If you live in Ontario and you’re turning 50, expect to receive a birthday letter in the mail: not from your loved ones (though they may send one too) but from Ontario’s provincial cancer agency, Cancer Care Ontario.
These birthday letters represent a paradigm shift. A health care agency is reaching out proactively to people at risk of a condition and providing advice on what to do. In this case, it’s informing people of their risk of colorectal cancer, the second-biggest cause of cancer death in Canada. And it’s recommending that patients visit their family doctor or nurse practitioner to talk about getting a fecal occult blood test (FOBT), a screening test that can catch colorectal cancer early, when it’s more likely to be curable.
An FOBT is a simple test, but it can make some people uncomfortable. 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 prepaid, preaddressed 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 see if there are any 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 similar programs. The good news is that 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’re lucky to live in a country where everyone has publicly funded insurance for essential health care, regardless of means.
My colleagues and I wondered whether the proactive approach of contacting patients to get screened would narrow the gaps between rich and poor, and between 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 between long-term residents and new immigrants narrowed a bit. But the gaps were still pretty big. Six years after the program was launched, 64 percent of women and 61 percent of men who had lived in Canada a long time and were in the wealthiest neighbourhoods got screened for colorectal cancer. Yet only 40 percent of women and 36 percent of men who were immigrants and lived in the poorest neighbourhoods received screening.
The gaps between rich and poor, and between long-term residents and new immigrants, 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 having a colonoscopy. It’s worth mentioning that US guidelines include colonoscopy as one of the recommended screening tests for colorectal cancer, and that position has also probably influenced opinions in Canada.
We found that more than 40 percent of long-term residents living in the wealthiest neighbourhoods had a colonoscopy, compared with about 10 percent of immigrants living 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 out a birthday letter prompting you to get screened is a good thing. It has the potential to level the playing field, providing information to everyone, regardless of background. But we probably 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 US National Cancer Institute has said, when it comes to screening for colon cancer, the best test is probably the one you’re willing to do.
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