Ontario offering earlier breast screening to women at high risk

Family physicians are the primary link to breast cancer screening for women with a genetic mutation or other risk factors
As healthcare professionals, we have much to be proud of when it comes to screening for cancer. Ontario, for example, has made great strides in the screening and treatment of cancer, however there is still much work to be done.  While the incidence of breast cancer in Ontario is stable and mortality rates have declined, further improvements could result from higher screening participation.
Almost 9,000 women in Ontario will be diagnosed with breast cancer this year. With regular screening, breast cancer can be detected earlier, providing women with more treatment options and a better chance for a successful recovery.
Now, thanks to a recently announced expansion of the Ontario Breast Screening Program (OBSP), more women in Ontario will access to potentially life-saving breast cancer screening, and are being encouraged to “screen for life.”
Family physicians and nurse practitioners have an especially important role to play in helping women understand the importance of early detection through screening. Being aware of the changes to the OBSP, and how these changes will affect you, will help ensure that we can continue to successfully improve survival rates.

OBSP: What has changed?
As of July 1, women in Ontario aged 30 to 69 who are at high risk for breast cancer are able to receive genetic assessment (if appropriate), and screening via annual breast magnetic resonance imaging (MRI) and mammograms through the OBSP. In addition to screening, the OBSP also provides automatic recalls and coordinated follow-up for women who have abnormal screening results. To date, the OBSP has provided over 4.1 million screens to more than 1.2 million women and detected more than 22,000 breast cancers, the majority in early stages. Until now, women in Ontario had to wait until age 50 to access these screening services through the OBSP, regardless of their risk of developing cancer. With the expansion of the OBSP, an estimated 34,000 additional women at high risk are eligible for organized screening.
The expansion follows evidence-based recommendations from Cancer Care Ontario (CCO), the Program in Evidence Based Care (PEBC), and the Ontario Health Technology Advisory Committee (OHTAC). Regular screening and early detection are particularly important for women at high risk, who have a 25 per cent or greater lifetime risk of developing breast cancer (two to five times higher than that of the general population). For women who carry the BRCA1 or BRCA2 gene mutation, the lifetime risk increases to 85 per cent. Breast cancers in this high-risk population also tend to be more aggressive and develop at a younger age than in the general population.
Women aged 30 to 69 are considered to be at high risk for breast cancer if they meet any one of the following risk criteria:
•    Are known to be carriers of a deleterious gene mutation (e.g. BRCA1, BRCA2)
•    Are the first degree relative of a mutation carrier (e.g. BRCA1, BRCA2) and have declined genetic testing
•    Are determined to be at ≥ 25% lifetime risk of breast cancer -- must have been assessed using either the IBIS or BOADICEA risk assessment tools, preferably at a genetics clinic
•    Have received chest radiation before age 30 and at least 8 years previously.

What this means for you
The expansion of the program has implications for those on the frontlines of Ontario’s healthcare system. CCO and the Ministry of Health and Long-Term Care (MOHLTC) are encouraging women to take charge of their health and determine when screening is appropriate by discussing their risk profile with their family physician or nurse practitioner. Though only one per cent of Ontario women are estimated to be at high risk, family physicians and nurse practitioners can expect an increase in the number of visits from women seeking information about their risk for breast cancer and their need for screening. For those not at high-risk, screening should start at age 50.
OBSP High Risk Screening Centres will facilitate genetic assessment and testing, and will also offer access to annual breast screening MRI and mammography services. Upon referral, an OBSP Navigator will book appointments for your patient to have further assessment at a genetics clinic and/or to receive a breast screening MRI and mammogram as appropriate.
Women who are identified as high risk should be referred to the OBSP directly for screening. Women with family histories that put them potentially at higher risk for breast cancer should be referred to the OBSP for genetic assessment and testing to further evaluate their risk profile.  The OBSP will inform you and your patient of screening results, arrange follow-up breast assessment services after abnormal screens, and provide automatic annual recalls for women who are due to be re-screened. Navigators working at OBSP High Risk Screening Centres are specially trained healthcare professionals who work one-on-one with women, helping them to make informed decisions as they deal with testing and/or a new diagnosis.
The newly expanded program is already rolling out at selected centres across the province. Services are currently being offered in a limited number of centres across all regions of the province to ensure and maintain OBSP’s high-quality standards for screening services. In the future, other centres will be added to ensure that women at high risk for breast cancer have even better access to timely, accessible and high-quality screening services.
Screening for breast cancer has always been a top priority. By working with providers in Ontario to implement these changes, we are confident that we can help save even more lives in the years ahead.
To learn more about breast cancer screening and the OBSP, visit www.cancercare.on.ca/obsphighrisk

Dr. Linda Rabeneck is Vice President of Prevention and Cancer Control at Cancer Care Ontario

SIDEBAR:
As of July 1, the Ontario Breast Screening Program has expanded:
•    Women in Ontario aged 30 to 69 who are at high risk for breast cancer now are able to receive annual breast screening MRI and mammography through the OBSP
•    An estimated 34,000 additional women are eligible for the program
•    Family physicians and nurse practitioners can expect an increase in visits from women seeking information about their risk for breast cancer and their need for screening
•    All other women aged 50 and over should be screened every two years
•    Public information about breast cancer screening in Ontario can be found at www.ontario.ca/screenforlife
•    Provider tools and guidelines are available on Cancer Care Ontario’s website at www.cancercare.on.ca/obspresources