B.C. Cancer Agency Colon Cancer Program

Dr. Glen Burgoyne (biography and disclosures)

What I did before

Prior to this program there were definite gaps in my approach to colon cancer screening. These included:

1. Difficulty in using a guaiac based stool test. These were difficult and inconvenient for the patient to use, leading to poor compliance. I would often get a notice from the lab stating the kit had been picked up but not returned.
2. Conflicting guidelines for testing provided by different bodies. Some low risk patients were expecting screening by way of colonoscopy especially if they had been reading information from the USA where screening guidelines may be more aggressive. It was often hard to dissuade them.
3. If a screening colonoscopy was warranted for higher risk patients there was often a long wait before the procedure was completed.
4. Conflicting advice from various specialists for appropriate follow up of polyps found at colonoscopy.

In a busy practice, the advice for colon cancer screening may often be overlooked, especially for patients who attend infrequently.
Overall I did not feel like I was doing the best job in this important area of cancer screening and prevention.

What changed my practice

In 2009 the BC Cancer agency initiated a pilot population-based approach to colon cancer screening. I was fortunate to be located in Penticton, the first site of the pilot program. A provincial colon cancer screening program is now being implemented province-wide.

In some ways it is similar to the very well established and well accepted screening programs for cervical and breast cancer. It has made the whole process of colon cancer screening very user friendly both for the physician and the patient.

What I do now

Features of the program:

1. Screening is offered to asymptomatic patients between the ages of 50 and 74. Exclusions include patients who:
   • Have a personal history of colorectal cancer, ulcerative colitis or Crohn’s disease. These patients should continue to obtain care through their specialist or primary care provider.
   • Currently have symptoms, e.g. rectal bleeding, persistent change in bowel habits, abdominal pain, unintentional weight loss or iron deficiency anemia. These patients should be investigated outside the screening program.
   • Are on a definite surveillance plan through a specialist.
2. Screening is offered to average risk patients every 2 years with a single fecal immunochemical test (FIT). This test is very easy to use with a single specimen, no dietary restrictions and a greater sensitivity than the outdated guaiac testing. The kit can be obtained from any public or private lab in BC using the standard outpatient lab requisition provided by the physician.The screening program has recently adopted a one test protocol with a lower cut off value for a positive test.  It was felt this would increase the patient uptake and compliance while maintaining test sensitivity.Higher risk patients (those with one first degree relative diagnosed with colorectal cancer under the age of 60, or two first degree relatives diagnosed at any age) should omit the FIT and go straight to colonoscopy.These patients should be referred to the screening program. The colonoscopy will be arranged by the patient care coordinator.

   These recommendations are consistent with GPAC Guidelines.

3. Those with a positive FIT and high risk patients are offered a “fast track” colonoscopy with the goal of these being completed within 60 days. These are arranged by patient care coordinators who will be located at most major endoscopy centres.
4. Once the patient is entered into the colon cancer screening database they will get a recall notice every 2 years with a follow up note to the physician if this is not completed. This is similar to the recall program for the mammography and cervical cancer screening programs.
5. If a cancer is found, the appropriate surgical referral can be made by the family physician or the endoscopist.
6. If there is a polypectomy, specific follow up guidelines are provided, with repeat colonoscopy arranged by the program.
7. There are comprehensive quality control measures built into the program – both for colonoscopy and for pathology.
8. Family physicians are informed in a timely manner of all tests, procedures and pathology reports/results as well as recommendations for follow up of any findings.

Patient brochures with information about the screening program will be provided to physician offices and some information will be provided through province-wide public advertising.

Based on my experience with this program over the past 4 years I can whole heartedly endorse it. It has made the whole area of colon cancer screening much easier for me to incorporate into my practice and it has been very well received by patients.

I would encourage all family physicians to make use of this excellent program when it becomes available Nov 15, 2013.

For more information on this cancer screening program, or others, please visit www.screeningbc.ca

Please indicate how this article will change your practice:

B.C. Cancer Agency Colon Cancer Program

• I disagree with this approach
• I will consider changing my practice, but need more information/time
• I will likely change my practice
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• I already do this

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