If you live in Ontario and you’re turning 50, expect to receive a birthday letter in the mail. It’s not from your loved ones (though they may send one, too) – it’s from the province’s cancer agency, Cancer Care Ontario.
These letters represent a paradigm shift. A health-care agency is reaching out to people at risk of a condition and providing advice. It’s informing people of their risk of colorectal cancer, the second leading cause of cancer death in Canada. And it’s recommending patients visit their family doctor or nurse practitioner to talk about getting a fecal occult blood test (FOBT), which can catch colorectal cancer early when it’s more likely to be curable.
An FOBT is simple but it can make people queasy. It involves placing a small amount of your poop on a card. You do this after three separate bowel movements, seal the card in a pre-paid, pre-addressed envelope and put it in the mail. If the test comes back negative, you repeat it in two years. If the test is positive, the next step is a colonoscopy, where a physician puts a camera into your colon to look for suspicious growths that need removing.
Cancer Care Ontario launched these birthday letters in 2008 as part of its Colon Cancer Check program. Many other Canadian provinces have a similar program. The good news is studies have found that the launch of Ontario’s program increased the percentage of people receiving FOBT.
But we’ve known for some time that immigrants and people who are poor are less likely to be screened for colorectal cancer. This seems unfair, especially since we live in a country where everyone has publicly-funded insurance for essential health care, regardless of means.
My colleagues and I wondered if the proactive approach of contacting patients to get screened would narrow the gap between rich and poor, new immigrants and those who have lived for some time in Canada.
Our study found that after the Colon Cancer Check program and birthday letters were introduced, the gaps in screening between rich and poor in Ontario, and long-term residents and new immigrants, narrowed a bit. But the gaps were still pretty big.
Six years after the program was launched, 64 per cent of women and 61 per cent of men who had lived in Canada a long time and were in the wealthiest neighbourhoods got screened for colorectal cancer. Yet only 40 per cent of women and 36 per cent of men who were immigrants and lived in the poorest neighbourhoods received screening.
The gaps between rich and poor, and long-term resident and new immigrant, seem to be driven largely by differences in the type of screening test received. Even though Colon Cancer Check recommends patients get an FOBT to screen for colorectal cancer, many patients – especially those who have lived longer in Canada – get a colonoscopy as a screening test instead.
Canadian guidelines don’t recommend colonoscopy for screening for average risk patients.
But many doctors (and patients) don’t agree with the guidelines. They think it isn’t worth fussing with an FOBT first and that it would be better to just go straight to a colonoscopy. U.S. guidelines include colonoscopy as one of the recommended screening tests for colorectal cancer and that’s also probably influenced opinions in Canada.
We found that more than 40 per cent of long-term residents living in the wealthiest neighbourhoods had a colonoscopy – compared to about 10 per cent of immigrants in the poorest neighbourhoods. Colon Cancer Check narrowed the gap between immigrants and long-term residents for FOBT, but there is still a persistent gap for colonoscopy.
Mailing a birthday letter prompting you to get screened can level the playing field – providing information to everyone, regardless of background. But we need to make more of an effort to reach people who don’t get screened and understand what’s holding them back.
Perhaps it’s also time to reconsider what options we give people to be screened. Maybe everyone eligible for screening should hear the pros and cons of colonoscopy and FOBT – not just those who are better off or better connected. As the U.S. National Cancer Institute has said, when it comes to screening for colon cancer, the best test is likely the one you’re willing to do.
Tara Kiran is a family physician and researcher in the Department of Family and Community Medicine, St. Michael’s Hospital, University of Toronto, and an adjunct scientist at the Institute for Clinical Evaluative Sciences.