Colorectal screening

More research is needed to better understand colorectal cancer risk and screening. Governments and funders should invest in research to improve colorectal cancer screening in the following ways:  

• Understand and find ways to reduce barriers to colorectal cancer screening. 
• Find better ways to increase screening participation. 
• Further investigate the causes of changing epidemiological trends in colorectal cancer, particularly the rising incidence in younger adults under the age of 50. Investments in genetic, environmental, lifestyle and early detection research are pivotal in addressing this growing concern.  
• Find new and innovative ways to detect colorectal cancer early. Improve how eligible individuals enter, are invited and reminded to screen, including the use of a combination of outreach approaches and digital methods, such as text notifications or mobile apps that protect privacy. 
• Improve how we predict colorectal cancer risk in people and find better ways to screen people based on their risk level. 
• Improve early detection, diagnosis and treatment, especially for communities that are underserved. 
• Invest in research to determine the optimal intervals for polyp surveillance. 
• Find ways to improve access and reduce wait times for individuals awaiting screening in rural areas. 
• Conduct more research into optimal follow-up strategies and promote them to physicians. 

Data is crucial to monitor the health of a population, improve healthcare quality and delivery, and inform research and practice. Important opportunities are found in the pan-Canadian cancer data strategy (including race-based data collection) and pan-Canadian Health Data Charter. Without data, it is difficult to evaluate the impact of screening on cancer burden, to identify potential areas of program inefficiencies, and to compare outcomes across provinces and territories. The federal government should work with provinces, territories and others who collect and work with data to do the following: 

• Identify areas to improve colorectal cancer screening data. 
• Collect data to fill gaps in colorectal cancer screening, including equity-focused data collection across the cancer control continuum. 
• Connect databases to monitor, evaluate and report on colorectal cancer screening in Canada. 

Guidelines for defining and screening who are at high risk of colorectal cancer vary by province or territory. CCS calls on the federal government to create colorectal cancer screening guidelines for individuals at high risk of colorectal cancer. Guidelines should do the following: 

• Clearly define who is at average and high risk of colorectal cancer. 
• Provide clear screening and follow-up recommendations for individuals at average and high risk of colorectal cancer. 
• Recommend tools to determine risk levels that are easy to access and to use. 
• Encourage healthcare providers and support them with how to discuss the benefits and limitations of screening and consider patient values and preferences to help people make decisions about screening. 
• Include a plan to ensure guidelines reach healthcare providers and people that are eligible for colorectal cancer screening. Create a pan-Canadian working or oversight group to ensure progress in this area. 
• Educate the public on risk factors and who is considered average and high risk of colorectal cancer.  
• Ensure guidelines for individuals at high risk also outline and encourage screening for other associated malignancies or hereditary conditions. 
• Ensure individuals at a high risk for colorectal cancer receive education on how to manage their risk. 

Provinces and territories are responsible for reviewing and updating their colorectal cancer screening program guidelines, including start and stop age. CCS calls on provinces and territories to do the following: 

• Review and update their colorectal cancer screening guidelines so that they align with the latest available research and the changing healthcare environment. 
• Start organized screening programs at age 45 for individuals who are at an average risk of colorectal cancer.  
• Allow self-referral for colorectal cancer screening using FIT without needing a healthcare provider’s referral, specifically in Nunavut, Northwest Territories, British Columbia, Quebec, New Brunswick and Nova Scotia. Ensure appropriate follow-up is in place for those who are unattached (without a primary care provider) and self-refer. 
• Allow individuals (when applicable) who are 75 or older to continue screening for colorectal cancer where clinically appropriate. 

Provinces and territories are responsible for understanding their population and tailoring colorectal cancer screening programs to their needs. CCS calls on provinces and territories to do the following: 

• Fully implement an organized colorectal cancer screening program in provinces and territories that lack a program or have only partially implemented one (Quebec and Nunavut). 
• Invest in additional resources and system capacity to accommodate a lower screening start age, increase overall program participation and ensure barrier-free screening access to all eligible people. 
• Collect family history (colorectal cancer and polyps) in primary care, especially amongst younger adults, to better inform screening and referral for risk assessment. 
• Provide access to a healthcare provider through screening programs to help patients understand the benefits and limits of screening and discuss their overall health, risks, values and preferences.  
• Conduct robust reporting on screening intervention methods to inform which interventions, at the local level, are most effective at increasing colorectal cancer screening participation rates. 
• Support healthcare providers with how to discuss the benefits and limitations of screening and consider patient values and preferences to help people make decisions about colorectal cancer screening.  
• Involve patients – especially people from communities that are underserved – when developing guidelines to remove barriers and create trauma-informed and culturally safer care.  
• Create a process to evaluate emerging tools and methods for early detection of colorectal cancer. 
• Invest in resources to enhance system capacity for timely access to diagnostic colonoscopy and referral for surgical and medical interventions. 
• Explore the development of a screening program component that targets and meets the needs of individuals at high risk of colorectal cancer. 

Provinces and territories need to work together with healthcare providers and health organizations to raise awareness about colorectal cancer risk and early detection. CCS calls on provinces and territories to do the following:    

• Reach people for screening through different methods identified as being effective, such as invitation letters mailed directly to the individual or use other preferred methods identified within specific communities. 
• Mail letters (electronically or paper based) to remind past participants about how often to get screened.  
• Invest in strategies related to community demand, access and provider delivery to improve colorectal cancer screening rates and ensure that the strategies address various factors influencing screening behaviours, awareness, stigma, education and accessibility are addressed. 
• Offer expanded screening and recruitment strategies including referral through other screening programs and screening program websites, as well as through the distribution of FIT kits at public events and pharmacies for people who do not have easy access to a regular healthcare provider. 
• Offer complete and easy-to-understand information about screening benefits and limitations using numbers, infographics and plain language. Tailor materials for different groups and provide them in various languages and formats. 
• Give healthcare providers helpful tools and resources for discussing colorectal cancer risk and screening with patients. 
• Create a pan-Canadian colorectal cancer screening awareness campaign by leveraging public platforms, in-person social events, media platforms and national news platforms.  
• Educate healthcare providers on genetic screening/testing for those with a family history or genetic predisposition for colorectal cancer.  
• Use technology to increase public participation in colorectal cancer screening programs. This may include user-friendly online digital platforms to book tests, access educational resources and track screening status. 

Communities that are underserved face barriers to accessing and participating in colorectal cancer screening. CCS calls on provinces and territories to do the following: 

• Recognize community-specific needs and implement tailored strategies to meet their unique needs and concerns. For example, utilize mobile clinics and telehealth in rural, remote and underserved areas to educate and distribute FITs. 
• Use tailored approaches in colorectal cancer screening that are culturally safe and responsive to meet the needs of diverse populations. Some examples include partnering with local organizations, band councils, community centres and trusted community members such as community health workers, peer educators, language-specific navigators and Elders to educate about screening, dispel screening myths, and help with referrals and kit completion. 
• Co-design culturally relevant, tailored approaches to increase access and uptake to colorectal cancer screening interventions that align with First Nations, Inuit and Métis community-specific needs, priorities, and infrastructure. 
• Fund the training of healthcare providers outside of their usual scope of practice to perform flexible sigmoidoscopies and colonoscopies to those in remote areas. 
• Contribute greater funding towards increased participation in colorectal cancer screening in underserved communities. 

Healthcare providers are critical to expanding access and increasing participation in colorectal cancer screening. CCS calls on provinces and territories to do the following: 

• Assess the number of lab technicians and support staff in labs required to carry out more FIT analysis with lowering the screening start age, including the number of endoscopists required for follow-up colonoscopies and programmatic screening staff. This may include increasing entry into university and college programs and placement and training positions for staff in related positions. Ensure that financial support including bursaries and scholarships, is offered to reduce enrollment barriers. 
• Encourage healthcare professionals to engage in continual professional development or accreditation opportunities through the Canadian Association of Gastroenterology to improve their skills and knowledge in colorectal cancer screening procedures. 
• Engage with the College of Family Physicians of Canada and other regulatory bodies to promote continuous medical education and increase awareness for healthcare professionals about colorectal cancer screening.  
• Invest in trained patient navigators to help individuals, particularly those from under-screened communities through the screening process. 
• Increase investments in clinical and administrative resource capacity to effectively manage workload supporting the implementation of strategies aimed to increase screening participation. 
• Leverage the expertise of healthcare professionals, such as nurses, nurse practitioners and nurse navigators, to support individuals who are unattached and to also support with self-referrals. 
• Provide funding for equity, diversity and inclusion efforts, retention strategies, and supports and incentives, particularly for program staff and healthcare professionals in rural, remote and underserved communities involved in colorectal cancer screening.  
• Monitor and use colorectal cancer screening workforce data to plan future workforce investment and training needs.