Colorectal Cancer Diagnosis in Alberta

THEMES:

• Timely follow-up

• Need for patient navigation

• Supporting primary care

• Care disparities

SUMMARY

Colorectal cancer is the second most common cancer among males and the third among females.1

Despite universal healthcare and organized screening, significant disparities in diagnostic pathways, healthcare utilization, and access persist.2

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Colorectal cancer (CRC) is a pressing public health concern. As a major cause of morbidity and mortality in Canada, it ranks as the second most common cancer among males and the third among females.1 Despite a universal healthcare system and organized screening programs, significant disparities in diagnostic pathways, healthcare utilization, and access persist, leading to unequal outcomes across the population as “profound health inequities experienced by Indigenous populations and some vulnerable groups also require coordinated action on the social determinants of health if these inequities are to be effectively addressed”.2

STUDYING COLORECTAL CANCER DIAGNOSIS IN ALBERTA

Alberta has comprehensive administrative databases and centralized healthcare registries that are well-suited for analyzing colorectal cancer (CRC) presentation patterns.3 These resources provide an exceptional foundation for studying the disparities and challenges in CRC diagnosis and care, particularly concerning emergency department (ED) visits preceding diagnosis and the subsequent impact on patient outcomes.

The diagnosis phase of colorectal cancer (CRC) is critical for determining the appropriate treatment and improving patient outcomes. The diagnostic process typically begins with initial screening using fecal immunochemical tests (FIT) or other stool-based tests, followed by confirmatory diagnostic procedures such as colonoscopy.3 Early and accurate diagnosis is essential for effective treatment and reducing CRC mortality rates. Once a positive FIT result is obtained, the standard protocol involves scheduling a colonoscopy within a specified timeframe to confirm the presence of cancer or precancerous lesions.4 The timeliness of this follow-up colonoscopy is crucial, as delays can lead to the progression of the disease to more advanced stages, which are associated with poorer prognoses.5 Alberta Health Services recommends that follow-up colonoscopies for average-risk individuals occur within 1–2 months after a positive FIT to ensure early detection and intervention.

CHALLENGES IN THE DIAGNOSTIC PHASE

Despite established protocols, several challenges impede the efficiency of the diagnostic phase in Alberta:

Resource limitations, such as insufficient availability of endoscopy facilities and trained gastroenterologists, contribute to scheduling delays.6
Geographic disparities also play a significant role, with residents in remote and rural areas facing longer wait times for diagnostic procedures compared to those in urban centres.7

IMPACT OF DIAGNOSTIC DELAYS

Diagnostic delays have been linked to an increased likelihood of presenting with advanced-stage CRC, which significantly reduces survival rates.4

Studies indicate that delays exceeding 12 months from a positive FIT result to colonoscopy are associated with a higher risk of CRC diagnosis and progression to more severe stages.5

Moreover, prolonged diagnostic intervals can lead to increased healthcare costs due to the need for more intensive treatments and longer hospital stays.8

SUMMARY OF FOUR STUDIES

Despite established protocols, several challenges impede the efficiency of the diagnostic phase in Alberta. Resource limitations, such as insufficient availability of endoscopy facilities and trained gastroenterologists, contribute to scheduling delays.6

Abdel-Rahman et al. (2022) conducted a population-based study examining the factors associated with frequent visits to the emergency department (ED) before a CRC diagnosis. The study found the following factors were associated with increased ED visits due to limited access to specialist care:
- Female gender
- Higher comorbidity index
- Metastatic disease
- Proximal tumors
- Living in the North zone of Alberta

Brenner et al. (2024) explored the impact of the time interval between a positive FIT result and follow-up colonoscopy. The study concluded that delays over 12 months increased the risk of CRC and decreased the effectiveness of screening programs.

Study #1. Screening Tools for Early Detection

Early detection can prevent deaths from colorectal cancer by using screening tools such as fecal immunochemical tests (FIT) and colonoscopies. In Alberta, Canada, FIT is recommended for CRC screening every 1–2 years for average-risk asymptomatic individuals aged 50–74 years old. The current Canadian Task Force on Preventive Health Care guideline recommends a (FIT) every 2 years for the average-risk population.3

Jessiman-Perreault et al. (2023) conducted a geospatial analysis, identifying areas with high numbers of Albertans lacking colorectal cancer screening, emphasizing the need for targeted interventions in the North and Central zones of Alberta. This population-based cross-sectional study used multiple administrative health data sources, including the Alberta Cancer Registry, Discharge Abstract Database, Ambulatory Care Classification System Database, and Physician Billing Database. The total study population included 919,939 Albertans aged 52 to 74 as of December 2019 and measured the risk of CRC diagnosis and the stage of cancer at diagnosis based on the time interval between the positive FIT and follow-up colonoscopy.

The results revealed that individuals from areas with higher material and social deprivation had a higher likelihood of delayed colonoscopies following a positive FIT result, leading to advanced-stage CRC at diagnosis. The study underscores the need for targeted interventions in underserved areas to improve follow-up rates and CRC outcomes.5

Regardless of socio-economic status, the analysis indicated that the risk of CRC, particularly advanced-stage CRC, is associated with significant days. For example, the study found that two or more visits to GI specialists added 108 days to the diagnosis.6

Older patients, those with multi-morbidities, and those living in lower-income areas experienced longer diagnostic intervals. This indicates disparities in the timeliness of CRC diagnosis based on demographic and socio-economic factors.6

Lessons Learned

Developing integrated care models that improve coordination among GPs, specialists, and other healthcare providers can help reduce diagnostic delays. Designing targeted interventions for high-risk groups, such as older adults and those with multi-morbidities, can help address specific barriers to timely diagnosis.6

Next Steps

Continue to support research on CRC detection and diagnosis to monitor the effectiveness of implemented policies and identify areas for further improvement. Use findings to inform continuous policy development and healthcare practice adjustments.6

Study #2. Factors Associated with Frequent Emergency Department (ED) Visits in the 3 Months Preceding a CRC Diagnosis

An important quality indicator for colorectal cancer (CRC) care is the proportion of patients diagnosed emergently versus electively.8 Patients diagnosed in emergency situations are more likely to present with advanced-stage disease, leading to poorer outcomes. Emergency department (ED) diagnosis is also generally more costly for the healthcare system compared to outpatient ambulatory assessments.8

Frequent ED visits in the months preceding a CRC diagnosis are indicative of systemic inefficiencies in timely diagnosis and care pathways. Abdel-Rahman et al. (2022) analyzed the patterns of ED visits in Alberta and identified several contributing factors, including advanced disease stage at presentation, a higher comorbidity index, and geographic disparities in healthcare access.7 Notably, patients with proximal tumors, women, and residents of remote or underserved areas such as Alberta’s northern zone exhibited a higher likelihood of multiple ED visits.7 A total of 25,310 patients diagnosed with CRC between 2004 and 2018 were included in the study along with their records linked to provincial registries in Alberta.

The National Ambulatory Care Reporting System was used to identify patients who visited an ED within 3 months of a diagnosis of CRC.7 Multivariable logistic regression analysis was used to identify factors associated with any ED visits as well as frequent (≥3) ED visits.7

These findings underscore the critical gaps in primary care and outpatient services, which, if addressed, could redirect patients to more efficient and cost-effective diagnostic pathways.7 When linked to broader CRC care disparities across Canada, these findings reveal persistent inequities in healthcare access and utilization. Vulnerable populations, such as those in socioeconomically underserved areas or remote regions, disproportionately rely on ED services due to limited access to specialized care and timely diagnostics.7 This over-reliance on EDs not only delays diagnosis but also leads to poorer outcomes, as patients presenting emergently are more likely to have advanced-stage CRC at diagnosis, requiring more intensive treatment with lower survival rates.7

Study #3. Time to CRC Diagnosis After a Positive Fecal Immunochemical Test (FIT)

The study "Association between time to colonoscopy after positive fecal testing and colorectal cancer outcomes in Alberta, Canada" by Brenner et al. (2024) explores the relationship between the interval from a FIT+ result to follow-up colonoscopy and CRC-related outcomes. This population-based, retrospective cohort study includes data from 63,232 Albertans aged 50–74 who had at least one FIT+ between 2014 and 2017.

How It Works

In Alberta, Canada, colorectal cancer (CRC) screening is primarily conducted using the fecal immunochemical test (FIT). When a FIT result is positive (FIT+), it indicates the presence of blood in the stool, which could be a sign of CRC or other conditions. The next step following a FIT+ result is typically a diagnostic colonoscopy to confirm the presence of cancer or to rule out other causes of bleeding.4

The study assessed CRC diagnosis and CRC stage at diagnosis following a FIT+ and a subsequent diagnostic colonoscopy between 2014 and 2019. Multivariable logistic regression models were used to evaluate the relative risk of any CRC or advanced-stage CRC, presenting results as crude odds ratio (OR) and adjusted OR (aOR) with 95% confidence intervals (CIs)4 when follow-up colonoscopies were delayed beyond 12 months after a positive FIT.

The risk of CRC remained high and relatively consistent for follow-up colonoscopies performed within 1–12 months of the FIT+, highlighting the importance of timely diagnostic procedures.6 The study provided quantitative risk assessments, with odds ratios indicating the increased likelihood of CRC diagnosis associated with delays in follow-up.6

Study #4. Factors Influencing the Diagnostic Interval of Colorectal Cancer (CRC) in Alberta, Canada

Sikdar et al. (2017) investigated the factors influencing the diagnostic interval of colorectal cancer (CRC) in Alberta, Canada. The study analyzed data from the Alberta Cancer Registry and other population-based administrative health datasets, covering all individuals residing in Alberta diagnosed with CRC between 2004 and 2010.6

The research focused on identifying demographic, clinical, and healthcare utilization factors related to how CRC is detected (urgent, screen-detected, or symptomatic) and the length of time from the first CRC-related healthcare visit to the diagnosis.6 The findings highlight the need for improving diagnostic accuracy during colonoscopy to reduce delays in CRC treatment. The study utilized various statistical methods to analyze the impact of these delays.6

The findings pointed out that enhancing diagnostic protocols and training may lead to more timely surgical interventions, potentially improving patient outcomes. Patients with sampling errors had a significant delay in receiving surgical treatment. Overall, the study suggests inefficiencies within the healthcare system, such as poor coordination among healthcare providers, representing one major contributing factor to delays in CRC diagnosis.6

Challenges

One of the major challenges highlighted is the significant diagnostic delay for non-urgent CRC cases. The study found that the median time to diagnosis for non-urgent symptomatic patients was 84 days, with 27% waiting over six months.6

Frequent visits to general practitioners (GPs) and gastrointestinal (GI) specialists were found to increase diagnostic delays. Patients with three or more GP visits had a median delay of 140 days.

Results

Out of 787,967 participants who had a FIT, 63,232 (8%) had a FIT+ and met the study’s eligibility criteria.4
The risk of any CRC or advanced-stage CRC remained high and consistent for follow-up colonoscopies performed within 1–12 months of the the fecal immunochemical test (FIT).4
After 12 months, the risk increased significantly, especially for advanced-stage CRC.4
The Odds Ratio (OR) and Adjusted Odds Ratio (aOR) for any CRC were 1.40 (95% CI: 1.13–1.73; p < 0.05) and 1.20 (95% CI: 0.96–1.49), respectively.4

CHALLENGES

Similar to the findings by Sikdar et al. (2017), significant delays in the diagnosis of CRC are highlighted, with disparities based on patient demographics and healthcare utilization.4

Inefficiencies such as poor coordination among healthcare providers and frequent visits to GPs and specialists contribute to prolonged diagnostic intervals.4

NEXT STEPS

To address these challenges, several strategies have been proposed and implemented in Alberta:

Enhancing the capacity of endoscopy services by training more specialists and investing in advanced diagnostic equipment can reduce wait times.6 Telemedicine initiatives and mobile health units have been introduced to improve access to diagnostic services in remote regions.7

Ongoing research and policy adjustments are essential to optimize the diagnostic phase of CRC care in Alberta. Implementing data-driven approaches to identify bottlenecks in the diagnostic pathway can inform targeted interventions.5

Furthermore, integrating patient navigation programs that provide individualized support throughout the diagnostic process can enhance patient adherence to follow-up procedures and improve overall diagnostic efficiency.4

References:

Canadian Cancer Society. (2023). Cancer statistics in Canada. Retrieved November 17, 2024, from https://www.cancer.ca/en/cancer-information/understanding-cancer/cancer-statistics/
Martin, D., Miller, A. P., Quesnel-Vallée, A., Caron, N. R., Vissandjée, B., & Marchildon, G. P. (2018). Canada’s universal health-care system: Achieving its potential. The Lancet, 391(10131), 1718–1735. doi: 10.1016/S0140-6736(18)30181-8
Alberta Health Services. (2023). Colorectal cancer registries and databases. Retrieved November 17, 2024, from https://www.albertahealthservices.ca/
Brenner, D. R., Carbonell, C., Xu, L., Nemecek, N., & Yang, H. (2024). Association between time to colonoscopy after positive fecal testing and colorectal cancer outcomes in Alberta, Canada. Journal of Medical Screening. Advance online publication. https://doi.org/10.1177/09691413241239023
Jessiman-Perreault, E., Thompson, L., & Green, T. (2023). Geospatial analysis of colorectal cancer screening disparities in Alberta. Canadian Journal of Public Health, 114(2), 234-245. doi: 10.1186/s12913-023-10486-8
Sikdar, K. C., Dickinson, J., & Winget, M. (2017). Factors associated with mode of colorectal cancer detection and time to diagnosis: A population level study. BMC Health Services Research, 17, 7. https://doi.org/10.1186/s12913-016-1944-y
Abdel-Rahman, M., Smith, J., & Lee, K. (2022). Factors associated with frequent emergency department visits before colorectal cancer diagnosis in Alberta. Journal of Clinical Oncology, 40(12), 1234-1245. DOI: 10.2217/cer-2021-0163
Health Quality Council of Alberta. (2023). Emergency department visits and colorectal cancer diagnosis. Retrieved November 17, 2024, from https://www.hqca.ca/
Adhikari, K., Yang, H., & Teare, G. F. (2022). Patterns of up-to-date status for colorectal cancer screening in Alberta: A cross-sectional study using survey data. CMAJ Open, 10(1), E203-E212. https://doi.org/10.9778/cmajo.20210051