The reason that so many people die from lung cancer is that by the time it is usually diagnosed, the cancer has spread to other parts of the body or is too big. When the cancer has spread or is too big, treatment has less of a chance of working.

The good news is that Ontario now has an effective and evidence-based way to check, or screen, people who are at high risk of getting lung cancer. According to Dr. Lisa Del Giudice, Regional Primary Care Lead – Cancer Screening, Toronto Central Regional Cancer Program, this means that some lung cancers can be found early, when treatment has a better chance of working.

The new Ontario Lung Screening Program (OLSP) is an organized lung cancer screening program that is currently available at four hospitals in Ontario.

Who can qualify for lung cancer screening?

People may qualify to get screened for lung cancer if they:

• Are 55 to 74 years old, and
• Have smoked cigarettes every day for at least 20 years in total (it does not have to be 20 years in a row, which means there could be times when someone did not smoke).

To find out if you qualify for lung cancer screening, Dr. Del Giudice recommends speaking with your health-care provider or contacting an OLSP site hospital. To find a hospital that offers lung cancer screening through the OLSP, call 1-866-662-9233 or visit the OLSP website for a list of locations.

If you qualify for lung cancer screening and you do not have a health-care provider, the hospital will help find you one so that you can get screened.

What is the screening test for lung cancer?

People who qualify to get screened will be offered a special type of computed tomography (CT) scan that uses a small amount of radiation. This test is called a “low-dose CT scan.” Getting screened with a low-dose CT scan is the best way to find lung cancer early when it may be easier to treat.

Lung cancer screening is not for everyone. Dr. Del Giudice says that “people who are not at high risk of getting lung cancer should not get screened because there may be more risks than benefits for them.”

For more information about lung cancer screening, please visit Cancer Care Ontario. If you think you have any signs or symptoms of lung cancer, speak with your health-care provider.

There are several things you can do to lower your risk of lung cancer:

• Do not smoke and avoid second-hand smoke;
• Protect yourself from cancer-causing substances;
• Eat a healthy diet;
• Know your personal risks.

Learn more about your lung cancer risk and how to reduce your risk at My CancerIQ.

Blog Authors:

Toronto Central Regional Cancer Program, Cancer Screening

Dr. Lisa Del Giudice, Regional Primary Care Lead – Cancer Screening, Toronto Central Regional Cancer Program Family Physician, Sunnybrook Health Sciences Centre Academic Family Health Team

¹Cancer Care Ontario [Internet]. Toronto (ON): Lung Cancer. Available from: cancercareontario.ca/en/types-of-cancer/lung 

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But now, nearly a year later, there’s another crisis brewing beneath the surface: undetected breast cancers.

In a regular year, about 73,000 women participate in the Ontario Breast Screening Program (OBSP), which invites women aged 50-74 for a screening mammogram every two years. Each year, about 430 of those women go on to receive a diagnosis of breast cancer.

Last year, just 28,000 Ontario women underwent screening mammography. Those tests detected 148 cancers, most at their early stages. The missing mammograms mean about 200 more women in Ontario have undetected breast cancers.

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Screening mammography is a test done on people who are at risk of getting cancer, but have no symptoms of the disease. The goal of a screening test is to detect breast cancer in its earliest stage, when it’s more curable and requires less aggressive treatment. Research shows that early detection helps reduce breast cancer deaths.

The decline in screening tests means instead of catching a cancer when it is small and undetectable by a physical exam, a woman seeks medical care when she notices a lump or change in her breast. By then, it’s more likely the cancer will be advanced. And while we can’t turn back time to know if an advanced cancer might have been seen on a screening test, we do know that a screening test is one step we can take to try to catch breast cancer early.

At Sunnybrook, our OBSP screening site reopened last summer when we were permitted to do so, and since, the team has been holding some “Saturday Blitzes” to get through the backlog of breast screening tests. Our backlog is cleared, and if you are due for a mammogram, we want to see you.

If you missed a mammogram in 2020 or are due for one in 2021, please call your health-care provider or screening site and book it today.

We have heard from women that they were frightened to come to the hospital. We have also heard that some didn’t think their screening would take place because it isn’t important. It is important and we want to reassure you, it is safe. We have COVID-19 safety rules in place to protect you and our staff.

And, if something highly suspicious is spotted on your test, your health-care professional can refer you to the Marion Solway Breast Rapid Diagnostic Unit, where investigation with a diagnostic mammogram, ultrasound and biopsy are performed and a rapid diagnosis provided within 24-48 hours of those tests.

It’s particularly important for high-risk women to undergo routine screening. If you have a family history of breast and/or ovarian cancer, you can be referred to the High-Risk Breast Clinic at Sunnybrook’s Louise Temerty Breast Cancer Centre where our team of physicians, radiologists who specialize in breast imaging and genetic counsellors can assess if you are at high-risk of developing breast cancer and if so, provide you with recommendations for screening and risk-reducing strategies.

As always, if you notice a lump or change in your breast, please contact your health-care provider right away.

As 2021 gets underway with COVID-19 still a part of it, we all must balance the risks of COVID-19 against the harms related to interruptions in cancer screening, including the development of more cases of advanced cancer requiring more aggressive treatments, utilization of health care resources and cancer-related deaths. Please ask your health-care provider about cervical, lung and colorectal cancer screening as well. If you do not have a family doctor or nurse practitioner, contact Health Care Connect by calling 1-800-445-1822 or visit ontario.ca/healthcareconnect to be connected to a primary care provider.

What are you doing next Saturday? We hope you’ll consider booking your mammogram screening test. It could save your life.

If you have breast tissue, it is recommended that you be screened according to provincial guidelines, regardless of your gender identity or sexual identity. Ontario Health (Cancer Care Ontario) is working to implement a policy for the inclusion of trans and gender diverse people in its organized screening programs. More info can be found here.

Blog authors:

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For the 2SLGBTQ+ community, there are many barriers to healthcare that lead to lower cancer screening rates, says Dr. Ed Kucharski, Chief Medical Officer for Casey House and Assistant Professor at the Temerty Faculty of Medicine, University of Toronto.

“There’s actually not a lot of research because we haven’t historically collected gender identity or sexual identity with screening data,” he says. “But we do know that many in the 2SLGBTQ+ community screen for cancer at lower rates and that can lead to missed cancer, or cancer being diagnosed at a later stage when there are fewer treatment options.”

Dr. Kucharski says a greater number of 2SLGBTQ+ people don’t have primary care providers (family physicians or nurse practitioners, for example), or may avoid medical care due to fear of or past experience of homophobia or transphobia. They may also have been denied or avoid healthcare because their appearance doesn’t match the gender marker on their health card.

“It can also be because healthcare discussions are focused elsewhere and screening then just doesn’t come up,” he says. “For gay men, healthcare discussions have historically focused on HIV or STI screening and less so on cancer screening.”

Dr. Kucharski encourages everyone: If you are eligible for screening, you should be screened, regardless of gender identity and/or sexual orientation. “The trick for us as providers is to do it in a culturally competent manner,” he says.

And, he adds, there’s no one-size-fits-all approach.

“Generally, when recommending screening with my patients, I suggest we look at the organ systems that are present,” says Dr. Kucharski. “From there, we can start conversations carefully, with the understanding that the thought of screening can be very unsettling to some 2SLGBTQ+ people.

“But knowing that cancer screening can help find cancers early, it’s important that we all consider taking part in screening programs or other preventative measures.”

In Ontario, there are four provincial screening programs aimed at finding cancers before you would notice any symptoms.

Here’s an overview of each from Dr. Kucharski:

Cervical Cancer Screening:

Anyone with a cervix who is over the age of 25 and has ever been sexually active should be screened for cervical cancer. Sexually active means any skin-to-skin genital contact with anyone of any gender. In Ontario, cervical cancer screening is a Pap test, which looks for changes in cells in the cervix.

For trans men who are taking testosterone, we still recommend a Pap test, if you have a cervix. If you’ve had a hysterectomy, talk to your doctor to determine if you should still undergo Pap tests — it will depend on what type of hysterectomy you’ve had.

Most trans women who have had gender-affirming surgery do not need cervical cancer screening because the surgery typically does not include the creation of a cervix.

The vast majority of cervical cancer is caused by human papillomavirus (HPV). Whether you take part in screening or not, consider speaking to your primary care provider about getting the HPV vaccine.

Colorectal Cancer Screening:

If you are 50 years of age or over, you should be screened for colorectal cancer, regardless of your sexual or gender identity.

To determine your risk and the best type of screening for you, speak with your primary care provider and/or go to mycanceriq.ca

Gender identity or sexual orientation does not affect colorectal cancer risk. Here’s more information about colorectal cancer screening, including a new and better screening test available in Ontario.

Breast / Chest Cancer Screening:

If you have breast tissue, it’s recommended that you be screened according to the provincial guidelines, regardless of your gender or sexual identity.

That means if you are between ages 50-74, it’s recommended you get screened with mammography every two years. Screening is the best way to find breast cancer early.

For trans men: If you’ve had a chest surgery and have no breast tissue, your risk of breast cancer is reduced. Talk to your primary care provider about your individual risk or go to mycanceriq.ca. If you have not had a chest/top surgery, you should consider mammography screening. To make a screening more comfortable, providers can call ahead to ask about the Ontario Breast Screening Program site’s experience working with LGBTQ2S patients. Further, some patients might consider bringing a friend for support.

For trans women: if you’ve been on gender-affirming hormones (like estrogen) for 5 or more years, and you are over age 50, it’s recommended you take part in mammography screening every two years.

Lung Cancer Screening:

Members of the 2SLGBTQ+ community smoke at higher rates than the general population, says Dr. Kucharski, which makes it important to know if you are eligible for Ontario’s lung cancer screening program.

If you are between the ages of 55 to 74 and have smoked cigarettes daily for at least 20 years (cumulative; it doesn’t have to be 20 consecutive years), you should speak to your doctor (or contact an Ontario Lung Screening Program site yourself) about whether you are eligible for screening, regardless of sexual or gender identity.

The cancer screening is done on individuals who may be at risk of getting lung cancer, but who generally feel well.

You can find more information about Ontario’s lung cancer screening program here.

A Note about Anal Cancer:

Men who have sex with men have a higher risk of anal cancer, which is caused by HPV. Men who have sex with men who also have HIV have an even higher risk of anal cancer. While there’s no formal screening program for anal cancer, some providers do recommend and provide an anal Pap test to check for cell changes. Men who have sex with men should also strongly consider the HPV vaccine, which helps reduce the risk of HPV infection.

Resources:

Rainbow Health Ontario

Sherbourne Health Centre

Canadian Cancer Society

Check It Out Guys

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*This post was reviewed and amended June 10, 2022

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Dr. Ed Kucharski, Chief Medical Officer for Casey House and Assistant Professor at the Temerty Faculty of Medicine, University of Toronto, says there are many barriers that may prevent 2SLGBTQ+ people from accessing cancer screening programs as well as healthcare in general.

Fear or experience of homophobia or transphobia, having a health-card gender marker that is different from how one looks, or bad past experiences all create barriers, he says. In addition, being focused on other healthcare concerns might prevent cancer screening conversations from happening.

Dr. Kucharski has 5 Tips for Healthcare Providers when it comes to discussing cancer screening with 2SLGBTQ+ patients:

Start the conversation:

We know that cancer screening can help catch cancer early and save lives. Anyone who is eligible for screening should be screened.

That said, remember it’s not one-size-fits-all and that you should consider a patient’s individual situation and needs when talking about screening.

Words matter:

Dr. Kucharski suggests healthcare providers discuss cancer screening using the words and pronouns the patient prefers.

“Speaking about a Pap test with a trans man, for example, you might instead refer to this as ‘cell collection from the front’,” he says. “But again, there’s no blanket approach – talk to your patient about what words they prefer.”

Help ease the way:

As a healthcare provider, do what you can to help make the screening process easier for your patient. If you are recommending a trans man undergo mammography screening, you could call ahead and let the clinic know that this person will be presenting as male, Dr. Kucharski said. That way, the provider can assess if this clinic can provide culturally competent care to the patient and also allows the clinic to get it right when the patient arrives. For example, using the correct name and pronouns if they don’t match the health card.

Be empathetic:

Cancer screening tests are unsettling to anyone. It can be even more unsettling for members of the 2SLGBTQ+ community who may have been met with homophobia or transphobia at other medical appointments, or even thinking about having a cervix or breasts when that is not in keeping with their gender identity.

“Please keep this in mind when discussing screening with your patients,” Dr. Kucharski said. “And remember, it’s not one-size-fits-all and it’s important to consider other options, like vaccination, if someone doesn’t feel comfortable participating in screening.”

Educate yourself:

There are good resources available for healthcare providers and patients. Here are some sites with good information:

Rainbow Health Ontario

Sherbourne Health Centre

Canadian Cancer Society

Check It Out Guys

Dr. Kucharski and Amy Bourns, with Allan D. Peterkin and Cathy Risdon edited Caring for LGBTQ2S People, published by University of Toronto Press in April 2022.

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*This post was reviewed and amended June 22, 2022

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Answer: Let me start by saying that you being aware that your grandfather had colon cancer is a very important first step. The new national guidelines released this week specifically target high-risk patients, and without knowing your family history, you don’t know whether you’re at risk!

What we do know is that if you have a first-degree relative with colorectal cancer, your chance of developing this disease is doubled, making you high risk. That means we need to be more vigilant with your colorectal cancer screening.

Before we dive into this, it’s important to remind you that the definition of ‘screening’ is someone with no signs or symptoms of colorectal cancer. If there are any signs or symptoms, like changes in your bowel habits or blood in your stool as outlined in another post here, then the term ‘screening’ does not apply and you need diagnostic tests regardless of age or family history. In this post, we are talking specifically about people with absolutely no symptoms. In the general population, these people can be divided into high risk and normal risk of developing colorectal cancer.

So let’s look at these new guidelines for screening in high-risk people.

Firstly, what is a first-degree relative? A first-degree relative is a sibling, mother, father or child. A second-degree relative would be an uncle, aunt, cousin or grandparent. These new guidelines differentiate the intensity of colorectal screening based on either a first-degree or a second-degree relative diagnosed with colorectal cancer, and at what age the diagnosis was made. The guidelines state that if you have a first-degree relative diagnosed with colorectal cancer, you should be screened with a colonoscopy at the age of 40-50 (40 in my opinion!) or 10 years prior to that person’s diagnosis. If that colonoscopy is normal, you should have another in five-year intervals.

So what does that timeline look like?

Here’s an example. Let’s say Peter is diagnosed with colon cancer at age 75. His first-degree relatives (his kids) should start being screened at age 40-50. Peter should speak to his siblings about getting screened if they haven’t already taken part in a screening program.

Here’s another example. Say Gina, aged 35, has three small children. She has been diagnosed with colon cancer. When those kids hit age 25 (10 years prior to her age at diagnosis) they should begin their colonoscopy screening. Let’s say Gina has a younger brother who just turned 29. He should start his screening now. Maybe Gina’s Mom and Dad haven’t taken part in colonoscopy screening before. They should start. Now that a first-degree relative has been diagnosed, the whole family moves into the high-risk category.

One day last week, I conducted colon cancer removals in three patients all in their 30s. For those patients, it means all of their first-degree relatives — any siblings, and current or future children — should have colonoscopies when they are in their 20s (or for their siblings and parents already passed that age, screening should start now.)

This means a lot of people will now need colonoscopies starting in their 20s and for me, that raises a lot of questions: Do they all know about being screened? Will they all do it? Will their primary care physicians or nurse practitioners identify this need in time? You can help spread the word by telling people about the new guidelines!

And so what about your grandfather’s diagnosis? The guidelines state that if you have a second-degree relative with colorectal cancer, you should begin screening with either a stool test or a colonoscopy at the age of 50. For your mom – his first-degree relative – she should have (and hopefully has) already started being screened, and should continue to do so every five years.

So you can see why knowing your family history, and knowing your risk, can save your life. I can’t stress that enough: when caught early, colorectal cancer is treatable. But it often has no symptoms in its early stages, so screening can help us catch it early. And screening if you are high-risk is extremely important. Talk to your family about your family history.

See the entire new guidelines here (it’s a PDF from the Canadian Association of Gastroenterology) and if you have questions, talk to your doctor.

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The study published CMAJ Open found that nearly one in 20 patients underwent tests for colorectal cancer and nearly one in 11 women underwent screening for breast cancer, within a year of receiving their diagnosis of metastatic cancer.

Dr. Simron Singh, medical oncologist, and Dr. Matthew Cheung, haematologist, conducted the research. They say cancer screening is extremely important in catching cancers early, and it can save lives. But, when a person is already undergoing treatment for advanced cancer, screening is typically of little or no benefit — and instead can cause distress.

What are the key takeaways from this study?

Screening can save lives. That’s important to remember. The screening programs for breast cancer and colorectal cancers are extremely successful – and we are really pleased that Ontarians are getting the message about getting screened.

For the people we looked at in the study — people already facing advanced stage cancers — screening instead can be stressful, uncomfortable and ultimately of no benefit. For patients with advanced cancer, time is likely better spent focusing on symptom control and quality of life as opposed to pursuing additional tests that are unlikely to offer benefit. 

What does this mean for patients?

For healthy Ontarians, continue to take part in cancer screening programs.

For those with advanced cancers, when you receive a reminder about a routine screening, talk to your oncologist to determine whether or not screening tests would be beneficial to you.

What does this mean for care providers?

We hope this research spurs more conversations between oncologists and their patients, and a more personalized approach to screening. Oncologists and family physicians should talk to their patients who have advanced cancers about screening for other cancers.

Why did you want to study this?

Choosing Wisely Canada is a movement that is looking at reducing unnecessary tests, and its recommendations include not doing routine cancer screening on people who already have advanced cancers. We wanted to see how often this was happening, and it turns out, it’s happening far more than we initially thought. During our study period, 1 in 11 women with advanced cancer underwent breast cancer screening and 1 in 20 people with advanced cancer underwent colorectal cancer screening. These tests aren’t without risk of complications and can be extremely difficult for people who are already ill.

What comes next?

Currently, all Ontarians receive reminders in the mail when it’s time to take part in a cancer screening program, like the Ontario Breast Screening Program. We are looking at whether the wording on those reminders could be tweaked to provide some advice for people already facing cancers to speak with their oncologist.

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Breast cancer is the most commonly diagnosed cancer in Ontario women. One in eight women will be diagnosed with breast cancer in her lifetime. In Ontario, breast cancer happens mostly in women ages 50 to 74 (61 percent of cases). Regular breast cancer screening is important because it can find cancer early when it may be smaller and easier to treat.

Limiting alcohol can reduce your risk. A healthy lifestyle, including limiting alcohol, can reduce your risk of breast cancer. Other factors that may lower a woman’s chance of getting breast cancer are not smoking or using tobacco products, having a healthy body weight, and being physically fit.

Breast cancer has one of the highest survival rates out of all of the cancers in Ontario. Studies show that regular mammograms (and proper follow up testing for abnormal results) lower the risk of dying from breast cancer in women ages 50 to 74. Deaths from breast cancer in the Ontario population went down by about 47 percent in women ages 50 to 74 from 1990 to 2013. This decrease in deaths is probably due to improvements in breast cancer treatment and more women getting screened.

Between 1990 and 2017, more than 39,000 breast cancers have been found by the Ontario Breast Screening Program (OBSP) through mammography, most of which were in early stages. From the start of the program in 1990 to July 2017, over 1.9 million women ages 50 to 74 had a mammogram through the OBSP, resulting in more than 7.4 million mammograms completed.  The OBSP recommends that most women ages 50 to 74 get screened every two years with mammography. Eligible women can make their own appointments or be referred for screening by a healthcare provider.

Changes in the breast are not always signs of cancer. All women – regardless of age or risk factors – should be breast aware. This means knowing how your breasts normally look and feel so you can tell if there are changes.

This Breast Cancer Awareness Month, talk with your healthcare provider about breast screening.  For more information, visit www.cancercareontario.ca/bcam

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Oh, the Pap test. ~cue crossed legs and sweaty palms~

But, the discomfort certainly doesn’t seem so bad when you consider a Pap screening test — where a doctor collects cells from the inner part of your cervix — is the only way to find early cell changes that might lead to cervical cancer.

To figure out why a timely Pap test is so important, I talked to Dr. Lisa Del Giudice, family physician on the Sunnybrook Academic Family Health Team and Regional Primary Care Lead, Toronto Central Regional Cancer Program.

What’s a Pap test looking for?
A Pap test is looking for abnormal cells — cancer or pre-cancer — in the cervix. Sometimes other gynecological cancers can be detected during a Pap test.

A Pap test isn’t the same as a test for sexually transmitted diseases (STDs).

“Sometimes an STD can be picked up on a Pap, but it is not really the appropriate way to test for STDs,” Dr. Del Giudice says. “The appropriate STD tests can be done at the same time if there is any concern in this regard.”

How can it help prevent cervical cancer?
In 2015, about 640 women were diagnosed with cervical cancer in Ontario and about 150 women died from the disease, according to Cancer Care Ontario. Cervical cancer is almost entirely preventable with regular screening, appropriate and timely follow-up of abnormal results.
“The Pap test can find the abnormal cells or high-risk human papillomavirus (HPV) early so that next steps can be taken or the patient can be screened more often,” Dr. Del Giudice says. (Some HPV can lead to the abnormal cell changes and cause cancer).

How often should I have it?
It is recommended that women aged 21 to 69 have a Pap test every three years if they are or have ever been sexually active. Sexually active doesn’t just mean sexual intercourse — oral and digital contact also count. Women who have sex with women should have regular Pap tests.

Research suggests that smoking puts you at higher risk for cervical cancer. If you smoke and are sexually active, be extra certain to book your Pap test every 3 years.

“If you’ve had a total hysterectomy (uterus and entire cervix removed) then you no longer need to undergo Pap screening. But, if your cervix was left partially intact you still do. Same if you’ve had your ovaries removed — you should still have regular Pap tests,” Dr. Del Giudice explains.

Who can do the Pap test?
A Pap test can be done at your family doctor’s office. If you don’t have a doctor, you can get a test done at a walk-in clinic or sexual health clinic.

What happens if the Pap test ‘finds something’?
If your doctors sees an abnormality (something that looks like it could be cancer or pre-cancerous cells), they may want to repeat the test, or do further testing to high-risk HPV and/or refer you to a gynecologist for a colposcopy (a test that takes a bigger sampling of your cervix to check for and to remove pre-cancerous or cancer cells.

Any tips for making it a little less uncomfortable?
If you’ve had a painful Pap test in the past, mention it to your doctor. All women are different – your cervix might tilt to the front or back or side. Ask your doctor to note any tilt in your file (so you both can avoid the whole poke-around-down-there-trying-to-find-the-right-of-way next time)

For post-menopausal women, talk to your doctor about possibly applying topical estrogen for one to two weeks before your Pap test.

You can take an Advil a half hour before the test. And try your very best to take a deep breath and relax. (Easier said than done, but try!)

If during the test you are in pain, ask your doctor if you can tip your pelvis up to reposition (by putting your hands under your bum).

I can’t remember if my last Pap was two years ago or three – but I think it’s definitely worth a call to my family doctor (or a look in my MyChart!) to see if it’s time to book one. I think I can stand a few moments of discomfort knowing it’s for a potential lifetime of better health.

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