Journal of Family Practice Oncology

Issue Number 22, Spring 2014 | www.fpon.ca

Insight into BC’s Colon Screening Program

By Dr. Jennifer Telford, Medical Director, Registering eligible patients into the program Provincial Colon Screening Program ensures that the BC Cancer Agency receives FIT results and can refer patients with an Since November 15, 2013 the Colon abnormal FIT or those that are higher than Screening Program has been available average risk to one of 20 health authority across the province. Physicians can register patient coordinators for pre-colonoscopy asymptomatic patients ages 50 to 74 in the assessments. Colon Screening Program as follows: Abnormal FIT Results Colon Screening Program For average risk patients: Jennifer Telford MD MPH FRCPC February 20, 2014

FECAL IMMUNOCHEMICAL TEST (FIT) An abnormal FIT indicates that there www.screeningbc.ca/colon may be bleeding from somewhere in the • Select the ‘Fecal Occult Blood, age 50- colon or rectum. Blood can be present 74, asymptomatic q2y (copy to Colon in the stool for many different reasons, Watch Dr. Jennifer Telford’s hour long Screening Program)’ option on the including hemorrhoids, ulcers, anal fissures, Webcast on the BC’s new Provincial updated Standard Outpatient Laboratory diverticular disease, or inflammation. Colon Screening Program at www.fpon.ca Requisition. – CME Initiatives. • A copy of the FIT report will be sent to the Approximately 15% of individuals screened with Colon Screening Program at the BC Cancer FIT will have an abnormal FIT result and will Agency. require colonoscopy. Of those with an abnormal • For colorectal cancer screening in FIT, 4% will have cancer and approximately 60% individuals less than 50 years of age. • If the FIT result is abnormal, the BC Cancer will have a pre-cancerous polyp, an adenoma. Agency will facilitate the patient’s referral • For colorectal cancer screening in Most adenomas will not progress to cancer, to the appropriate health authority for individuals over 74 years of age. and for those that do, it will take many years colonoscopy. – Individuals 75-85 years can be for this transition to occur, which is why evaluated on a case-by-case basis • Physicians do not have to complete the patients should be screened regularly. Colonoscopy Referral Form for patients • For screening individuals who are in poor with abnormal FIT results if the Colon When is FIT not appropriate? health. If a patient is not medically fit to Screening Program is copied on the lab undergo colonoscopy, then they should FIT is recommended for individuals aged 50 to report. not undergo FIT. 74. FIT is not recommended in the following continued on page 2 For higher than average risk patients: situations: SCREENING COLONOSCOPY • Use the Colon Screening Program Join us for Family Practice Oncology CME Day on Nov. 1 Colonoscopy Referral Form to refer Please mark November 1 on your calendar as a great opportunity to gain the latest patients with at least one of the following: knowledge on the some of the most important topics in primary care oncology. This is the – One first degree relative diagnosed with date of the Network’s annual Family Practice Oncology CME Day to be held once again colorectal cancer diagnosed under the at the BC Cancer Research Centre. We promise insightful presentations age of 60. from leading oncologists; case-based workshops on colorectal – Two or more first degree relatives with screening, advanced cancers and side-effect management of cancer colorectal cancer diagnosed at any age treatment; plus the chance to reconnect with colleagues and save the date – A personal history of adenoma(s). contacts from throughout BC. Registration will open this summer – An abnormal FIT result when the Colon at www.fpon.ca. Hope to see you there! saturday Screening Program was not copied on november Contact Jennifer Wolfe at [email protected]. the lab report. 1 CCOPE workshop success — more planned in 2014

Cancer Care Outreach Program the workshop delivery coincided on Education (CCOPE) is an with the release of the new Colon Workshop evaluation data: I am confident that I can provide ongoing partnership between Screening Program, we were patients with care and information regarding colorectal cancer the UBC Division of Continuing able to address questions about that is based on provincial guidelines / recommendations and Professional Development the new screening processes best practice approaches to care (n=122) 50% 47% (UBC CPD), the BCCA Screening and procedures in various 44% Groups, and Family Practice communities; read more about 40% Oncology Network (FPON). The the screening program on page 1. 30% overall aim of the program is to support BC family physicians CCOPE 2014 20% in providing best practice care Following the success of the 10% 7% along the cancer continuum. CCOPE program to date, breast, 0% 2% 0% colorectal and prostate cancer Strongly Disagree Neutral Agree Strongly Agree disagree Colorectal Cancer modules will be updated and Workshops redelivered to 15 BC communities Testimonials: as Mainpro-C workshops Ten, two-part Mainpro-C “Informed discussion combined with excellent course material”. workshops on colorectal cancer this year. Another module “Open discussion of cases. Helpful to hear from colleagues were rolled out throughout BC on family physicians’ role in regarding their issues”. this winter, with the last follow- advanced cancer is also under up session held in Creston, development. Full details will be “Group discussion was most effective. Allowed to appreciate BC in early March. This is the made available at www.ubccpd. spectrum of current care”. third module of our community ca/oncology-program. oncology workshop series and was very well attended with Want CCOPE in 132 participants across all Your Community? communities. The workshop If you are a GPO or physician format was well received and interested in bringing a CCOPE participants’ confidence on workshop to your community, colorectal cancer care increased; please contact Jennie Barrows at a snapshot of evaluation data [email protected], 604.875.8075. is included here. In addition, as

Insight into BC’s Colon Screening Program continued from page 1 Did You Know? • For individuals in a colonoscopy surveillance program. • In 2013 there were estimated to be approximately 1,700 males and 1,300 females diagnosed with colorectal cancer in BC. • For individuals up to date with colorectal screening. • In 2011, 2,912 people in British Columbia were diagnosed with colorectal cancer. – FIT within the last 2 years. • In 2011, 1,069 people in British Columbia died of colorectal cancer. – Colonoscopy or flexible sigmoidoscopy About the Provincial Colon Screening Program within the last 10 years for average risk. • The full program launched province wide on November 15, 2013– linking FIT with • For individuals with inflammatory bowel the BC Cancer Agency, Health Authority Patient Coordinators, and a monitoring and disease. reminder system. • For individuals with gastrointestinal • The Medical Services Plan (MSP) has paid for 305,000 FIT tests so far in 2013/14, symptoms. and expects to pay for more than 400,000 tests during the next fiscal year. For more information about the Colon • Over 500 patients with abnormal FIT results have been referred to the 23 patient Screening Program, and to request or coordinators around the province since the November launch. download the FIT requisition or colonoscopy referral form visit www.screeningbc.ca/colon.

2 FAMILY PRACTICE ONCOLOGY NETWORK JOURNAL / SPRING 2014 Update on the management of oral mucositis

By Dr. Allan Hovan, DOs Provincial Professional Practice Leader, Oral Oncology webcast with Dr. Allan Hovan • Treat pre-existing dental problems Program in Oral Oncology/Dentistry, To learn more about this topic, take part (cavities, gum disease, infections, BC Cancer Agency Vancouver Centre in our May 15 Webcast, 8 - 9:00 a.m., PST. broken/sharp teeth, etc.). Register for this complimentary, nationally Oral mucositis (OM) is one of the most • Establish comfort and excellent fit of any accredited session at www.ubccpd.ca/ significant adverse side-effects of cancer removable dentures; leave dentures out Events/Webinar_Program.htm therapy and yet tends to be under-reported if mouth becomes sore during cancer by patients and under-treated by physicians therapy. • There is no evidence that mucosal and dentists. OM is a significant quality of life • Maintain good fluid intake; eat bland, soft coating agents, antimicrobial lozenges issue for patients and their families. Left foods while maintaining adequate protein or antibacterial rinses will be helpful in untreated, it can lead to high levels of and vitamin levels in the diet. anxiety, depression and social isolation as preventing OM. • Maintain meticulous oral hygiene during well as cause delays or interruptions in the course of cancer therapy. Based on this systematic review, the cancer therapy delivery. following strategies should be considered for DON’Ts chemotherapy-induced OM: • Avoid commercially-available • There is some evidence to support the mouthwashes use of ice chips (cryotherapy) for the prevention of OM, particularly when • Avoid spicy, acidic or coarse food products patient s are receiving bolus 5-FU or high- • Do not consume alcohol and don’t smoke dose melphalan as part of the conditioning Over the last several years, the Mucositis for stem cell transplantation. Study Group of the Multinational Association • Keratinocyte Growth Factor (Palifermin) of Supportive Care in Cancer (MASCC) has has been found to be beneficial for the updated evidence-based guidelines for OM prevention of all categories of OM; in management. The first MASCC/ISOO particular for patients receiving high-dose Good oral hygiene remains the mainstay of guidelines were published in the journal chemotherapy and total body irradiation therapy for oral mucositis. Cancer in 2004 and the first update of these (TBI) for treatment of hematologic OM is common during high-dose H&N guidelines was described in publications in malignancies with stem cell transplant. radiotherapy/combined modality therapy 2006-2007. A summary of the most recent In summary, OM is a common and often (~ all patients will experience some level of update of the MASCC Mucositis Guidelines is unavoidable side-effect of cancer therapy. OM), stem cell transplant therapy (75-100%) now available. In addition, a set of papers has OM management is based on palliation of but is less commonly seen following standard been published in Supportive Care in Cancer symptoms as few agents have been shown to dose chemotherapy (40%). Certain in 2013 that details results for the different be helpful in preventing OM. Good oral chemotherapy drugs (eg 5-FU, methotrexate, categories of interventions for mucositis. Go hygiene remains the mainstay of therapy. cycylopho-sphamide, etoposide and cisplatin) to www.mascc.org to view Communication with the patient and family is are known to more commonly cause significant and download. important and a multidisciplinary approach OM compared to other agents. Signs and Based on this systematic review, the (to include nursing, radiation therapy and symptoms of OM may persist for many weeks following strategies should be considered dentistry) is important in OM management. following the cessation of therapy. for RT-induced OM: Contact Dr. Allan Hovan at The development of OM is predominantly • The use of midline radiation blocks and [email protected]. influenced by the type of malignancy and the 3-dimensional RT or IMRT to reduce cytotoxic therapy administered but patient mucosal injury. factors also play a role (eg. oral health status, • Benzydamine (Tantum) oral rinse can Dr. Allan Hovan is part of an Oral salivary output, age of patient, etc). As many help prevent RT-induced OM in patients Mucositis Guidelines Leadership team of the risk factors cannot be controlled, the with H&N cancer receiving moderate dose who will soon have the following importance of establishing and maintaining (<5000 cGy) radiation therapy. significant article published inCancer : excellent oral hygiene throughout cancer MASCC=ISOO Clinical Practice • Low Level Laser Therapy (LLLT) application therapy becomes increasingly evident. Guidelines for the Management of may be helpful in preventing severe OM Mucositis Secondary to Cancer Therapy. In terms of prevention, there are but requires specialized equipment which You can access this article at www.fpon.ca disappointingly few things that have been is not widely available. – Journal of Family Practice Oncology. shown to be helpful. In general terms, the following strategies apply:

FAMILY PRACTICE ONCOLOGY NETWORK JOURNAL / SPRING 2014 3 Breast screening recommendations for women in BC

By Dr. Christine Wilson, Medical Director, referral is required, we recommend women BC Cancer Agency Screening Mammography between the ages of 40-49 and 75+ discuss Program the benefits and limitations of screening mammography with their doctors. A referral is On February 4, British Columbia’s updated required for women under age 40 who are at Breast Screening Policy came into effect. This high risk of developing breast cancer. policy reflects the latest evidence and the province’s commitment to reducing breast The Screening Mammography Program has cancer deaths by finding cancer at an early stage. updated all of its materials to reflect this new policy. To order these materials or to obtain The updated policy has an increased more information on the breast screening policy emphasis on helping women make an or the Screening Mammography Program, informed decision about screening. While no please visit www.screeningbc.ca/breast.

Key policy recommendations include:

Breast Screening

RISK AGE POLICY

Average risk Ages 40-49 Health care providers are encouraged to discuss the benefits and limitations of screening mammography UPDATED with asymptomatic women in this age group. If screening mammography is chosen, it is available every two years. Patients will be recalled every two years. A health care provider’s referral is not required, but is recommended.

Ages 50-74 Routine screening mammograms are recommended every 2 years for asymptomatic women at average risk of developing breast cancer. Patients will be recalled every two years. A health care provider’s referral is not required.

Ages 75+ Health care providers are encouraged to discuss the benefits and limitations of screening mammography UPDATED with asymptomatic women in this age group. Health care providers should discuss stopping screening when there are comorbidities associated with a limited life expectancy or physical limitations for mammography that prevent proper positioning. If screening mammography is chosen, it is available every two to three years. Patients will not be recalled by the Screening Mammography Program of BC. A health care provider’s referral is not required, but is recommended.

Higher than Ages 40-74 Routine screening mammograms are recommended every year. Patients will be recalled every year. average risk UPDATED A health care provider’s referral is not required. with a first degree relative with breast cancer

High risk Under age 40 The Screening Mammography Program accepts women at high risk of developing breast cancer with a with a known health care provider’s referral, provided they do not have breast implants or an indication for a diagnostic BRCA1 or BRCA2 mammogram. Please discuss patient with a screening program radiologist before referral. mutation or prior chest wall radiation or Age 40-74 Please refer to recommendation for “Higher than average risk” women. strong family history of breast cancer

continued on page 5

4 FAMILY PRACTICE ONCOLOGY NETWORK JOURNAL / SPRING 2014 Other Procedures

PROCEDURE RECOMMENDATION

Breast Self Exam (BSE) Routine breast self examinations (when used as the only Breast cancer information kit now online method to screen for breast cancer) are not recommended for The complete Breast Cancer Information asymptomatic women at average risk of developing breast cancer. Kit containing a navigation guide, resource Women should be familiar with their breast texture and booklets and the Intelligent Patient Guide to appearance and bring any concerns to their health care provider. Breast Cancer is now available online at www. bccancer.bc.ca/breastkit. The Kit provides Clinical Breast Exam(CBE) There is insufficient evidence to either support or refute routine answers to common questions and steers clinical breast exams (in the absence of symptoms) alone or in patients to critical resources that will help conjunction with mammography. The patient and her health them through their cancer journey. care provider should discuss the benefits and limitations of this procedure to determine what is best for the patient. This excludes women with prior breast cancer history.

Magnetic Resonance Routine screening with breast MRI of women at average risk of developing breast cancer is not recommended. Imaging (MRI) Exceptions are made for higher than average risk groups including: BRCA1 and/or BRCA2 carriers, first degree family relatives of BRCA1 and/or BRCA2 not tested, and prior Hodgkin’s disease (or other lymphoproliferative diseases) at a young age (between the ages of 10-30 years old) treated with chest radiation.

Message from the President – Screening mammography remains the best way to detect breast cancer in women aged 50-74

In recent years there has been Agency does not agree with the limitations and the benefits for women in much debate and publicity the findings in this study. their forties. We encourage women age 40-49 surrounding screening to have a discussion about the limitations The effectiveness of screening women for breast cancer. The and benefits of screening with their primary mammography has been Screening Mammography care provider to determine whether screening well established by several Program in BC has seen a 25 is appropriate for them at that age. In large clinical trials across per cent reduction in deaths consideration of the evidence for screening in the world. These trials from breast cancer among this age group, BC also updated the screening have found a relative risk women in the province who interval for average risk women to every two reduction of breast cancer have regular screening years. deaths of between 15-25% for mammograms. Screening Dr. Max Coppes, President, women aged 50-69. Of eight Screening mammography remains the most mammography remains BC Cancer Agency randomized control trials for important tool for early detection of breast important for the early screening mammography, cancer. In BC, the participation rate of women detection of breast cancer and we hope you seven showed that screening mammography in the target population of 50-69 years of will continue to encourage women aged 50-74 is beneficial. The Canadian National Breast age is just over 50 per cent when the national to participate in regular screening every two Screening Study is the only randomized target is 70 per cent so we have a lot of room years. control trial that did not show a benefit. to improve. In February 2014, the British Medical Journal Recent changes were made to BC’s policy on More information and health professional (BMJ) published 25-year follow-up results breast cancer screening based on the results resources can be found at www.screeningbc. from the Canadian National Breast Screening of an evidence review. ca. I hope we can count on you to help clarify Study suggesting that annual screening in the facts and help women in BC decide if women age 40-59 does not reduce breast BC’s new guidelines for women in their forties screening mammography is right for them. cancer mortality beyond that of physical took the recommendations by Canadian examination (for the 50-59 year olds) or usual Task Force on Preventive Health Care into Contact Dr. Max Coppes at care (for 40-49 year olds). The BC Cancer account as well as other research, weighing [email protected]

FAMILY PRACTICE ONCOLOGY NETWORK JOURNAL / SPRING 2014 5 Yukon — strong proponent of GPO training

Meet the four the Agency oncologists in- Network-trained person plus understand how Yukon General they work. It is also refreshing Practitioners in to be in an academic centre as Oncology who part of a team especially after together with a chemo having been my own show for nurse, navigator and so long.” oncology pharmacist “My hat goes off to all those are establishing a who have completed the dedicated cancer care training before us and to those clinic at Whitehorse family physicians in Whitehorse General Hospital. who for decades have been Dr. Danusia providing cancer care and chemotherapy in this remote Kanachowski Four Yukon GPOs have completed (or nearly completed) the Network’s GPO Training setting – and doing it well.” “We realized we Program: (left to right) Robin Jamieson, Lucille Stuart, Sally MacDonald and Contact Dr. Robin Jamieson at needed to increase Danusia Kanachowski. [email protected] our capacity when cancer, including the ordering and monitoring we were without our Dr. Lucille Stuart chemotherapy nurse for a short time and of chemotherapy for many years.” “I just completed the full eight weeks of the had to consider sending all our IV chemo “With our new team of GPOs, cancer care program including the two-week introductory patients to Vancouver,” explains Dr. Danusia navigator, chemotherapy nurse and oncology module – which was uniformly excellent Kanachowski, palliative care physician pharmacist, we will be able to provide more – and the six weeks of clinical rotation in Whitehorse and 2004 graduate of the comprehensive care for many patients with which I found very stimulating. We had well Network’s GPO Training Program. “The cancer – enhancing and building on the informed speakers providing current, useful BC Cancer Agency was very supportive of expertise in the community.” establishing a GPO Program at Whitehorse information in every lecture. Then we worked Contact Dr. Danusia Kanachowski at General Hospital. We will soon have four with oncologists who were very prepared to [email protected] trained GPOs and a dedicated space teach – friendly, open and great with patients and with us – even though our presence within the hospital to assess patients Dr. Robin Jamieson pre-chemotherapy. We are lucky to have created extra work.” “I have nearly completed the Program’s six an amazing room dedicated to the delivery “Being part of this new GPO Program offers weeks of clinical rotation and found the of chemotherapy generously donated by a different sort of care opportunity which learning experience incredible. I have always members of the community.” I really enjoy –spending dedicated time had a strong interest in oncology – particularly with patients sorting through problems and “We are in the development stage at present with the advances in targeted therapy – so ensuring everything is taken of during a really determining our support requirements, how was delighted to accept the opportunity to be difficult time.” we can best integrate within the existing part of a GPO Program here.” system and transition patients effectively “Key among the training benefits was “Aside from the mammoth amount of from the Agency to GPO to family physician. learning how to assess patients during their knowledge, the key benefits of the training There are many excellent Yukon physicians, chemotherapy including knowing what to include the networking and getting to know who have looked after their own patients with ask and what to look for regarding side- effects plus understanding the required follow-up care and monitoring in the years Next GPO training course begins September 8, 2014 after chemotherapy and other treatment is completed.” The GPO Training Program is an eight-week course offering rural family physicians and newly hired Agency GPOs the opportunity to strengthen their oncology skills and “I feel more competent and confident knowledge. The program includes a two-week introductory module held twice yearly at knowing that the care we provide will be up the Vancouver Cancer Centre followed by six weeks of flexibly scheduled clinical rotation to the Agency’s standard.” at the Centre where participants’ patients are referred. The program is accredited by the Contact Dr. Lucille Stuart at College of Family Physicians of Canada and eligible physicians will receive a stipend and [email protected] have their expenses covered. Full details at www.fpon.ca continued on page 7

6 FAMILY PRACTICE ONCOLOGY NETWORK JOURNAL / SPRING 2014 Top ten things to think about CAM therapies

By Dr. Lynda Balneaves, Associate Professor to cope with symptoms, improve quality patients’ quality of life. It is important to in the UBC School of Nursing and an Affiliate of life, or to simply maintain hope. consider the positive and negative impact Nurse Scientist at the BC Cancer Agency. She Understanding their goals will help tailor on patients’ psychological, relational, and currently leads the UBC/BCCA Complementary your discussion as well as direct you financial wellbeing. Medicine Education and Outcomes Program towards relevant evidence. Remember that 7. WHO SHOULD THEY TALK TO? Patients (CAMEO). goals may be physical, emotional, and/or may be hesitant to share their CAM use relational. Cancer patients face many with their oncologists. For safe and tough choices. Often, they are 3. WHAT DOES THE comprehensive care, it is important that faced with many treatment EVIDENCE SAY? There is a they discuss ALL the therapies they are options that have both good growing body of high quality using with their oncology health care and bad risks attached to evidence regarding the team. efficacy and safety of CAM them. These choices are View the full webcast of this topic therapies. Check out the even more difficult to make at www.fpon.ca – CME Initiatives. when patients consider databases or evidence-based using complementary and resources at: www.bccancer. 8. HOW DO THEY SELECT A PRACTITIONER? alternative medicine (CAM). bc.ca/RES/ResearchPrograms/ There are many different types of CAM A growing number of cancer cameo/usefullinks.htm . providers out there – patients should look patients are using CAM and 4. WHAT ARE THE for a practitioner who is licensed and/or are turning towards their Dr. Lynda Balneaves POSSIBLE SIDE EFFECTS AND regulated and has experience caring for oncology health care team, CONTRAINDICATIONS? Like people with cancer. Individuals who claim including family physicians, for support in any treatment, CAM therapies can come to cure cancer, recommend stopping all making an informed decision. with side effects and may interact with treatment, and are very expensive should conventional cancer therapies. CAM may be consulted with caution. Here is a list of the top ten things you should also not be appropriate for some types 9. HOW WILL THEY MONITOR OUTCOMES? think about when talking to patients about of cancers and other health conditions. Patients need a plan about how they will CAM. Understanding the possible side effects monitor CAM use. Encourage them to keep 1. HOW’S THEIR FOUNDATION? Before will allow you and your patients to know a diary that keeps track of the positive and patients spend time and money on CAM, what to look for. negative effects over a specified period of they should first review their lifestyle 5. WHEN IS THE RIGHT TIME TO USE CAM? time. Consider how scheduled tests can be and determine what changes could be Because of the potential interactions included as part of the plan. made to their diet, activity level, stress between CAM therapies and chemo- 10. WHEN WILL THEY REVIST THE DECISION? management and exposure to tobacco therapy, radiation and surgery, it is At some point, patients should take a and sun. The AICR/WCRF Diet and important to select the right time to use step back and reflect on whether CAM Cancer Report provides clear lifestyle CAM. Waiting till conventional treatment is therapies are helping them achieve their recommendations that is easily accessible over or having a “wash out” period may be goals – consider arranging a follow-up visit at: www.dietandcancerreport.org. prudent. to discuss. 2. WHAT ARE THEIR GOALS? While some 6. WHAT IS THE IMPACT ON QUALITY OF Contact Dr. Lynda Balneaves at patients use CAM in the hopes of curing LIFE? CAM therapies may not only have [email protected]. their cancer, many individuals use CAM physiological effects but also impact

Yukon — strong proponent of GPO training opportunity to become immersed in these “I really enjoyed the program benefitting continued from page 6 areas.” not only from the most current knowledge, but also gaining a better appreciation of Dr. Sally MacDonald “The major benefit that the GPO Program will functional areas such as the approach bring to our community is that we can act as “I am the newest Yukon GPO also midway to guidelines and how to institute them advisors and helpers providing education to through my six weeks of clinical rotation. effectively.” Having just retired after 35 years as a full increase the quality of care for everyone. We service family physician, I appreciate those won’t be impinging on physicians’ existing “Agency staff were incredibly kind and parts of medicine that accompany the aging relationships with their patients, but adding generous with their time guiding us through process including oncology and palliative to their expertise while handling referrals cases and answering all our many questions.” from the Agency and caring for the many care and the advances and complexity Contact Dr. Sally MacDonald at patients without family physicians.” involved. I am enjoying the challenge and the [email protected]

FAMILY PRACTICE ONCOLOGY NETWORK JOURNAL / SPRING 2014 7 Your role in cervical cancer prevention

By Dr. Marette Lee, poorly screened present with performance, screening effectiveness depends Gynecologic Oncologist, more advanced cancers and on women’s participation, sample quality BC Cancer Agency more often die of their disease. and adequate management and treatment of Vancouver Centre In British Columbia one in five abnormal results. There are several simple women has an inadequate things you can do that will have a great Cervical cancer is almost screening history. Certain impact in the fight against cervical cancer. entirely preventable with populations such as South regular screening and 1. Identify eligible women for screening Asian women, new immigrants, vaccination. Since its First Nations women, and 2. Obtain high quality smears introduction, screening with women who are elderly and of a. SINGLE slide cytology in the form of the low socioeconomic status are at b. Label the slide in PENCIL with NAME Pap smear has been extremely Dr. Marette Lee the highest risk of having either and DATE OF BIRTH (dd/mm/yyyy) successful, decreasing no screening or poor screening. cervical cancer rates by about c. Use CYTOSPRAY IMMEDIATELY – even 10 seconds makes a difference! 70%. However, rates have plateaued in the What can I do? last 30 years and further progress is limited, 3. Make APPROPRIATE REFERRALs for As a primary care provider, you are on the mainly due to incomplete screening uptake. abnormal results – repeat every 6 months front lines of cervical cancer prevention for up to 24 months if ASCUS or LSIL, Inadequate screening remains the greatest and you have the greatest opportunity to otherwise refer for anything more severe. risk factor for cervical cancer. Women who are make a difference. Aside from laboratory continued on page 9

Cervical cancer screening and colposcopy

By Leah Jutzi MD FRCSC, Fellow, Gynecologic screening can be resumed and if the HPV test Treatment recommendations for Oncology, University of British Columbia/ is positive, the patient should be referred to cancer of the cervix BC Cancer Agency colposcopy. A cone biopsy or simple hysterectomy is In January 2013 the Canadian Task Force on Colposcopic abnormalities are managed based sufficient treatment for 1A1 (microscopic) Preventive Health Care released updated on the risk of progression to CIN3 and cancer. lesions. For patients with disease up to cervical cancer screening guidelines. These The majority of CIN1 lesions will regress and stage 2A, a radical hysterectomy may be guidelines recommend against screening the risk of progression to cancer is extremely offered and is the favoured treatment in women under age 20 given the exceedingly low low, thus these lesions are not treated. earlier stages. The fallopian tubes and in prevalence of cervical cancer in this age group. The SOGC recommends that all women with some cases the ovaries are also removed. The guidelines also state there is moderate CIN3 are treated. In BC, women under 24 For select patients who wish to preserve evidence against screening women aged with CIN2 or 3 are offered follow-up because fertility, a radical trachelectomy (removal 21-25. However, many Canadian professional there is a high rate of regression. For those of the cervix only) is an option. Based on societies do not feel it is safe to omit who have persistence of CIN2/3 at 2 years, the final pathology, adjuvant radiation is screening in these women. Many providers treatment is recommended. recommended to some patients. will likely opt to initiate screening at age 21; The alternate treatment option for stages however, well-informed patients may choose HPV vaccination in ‘older’ women and 1B1 – 2A is chemoradiotherapy. This involves to delay the initiation of screening. women with a history of dysplasia 5 weeks of external beam radiotherapy with 2 or more internal treatments and weekly View the full webcast of this topic Women continue to acquire new HPV chemotherapy. Chemoradiotherapy is the at www.fpon.ca – CME Initiatives. infections throughout their lives. The National Advisory Committee on Immunization treatment of choice for stages 2B – 4A. The Task Force has not made a statement recommends vaccination in women over 26 If patients recur, surgery, radiation and about HPV testing although it is available. since they may have been exposed to some chemotherapy can be utilized depending on In patients with a positive high-risk HPV test but not likely all HPV subtypes in the vaccine. prior treatment and the location and extent of and normal cytology, both tests should be In a large study, women with a history of recurrence. repeated in one year. If the HPV and cytology treatment for dysplasia who were vaccinated Contact Dr. Leah Jutzi at are both abnormal, the patient should be had a 46% reduction in any subsequent HPV [email protected] managed according to the cytology. If in related disease. Thus women with a history of one year both tests are negative, regular dysplasia should be offered vaccination.

8 FAMILY PRACTICE ONCOLOGY NETWORK JOURNAL / SPRING 2014 Your role in cervical cancer prevention populations. Studies have demonstrated This potential strategy offers hope in the continued from page 8 improved screening uptake in several struggle to reach and empower those who 4. Encourage SMOKING CESSATION populations using this strategy. If we are are most at risk. www.screeningbc.ca/Cervix/ going to make headway in cervical cancer ForHealthProfessionals 5. Encourage and provide HPV VACCINATION– prevention we must utilize new innovative recommended for women up to 45 Contact Dr. Marette Lee at [email protected] methods to increase screening utilization. years. Women who have a HISTORY OF DYSPLASIA are still eligible and in fact Trend in the age-standarized cervical cancer incidence rates for provinces for which have LOWER RECURRENCE RATES if data were available to 2009. Arrows indicate points of change determined by Joinpoint. vaccinated. 25 The Future of Screening 20 HPV testing is currently under consideration as a primary screening test in British 15 Columbia. HPV screening technology not 10 only offers increased sensitivity, but it also has the potential to break down barriers 5

to screening attendance. Self-collected Rate per 100,000 population HPV specimens have similar sensitivity 0 for detection of high grade dysplasia as 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 clinician collected cytology specimens. Alberta Britsh Columbia Ontario Quebec This approach has been shown to be both feasible and acceptable in hard to reach (from A. Mosavi-Jarrahi and E.V. Kliewer, J Obstet Gynaecol Can 2013;35(7):620-626.

Vocational rehabilitation support for cancer patients

By Maureen Parkinson, M.Ed, CCRC This workbook incorporates feedback for sale through the C&W Online Bookstore from over 35 patients and 25 health care http://edreg.cw.bc.ca/BookStore/public/ For the last 19 years, the BC Cancer Agency professionals including physicians, insurance bookstore/default.aspx has offered vocational rehabilitation support providers, lawyers and employer or employer for cancer patients across the province. Part of this guide, of particular interest and representatives. This Guide for Cancer These services include individual vocational assistance to physicians, is the Job Analysis Patients will be available for download from rehabilitation counselling and consultations Tool. This section helps patients who want the Coping with Cancer section of the BC on job search, educational, work related to return to their former employment to Cancer Agency website. Hard copies will be insurance issues, rehabilitation services, and examine specific tasks that they are expected human rights. Online information is available to perform in their job and to share this with to address some common concerns at: their doctors. This information can be helpful www.bccancer.bc.ca/PPI/copingwithcancer/ to physicians in order to determine a patient’s emotional/Work+Related+Issues.htm. job readiness, assess rehabilitation needs, identify where modifications at the workplace In 2011, a ‘Return to Work’ seminar was are needed and explore options with patients. developed for patients who expected to To see this tool go to: www.bccancer. return to work at their former workplace. The bc.ca/PPI/copingwithcancer/emotional/ information shared focused on three areas: Work+Related+Issues.htm. • Developing a rehabilitation plan; For vocational rehabilitation counselling • Enhancing workplace wellbeing; and support, cancer patients can book in-person • Handling workplace transition. appointments or phone consultations with Based on clinical research and participant a vocational rehabilitation counsellor by feedback, a companion workbook was calling their local cancer centres. Health created in 2012. A more extensive second care professionals can also consult with the edition, Cancer and Returning to Work: vocational rehabilitation counsellor by calling A Practical Guide for Cancer Patients will 604-877-6000 or 1-800-663-3333 ext 672126 be published later this spring. It has been (Mondays and Fridays). Cancer and Returning to Work: A Practical designed to be helpful for patients in Guide for Cancer Patients is soon to be Contact Maureen Parkinson at anticipating and problem solving around available online and in hard copy. [email protected]. challenges regarding returning to work.

FAMILY PRACTICE ONCOLOGY NETWORK JOURNAL / SPRING 2014 9 Hereditary cancer genetic testing in the news

By Mary McCullum, Nurse Educator & now dubbed the “Angelina effect”. For that wait times for appointments have also Melanie Taylor, Genetic Counsellor, example, in each of the 4 months following increased. Hereditary Cancer Program her announcement, the BC Cancer Agency’s In addition to more referrals, HCP staff Hereditary Cancer Program (HCP) saw a 100% Awareness of hereditary breast cancer and received many questions about hereditary increase in new referrals. Many previous the BRCA1/2 genes, increased tremendously cancer and genetic testing, which is likely true patients have also re-contacted HCP to in mid-2013 with media coverage of Angelina for physicians as well. Following are some request or provide updates and some have Jolie’s choice to have prophylactic mastectomy of the common questions and the current decided to re-consider earlier decisions to and breast reconstruction because she carries availability of hereditary cancer services in BC: decline genetic testing. Others have new an inherited BRCA1 gene mutation. questions about options for cancer risk Q. How common is hereditary cancer? Cancer genetics clinics around the world reduction. While increased awareness is A. While cancer is common, hereditary cancer describe significant impact on workload, important, the associated workload means is not. Only 5-10% of all cancers are caused by an inherited gene mutation. Q. Does the Hereditary Cancer Program focus Message from the chair only on hereditary breast/ovarian cancer (HBOC)?

By Dr. Phil White, Chair and and soon guidelines on female A. No!! The HCP offers risk assessment for all Medical Director of the Family genital tract cancers. Next on hereditary cancer syndromes. Referrals Practice Oncology Network and our list are guidelines for HPV for Lynch syndrome should be as common family physician in Kelowna related head and neck cancers. as HBOC referrals, but a large imbalance persists. This may be because hereditary As greater numbers of cancer Guidelines as such were colorectal cancer and other syndromes do patients become cancer identified as among the most not get the media attention given to HBOC. survivors, the follow-up care important tools the Network Q. My patient has a family history of cancer and monitoring undertaken by could provide for family and asks about genetic testing. How do I family physicians becomes all physicians when we started arrange genetic testing? the more important. The Family in 2002. In fact, some have A. In BC, publicly funded hereditary Practice Oncology Network been in use long enough that cancer genetic testing is only available develops tools and resources to support this we are now evaluating their effectiveness and through the Hereditary Cancer Program. growing responsibility and chief among them updating content. Revisions are underway Individuals/families who meet eligibility are clinical practice guidelines developed already on the Palliative Care suite while criteria can be referred. especially for family physicians. These the Canadian Partnership Against Cancer guidelines are brief and easily accessible. They is supporting evaluations of the breast and Q. How do I know if a patient should be also include flow charts and patient hand-outs colorectal guidelines as part of an overall effort referred to the Hereditary Cancer Program? while following the approved Guidelines and to further resources for cancer survivorship. A. Take a detailed, three generation family Protocols Advisory Committee format. Community based oncology workshops for history. Remember that if the family is large and people live to older ages, it is Work is well underway now, for example, on family physicians are another key resource likely there will be some cancers, but it a guideline for upper GI cancers which will provided by our Network. We partner with may not fit a hereditary pattern. Look cover diagnosis, management and follow-up of UBC’s Division of Continuing Professional for indications of possible hereditary cancers of the esophagus, stomach, pancreas Development to present the Cancer Care cancer such as: common cancers at and biliary tract. The development of this Outreach Program on Education now entering younger ages than usual, multiple guideline, led by Dr. Catherine Clelland of Port its fourth year. This program which includes close relatives with the same type Coquitlam with scientific writer Leslea Duke of the development and delivery of community of cancer, individuals with multiple Victoria, is supported by the Provincial Health based workshops on breast, prostate, cancers. If those features are present, Services Authority’s Shared Care Program. colorectal and soon advanced cancers requires significant support and I would like to thank compare the family history to the current Once completed later this spring, we anticipate Fiona Walks, the BC Cancer Agency’s Vice referral criteria at www.screeningbc. that this guideline will join those already President, Safety, Quality and Supportive Care ca/Hereditary/ForHealthProfessionals/ published at www.bcguidelines.ca including for her ongoing support and commitment. HereditaryCancerSyndromes. our suite of three palliative care guidelines; Watch for an opportunity to take part in your Q. Who is eligible for hereditary cancer guidelines on breast cancer diagnosis, community. genetic testing? management and follow-up; guidelines on colorectal screening for cancer prevention Contact Dr. Phil White at A. The first step is consultation with a genetic continued on page 11 and follow-up of colorectal polyps or cancer; [email protected]

10 FAMILY PRACTICE ONCOLOGY NETWORK JOURNAL / SPRING 2014 Managing symptoms in palliative care

By Dr. Pippa Hawley, Palliative Care Physician, antidepressant, anxiolytic, sedative and be very helpful in mechanical irritation BC Cancer Agency, Vancouver Centre appetite-stimulating effects. For those with of the diaphragm. Other treatments concurrent neuropathic pain, clonazepam include metoclopramide, chlorpromazine, Cancer patients experience cancer through or a sedating tricyclic such as nortriptyline haloperidol, sertraline, baclofen, nifedipine having symptoms. Though any one symptom can have a co-analgesic effect. Many of my and intravenous lidocaine infusion. can have an enormous impact on quality of patients also report very effective use of life, multiple symptoms can be overwhelming. Patients report effective use of medicinal medicinal cannabis for sleep. New symptoms can also cannabis for all of these symptoms. be important indicators of Diaphoresis: clonidine, In order to best manage cancer patients’ medical problems. It is very paroxetine, venlafexine symptoms I suggest: important that symptoms and gabapentin have been are regularly assessed shown to be helpful in hot • Ask about symptoms systematically and throughout the illness course, flash-related sweating, and regularly, using a validated tool if possible and that they are managed cimetidine can be useful for • Use a mechanism-based approach to aggressively, whatever the opioid-induced sweating. selecting treatments, recognising that cause. A measure of severity is All of these may be worth sequential trials of multiple agents may be important to trigger different trying sequentially for required approaches if necessary. tumour-related sweating. • Always specify the purpose of medications Acetaminophen can cause All physicians who have on your prescriptions Dr. Pippa Hawley sweating and patients may not been through the General • Use single drugs which target multiple recognize the association of Practitioner in Oncology symptoms wherever possible, thereby the drug with the side-effect. training program will have received teaching reducing polypharmacy on how to manage the most common Pruritus: Pruritus is often worst at night, and For further information I recommend one of symptoms, and should be familiar with sedation from antihistamines can be useful. the following: the BC Guidelines and Protocols Advisory Pruritus due to advanced Hodgkin’s disease, Committee’s Palliative Care guidelines [www. or from paraneoplastic syndromes can be The Pallium Palliative Pocketbook, available bcguidelines.ca/guideline_palliative2.html], particularly severe. Paroxetine, ondansetron on-line for $20 through the CHPCA’s which has algorithms for pain, dyspnea, and mirtazapine have been reported to be marketplace at http://market-marche.chpca. nausea and vomiting, constipation, delirium, helpful. I have also had some success in use net/The-Pallium-palliative-pocketbook- fatigue and depression. Other symptoms can of low dose methadone. A-peer-reviewed-referenced-resource. A be equally unpleasant. revised and updated edition will be available Singultus: nerve irritation anywhere from electronically in 2015, but the 3rd print Insomnia: In the absence of a clear reason the brain stem to the stomach can cause edition is still available and very current. for awakening, (e.g.pain, sleep apnea or need hiccups, including metabolic derangements to go to the bathroom), insomnia is rarely a such as uremia, hyponatremia and Symptom Management in Advanced Cancer. solitary symptom. It is usually accompanied hypocalcemia. Hiccups can be associated Twycross, Wilcock and Toller, 5th edition by anxiety and/or depression. Hypnotics with GERD, and can occur as a side-effect coming in fall of 2014, available from such as zopiclone or benzodiazepines of intravenous steroids (especially in men), palliativedrugs.com. There is also a Canadian may seem effective at first, but will not serotonin receptor antagonists, and some palliative care formulary companion volume. address the underlying disorder. A sedating chemotherapies (e.g. cisplatin). Low dose Contact Dr. Pippa Hawley at antidepressant such as mirtazapine will have corticosteroid therapy may conversely [email protected]

Hereditary cancer genetic testing Q. Is the cost of genetic testing covered in BC? and risk-reducing surgery. People who do continued from page 10 A. Yes, but only if the patient meets eligibility not inherit “the family gene” can follow counsellor or MD geneticist to confirm criteria. population cancer screening guidelines and be reassured that inherited cancer risk eligibility and identify the “best testable” Q. Why would somebody choose to have cannot be passed on to their children. family member. To be most informative, hereditary cancer genetic testing? genetic testing usually begins with a Q. Where can patients and physicians find A. Results may provide information about family member who has been diagnosed more information about hereditary cancer? personal cancer risks as well as risk for with cancer. If a gene mutation has already family members. Confirming high-risk A. Visit the website: www.screeningbc.ca/ been identified in the family, unaffected status can inform risk management hereditary. Call 604-877-6000 local 2325 relatives may be eligible for carrier testing. options, including enhanced screening with questions about specific cases.

FAMILY PRACTICE ONCOLOGY NETWORK JOURNAL / SPRING 2014 11 Delivering serious news: a therapeutic dialogue

By Dr. Tamara Shenkier, discussion of serious news hope. Cambridge : New York: Cambridge Medical Oncologist, can become a therapeutic University Press; 2009. BC Cancer Agency dialogue. This applies over 3. Buckman R. Practical plans for difficult Vancouver Centre the entire disease trajectory: conversations in medicine: Strategies that relaying biopsy results at How patients handle bad work in breaking bad news. Baltimore: initial diagnosis, confirming news - defined as any news Johns Hopkins University Press; 2010. a recurrence or transitioning that changes their view of from active treatment to the future in a negative way - exclusively supportive care. depends on the gap between The latter scenario can be the FAMILY PRACTICE ONCOLOGY their perception and the most challenging and warrants NETWORK CHAIRS reality of the situation. Even Dr. Tamara Shenkier additional analysis. NETWORK COUNCIL an experienced communicator Dr. Philip White can have a discussion go awry. The SPIKES Notwithstanding years of practice, physicians Kelowna protocol for delivering bad news and the who help patients transition from active 250.765.3139 NURSE acronym for responding to emotion treatment to palliative care may still [email protected] are practical and valuable tools for experience a sense of failure and grief. When CONTINUING MEDICAL EDUCATION navigating these potentially difficult specific anti-cancer interventions become Dr. Raziya Mia situations with confidence. ineffective we often hear phrases like “you Abbotsford are giving up on me” or “isn’t there any 604.851.4710 ext. 644744 [email protected] View the full webcast of this topic hope”. At this stage it is useful to separate at www.fpon.ca – CME Initiatives. the treatment of the cancer from the care of GUIDELINES AND PROTOCOLS the patient. While we cannot stop the cancer, Dr. Catherine Clelland we can still help our patients recognize and The first step is to ensure a comfortable GPO TRAINING PROGRAM explore their values and goals. These may physical setting (“S” for set-up). Next Dr. Bob Newman include dying at home free of pain, leaving a we must ascertain what our patients Sechelt digital legacy for their children or attending 604.885.2667 understand and expect (“P” for perception) their grandchild’s graduation. By listening [email protected] and how much detail they want to hear (“I” and proposing a plan to help achieve those for invitation). Once we share the serious goals we show a commitment to caring for information (“K” for knowledge) we need the person even if we can no longer manage to track our patients’ reactions by staying the cancer. FOR MORE INFORMATION attuned to verbal and non-verbal cues. If To learn more about the the cues indicate the patient is experiencing We build rapport when we demonstrate Family Practice Oncolgy Network strong emotions (“E”) we should stop understanding, respect and support and or become involved please contact: providing factual information and offer an when we give patients the psychological Jennifer Wolfe empathic response instead. space to explore difficult emotions. These Tel. 604.219.9579 skills can be learned and mastered. email: [email protected] Non verbal expressions of support such Therapeutic communication, a core skill at as pausing, leaning forward, moving your Visit the Network Website: the heart of caring for people with cancer, chair closer or offering a tissue indicate www.fpon.ca deepens our relationship with our patients your concern and attention. I rely on the The content of articles in this Journal and enriches our practice of medicine. NURSE acronym (Naming, Understanding, represent the views of the named Respecting, Supporting and Exploring) to Contact Dr. Tamara Shenkier at authors and do not necessarily represent help me respond to emotions with words. [email protected]. the position of BCCA, PHSA or any other organization. Statements such as “I wish the results were better” or “you weren’t expecting to Bibliography hear this” can align us emotionally with our 1. Baile WF, Buckman R, Lenzi R, Glober G, patients and the phrase “tell me more” can Beale EA, Kudelka AP. SPIKES – A six- Publications Mail Agreement give them the opportunity to explore their step protocol for delivering bad news: Number 41172510 feelings. Summarising (“S”) the conversation Application to the patient with cancer. Return all undeliverable Canadian and making explicit plans for the next contact Oncologist. 2000 2000;5(4):302-11. Addresses to is the crucial last step. 2. Back A, Arnold RM, Tulsky JA. Mastering BC Cancer Agency 600 West 10th Ave, Vancouver, BC communication with seriously ill patients: Bearing witness to strongly expressed V5Z 4E6 emotions can in itself be salutary and the Balancing honesty with empathy and

12 FAMILY PRACTICE ONCOLOGY NETWORK JOURNAL / SPRING 2014