Resuming Cancer Screening During COVID-19

By Aisha K. Lofters MD PhD CCFP Family Physician, Women’s College Hospital Family Practice Health Centre; Associate Professor and Clinician Scientist, Department of Family and Community Medicine, University of Toronto; Chair in Implementation Science, Peter Gilgan Centre for Women’s Cancers, Women’s College Hospital

Ontario’s health care system has been significantly impacted by COVID-19 and these impacts will be felt for a while. At Ontario Health (Cancer Care Ontario), we paused cancer screening back in March as a result of the pandemic, but we recently provided guidance on gradually starting up breast, colorectal and cervical screening. Because COVID-19 is affecting health system capacity differently across Ontario, here are some tips based on this guidance to help you make decisions about when to screen your patients in the coming months.

Breast Screening

Screening at Ontario Breast Screening Program (OBSP) sites is gradually beginning again. Each site is resuming based on local factors, such as availability of personal protective equipment, staffing, physical space and local COVID-19 infection trends.

If capacity is limited in your area, here are some tips on who to send for breast screening:

High Risk OBSP participants
Average risk initial screens
Average risk one year rescreens

Our website has more information on the current breast cancer screening guidelines.

Cervical Screening

If someone comes to your office and they are due for cervical screening, we suggest screening them. Annual screening for people at elevated risk for cervical cancer should also start up again as you begin to have in-person appointments. Examples of people at elevated risk include anyone who is:

Discharged from colposcopy with persistent low-grade cytology
Discharged from colposcopy with an HPV-positive test and a normal or low-grade cytology
Immunocompromised

In addition, colposcopy services are gradually resuming. To make sure people at the highest risk for cervical cancer are able to get a colposcopy appointment during COVID-19, we recommend only sending patients with a single high grade cytologic abnormality (e.g., HSIL+, AIS) or two consecutive low grade cytologic abnormalities (e.g., LSIL, ASCUS). Patients with a single low grade cytologic abnormality should be re-screened in primary care in approximately 12 months with cytology.

As a reminder, any patient who is positive for human papillomavirus (HPV) strains 16 or 18 should be referred to colposcopy regardless of cytology result.

Visit our website to find out more about the current cervical screening recommendations.

Colorectal Cancer Screening

As of October 20, 2020, screening with the fecal immunochemical test (FIT) has been expanded to all eligible people at average risk for colorectal cancer. Since ongoing fluctuations in COVID-19 cases and local variation in COVID-19 trends are expected, consider local trends in COVID-19 transmission and local capacity for diagnostic services (e.g., colonoscopy) prior to initiating colorectal cancer screening. If you have limited capacity for screening, we recommend focusing your screening efforts on people over the age of 60.

Because of COVID-19 safety precautions and potential delays with the mail, there may be delays in getting a FIT kit.

Here are some tips for sending in requisitions to prevent further delays:

Please do not batch fax requisitions as this can lead to errors and subsequent delays
Include a valid OHIP number with updated version code
Ensure that your patient’s mailing address information is correct
Do not send repeat orders until at least 4 to 6 weeks have passed to allow for processing and mailing time

You should also resume referrals to colonoscopy, especially for patients with an abnormal FIT result, patients who are at increased risk for colorectal cancer, or patients who are eligible for post-polypectomy surveillance with colonoscopy. You can find out more about the current colorectal cancer screening recommendations on our website.

This guidance is based on the best available evidence and we hope you find it helpful. Please contact us if you have any questions at cancerinfo@ontariohealth.ca.