She said while it's still too early to know whether people due for their tests during the past few months will forgo the screening or hesitate to go into a health facility in the coming months, they "should be reassured" that hospitals and clinics are focusing on using personal protective equipment and having proper infection prevention and control measures in place.
Dr. Shady Ashamalla, a surgical oncologist specializing in colorectal cancer and head of the division of general surgery at Sunnybrook Health Sciences Centre, agreed.
"The big emphasis is get screened, nothing has changed," Ashamalla said, imploring people due for screening to get tested. "But I also think it behooves the government to continue to push these things to make sure that everybody is aware that these are all still very important initiatives that can’t be ignored because we’re dealing with this pandemic."
He said society needs to "reap the benefit" of keeping COVID-19 case numbers at "manageable" levels.
"We can’t neglect all other health care because it is still a threat, and quite frankly more and more it's becoming more of a threat than COVID," he said.
According to data provided by Ontario Health, there were 450,963 fewer screening tests done between March 15 and May 31 compared to the same period last year.
- 154,902 fewer mammograms through the Ontario Breast Screening Program (4,065 from 158,967, a 97 per cent decrease)
- 192,810 fewer Pap tests through the Ontario Cervical Screening Program (26,269 from 219,079, an 88 per cent decrease)
- 103,251 fewer fecal tests through the ColonCancerCheck program (38,000 from 141,251, a 73 per cent decrease)
"It has had an impact on screening without a doubt in Ontario and frankly globally as well — all of the other cancer screening programs that we know and we’re in contact with in the rest of Canada and in Europe and the U.S. have all been impacted by the pandemic," said Rabeneck.
Ontario Health's Cancer Care Ontario has recommended the gradual resumption of routine breast and cervical cancer screening tests — mammograms and Pap tests — but new requisitions are still on hold for colon cancer screening tests — the fecal immunochemical test (FIT), which looks for blood in the stool. The agency said the latter are on hold while "LifeLabs process requisitions and mail-out FIT kits that have been on hold since March 23, 2020."
"Aligned with the Ministry of Health’s direction, LifeLabs is modifying its processes and working space to allow for physical distancing and other infection control practices before fecal immunochemical test (FIT) kit mailing can resume," said the agency in a statement to QP Briefing. Rabeneck said the mailing out of FIT kits to patients with requisitions already on file started this week, but that they're asking family doctors not to send out new requisitions just yet.
The partial resumption in screening comes after Chief Medical Officer of Health Dr. David Williams amended one of his directives at the end of May to allow for the "gradual restart of all deferred and non-essential and elective services, including in hospitals and for all regulated health professionals." The provincial directive was first issued in March, prompting Ontario Health (Cancer Care Ontario) to recommend that "all routine cancer screening tests be deferred," with the amendment enabling a ramping up of cancer screening — seen by Rabeneck as an important part of the province's delivery of cancer services.
The agency noted that in April and May, "a very small amount of breast and cervical screening tests that were already scheduled were completed," and that LifeLabs processed completed FIT tests for those who got their tests before the "mailing pause" in March.
While data isn't yet available on how many screening tests have been completed since the directive was amended, Rabeneck said she's "comfortable with our ability to very closely monitor the volumes" to see how these services are resuming across the province.
"We think that the readiness across the province may be a little variable depending on which part of the province we’re talking about," she said.
For Pap tests to resume, visits to a family physician's office would be necessary. Mammograms can be done at hospitals or independent clinics, Rabeneck noted. And as for the FIT test, a person could have an in-person or virtual appointment with their doctor and get the kit through the mail.
"A gradual phased resumption is what we’re doing," said Rabeneck, stressing that the screening programs involve hospitals, clinics and LifeLabs.
"We have to align our resumption of services across all these partners and make sure they’re all ready to move forward as well, so a lot of it is communication and coordination with our partners on the resumption of screening," she said.
But Ashamalla said he thinks there needs to be a "much more aggressive ramp-up" of cancer screening tests.
"The gravity of not doing this quickly needs to be understood by all parties that every month that goes by, there are individuals whose cancers are being missed and whose prognosis will change as time goes on," he said.
With a pause on most screening, Rabeneck acknowledged that people "could have had their cancer diagnosed earlier if the pandemic hadn’t happened and they had their screening at the time that they were originally scheduled for," but she added that it's still too early to know the "extent to which that might have happened."
"We will of course be measuring this, but it’s really impossible to say at this point in time," she said.
Rabeneck said while it's important "not to minimize" the decreases in the volume of screening tests done, "it’s really important to keep in mind that when a person has a screening test they’re feeling fine, they have no complaints, no symptoms."
"When I go for a mammogram, I don’t have any lump or any problem to my knowledge," she said. If a woman noticed a lump in her breast and needed a followup, that wouldn't be considering screening, but rather a diagnostic mammogram, said Rabeneck.
"Although there’s been a decrease in the number of diagnostic mammograms, the decrease hasn’t been as much as it has been for screening ... which is what you would, I think, want," she said.
While the volume decreases don't surprise Ashamalla, they "certainly concern" him.
He said while it's one thing to look at the testing numbers in a chart, it's quite another to "meet a patient who is 45 or 50, who (has) presented with rectal bleeding, we investigate, we find an advanced cancer and we know that three, four months ago ... finding that cancer would have been a different prognosis."
The purpose of a screening test is to find people before they are symptomatic, but such a test is only valuable if doing so improves their prognosis, Ashamalla explained, adding that screening everyone for pancreatic cancer wouldn't make sense because "the prognosis is so bad" that finding these patients before they develop symptoms wouldn't change their prognosis.
"So those screening programs save lives, they save thousands of lives every year, because cancers are found in their very early stages, whether it’s in the pre-malignant stage or in the early malignant stage, in a stage where there’s a high probability of cure if treated expediently," he said. "In the absence of a screening program, we are waiting for these tumours to declare themselves symptomatically and in these cancers we know that a symptomatic colon cancer has a worse prognosis than an asymptomatic colon cancer. So a lack of screening directly translates into higher death and worse prognosis for these types of cancers."
In May, Ashamalla told QP Briefing said he had seen a reduction in the number of new referrals he was getting each week — either for those who had an abnormal FIT test and needed a followup test like a colonoscopy, or people who had already been diagnosed with colon or rectal cancer and were being referred for surgery. While he's seen an increase, there's been a change in the makeup of the referrals.
"The referrals I’m seeing are almost exclusively symptomatic patients who have presented themselves to medical attention, have gotten a colonoscopy, something’s found, as opposed to that healthy mix of asymptomatic positive screening and symptomatic people," he said. "We're just not seeing those early cancers found on screening, highly curative, that group is still out there and has not been found or identified and (it's) scary to think that."
"Those cancers that would have been found in March or April, asymptomatic, now we’re two or three months further along, those are the cancers that are going to start become symptomatic," he added.
Stuart Edmonds, executive vice-president of mission for the Canadian Cancer Society, shared the view that screening tests are "critical." With many cancers, the sooner they are identified, the more options an individual has for treatments and the greater the chance of survival, he said.
"Obviously we want to get to a situation where anyone that actually is in the age group to be screened under normal circumstances would be screened, but right now I think what’s really critical is getting those high-risk individuals screened," he said, adding that getting a test done, and if the results come back normal, can reduce anxiety for people.
Photos courtesy of Ontario Health and Sunnybrook Health Sciences Centre