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Cancer Incidence and Screening, 2004-2008: Peel Region Summary Report
Cancer Incidence and Screening, 2004-2008: Peel Region Summary Report
ACKNOWLEDGEMENTS The original Technical Report entitled “Cancer Incidence and Screening, 2004 to 2008: Peel Region Technical Report” was prepared by Todd Norwood, Research Unit, Prevention and Cancer Control, Cancer Care Ontario with additional input from Eric Holowaty, Susitha Wanigaratne and Patrick Brown. Copies of the original Technical report may be requested by contacting [email protected] . This summary report was authored by Julie Stratton, Manager Epidemiology, Peel Public Health using the original Technical Report entitled “Cancer Incidence and Screening, 2004 to 2008: Peel Region Technical Report” as a guide. The summary statements made in this document were validated by Todd Norwood. This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annul grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results and conclusions reported in this document are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. Please use the following citation when referencing this report: Cancer Care Ontario, Peel Public Health. Cancer Incidence and Screening, 2004-2008: Peel Region Summary Report. 2011.
TABLE OF CONTENTS INTRODUCTION …………………………………………………………. 1 MATERIALS, DATA SOURCES AND DEFINITIONS……………….... 3 RESULTS ………………………………………………………………..... 5 Female Breast Cancer Incidence and Screening……………… 5 Cervical Cancer Incidence and Screening……………………... 9 Colorectal Cancer Incidence and Screening…………………… 12 Prostate Cancer Incidence and Screening…............................ 21 REFERENCES ………………………………………………………….... 23 APPENDIX A: DATA SOURCES ……………………………………...... 25 APPENDIX B: MAPS ……………………………………………………... 27
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INTRODUCTION Cancer incidence and cancer screening participation may be influenced by a number of individual and contextual factors including age, sex, socio-economic status, visible minority status, education, physician factors, and systemic factors. Studying areal variation in screening participation may be useful to program planners because this approach recognizes both contextual level impacts, such as local program delivery practices, and also acts as a surrogate for unmeasured and unknown individual factors. This report investigates the contribution of both individual factors (either an incident case of cancer or screening participation) and contextual factors (age, sex, income, educational attainment, period of immigration and visible minority status) to total variation in cancer incidence and screening participation rates across Peel Region, at the census tract level. PURPOSE The purpose of this summary report is to describe the key findings of an ecological regression study in Peel Region to describe cancer incidence and screening participation rates. The complete analysis and presentation of this study is documented in the report “Cancer Incidence and Screening, 2004 to 2008: Peel Region Technical Report.” This surveillance project was initiated by Peel Region to investigate associations between:
• Cancer incidence for breast, cervical, colorectal, and prostate cancers and the association with age, sex (where applicable), income, education, immigration and visible minority group, and
• Cancer screening for breast, cervical, colorectal cancers and the association with by age, sex (where applicable), income, education, immigration and visible minority group. Screening programs have existed for several years for the cervix, female breast and colon and rectum. Prostate Specific Antigen (PSA) tests for screening are not recommended by most authorities, are not covered by OHIP, and thus prostate cancer screening is excluded from this analysis.
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MATERIALS, METHODS, DATA SOURCES AND DEFINITIONS The discussion on the factors related to the screening procedures are based on results from logistical regression models presented in the technical report. The results presented are for the odds of being screened compared to not being screened. Please refer to the technical report to view the model coefficients which we used to calculate the odds ratios which are presented in this report. While we describe associations throughout the report between screening rates by age, sex, income, education, immigrant status and visible minority status, it is important to note that we cannot infer that screening rates are lower in all persons with these characteristics. A detailed description of the materials and methods and definitions used to describe the results in this summary report are described in detail in the Cancer Incidence and Screening, 2004 to 2008: Peel Region Technical Report”. A description of the data sources used is described in Appendix A.
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RESULTS FEMALE BREAST CANCER INCIDENCE AND SCREENING BREAST CANCER INCIDENCE Peel Region’s most recent (2004 to 2007) female breast cancer standardized incidence ratio (SIR) of 0.979 was similar to the provincial rate (p=0.318).1 In Peel Region census tracts (CTs), 3,022 incident cases of female breast cancer were registered from 2004 to 2008. Map 1 in Appendix B shows the residual standardized incidence ratios (SIRs) for female breast cancer once the effects of these covariates (such as age, income, education, immigration and visible minority group) are removed from the modeled estimates.
Residuals in this report are defined as the difference between the observed incidence rates and the predicted incidence rates after controlling for other related factors such as such as age, income, education, immigration and visible minority status. WHAT DOES THIS MEAN?
There are no census tracts in Peel that have an excess of new cases of breast cancer after controlling for other related factors such as age, income, education, immigration and visible minority status.
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BREAST CANCER SCREENING In Ontario, mammography, or a breast x-ray, is the screening tool used to detect breast cancer in women. Women aged 50 to 69 years are eligible to receive a screening mammogram through the Ontario Health Insurance Plan (OHIP) or the Ontario Breast Screening Program (OBSP) with a recommended frequency of once every two years. During the period of 2007 to 2008, the overall Peel Region participation rate for mammography was 72.4 women per 100 eligible women. The provincial target for 2010 was 70%, thus Peel Region as a whole was slightly above the provincial target.
Participation rate is defined as the number of screening events from within the screen-eligible population divided by the total screen-eligible population. The participation rate may be represented as a percentage, fraction or per standardized population, for example per 100,000 persons. Mammography participation rates vary across Peel Region’s CTs as displayed in Map 2 in Appendix B:
• All CTs (11) within Caledon had rates at or above the 2010 target. • Almost 12% of CTs (8 of 69) within Brampton – located predominantly to
the east – have participation rates between 50 and 60 per cent, or 10 to 20 per cent lower than the target rate. Within Brampton, 41% of CTs (28 of 69) had participation rates above the 2010 target and these are located in downtown Brampton, and to the west.
• Within Mississauga, Malton in the northeast had participation rates below 60%, representing 2% (3 of 125) of Mississauga CTs. Seventy-six per cent of Mississauga CTs had rates above 70% and these are located across the city with the exception of the northeast.
WHAT DOES THIS MEAN?
While there are areas that are meeting the target of 70% for mammography screening, there are some census tracts within Brampton and Mississauga that are 10 to 20 percentage points below the provincial target.
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WHAT FACTORS ARE RELATED TO BREAST CANCER SCREENING?
The factors associated with an increased odds of breast cancer screening at the census tract level of geography include:
• Age 60 to 64 years. Mammography screening by age group is shown in Table 1. This effect remains after taking account income, education, period of immigration and visible minority group).
• Income o With every $10,000 increase of median household income, the
odds of mammography screening increased by 4%. • Education
o With every 1% increase of post-secondary education, the odds of mammography screening increased by 1%.
• Long-term Immigrants o With every 1% increase of the proportion of immigrants who had
been in Canada for 11 years or more, the odds of mammography screening increased by 1%.
The factors associated with lower odds of mammography screening at the census tract level of geography include:
• Age less than 60 years and aged 65 to 69 years o Women aged 50 to 54 years, 55 to 59 years and 65 to 59 years had
a much lower odds of utilizing mammography (68%, 63%, and 30% respectively) compared to women aged 60-64 years.
• Visible minority status o A 1% increase in the proportion of the population by census tract
who identified as South Asian, was associated with a 1% decrease in the odds of mammography utilization.
o A 1% increase in the proportion of the population by census tract who identify as “all other visible minorities” (Filipino, Southeast Asian, Arab, West Asian, Korean, Japanese, others and multiple responses), was associated with a 1% decrease in the odds of mammography utilization.
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Age As shown in Table 1 there is a relationship between age and mammography screening. Table 1 - Mammography Counts and Age-Specific Rates by Age Group Peel Region Census Tracts (CTs), 2007-2008 Age Group (Years)
# eligibles receiving one or more
mammograms
Eligible population aged
20 to 69 years
Age-Specific Rate per 100,000
50-54 25,079 37,923 66,131 55-59 21,677 31,578 68,646 60-64 16,721 19,619 85,229 65-69 11,099 13,858 80,091
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CERVICAL CANCER INCIDENCE AND SCREENING CERVICAL CANCER INCIDENCE Peel Region’s cervical cancer standardized incidence ratio (SIR) was 0.848 from 2004 to 2007, which is significantly lower than Ontario as a whole (p=0.0433).1 From 2004 to 2008, 203 cancer cases were registered within Peel Region CTs. During this period, there was no evidence of spatial clusters of CTs with elevated cervical cancer incidence. Map 3 in Appendix B shows the residual standardized incidence ratios (SIRs) for cervical cancer once the effects of these covariates (such as age, income, education, immigration and visible minority group) are removed from the modeled estimates. WHAT DOES THIS MEAN?
There are no census tracts in Peel that have a significant excess of new cases of cervical cancer after controlling for other related factors such as age, income, education, immigration and visible minority status.
CERVICAL CANCER SCREENING Cervical cancer is detected by testing the cells lining the cervix for cytologically dysplastic or precancerous changes, known as a pap test. Pap tests are covered by OHIP; however, in 2000, Cancer Care Ontario launched the Ontario Cervical Screening Program (OCSP) to create an organized program with recruitment, recall and follow-up.2 Pap tests are recommended annually when a person is sexually active or once every two or three years if tests are normal for three years in a row. In Peel Region, the 2010 provincial target for pap test utilization is a participation rate of 85 in 100 eligible women, and the overall Peel Region rate is well below at 68.4%. Map 4 in Appendix B shows cervical cancer screening rates by census tract:
• Caledon is the only municipality in Peel Region having all CTs (11 of 11) at or near the target rate.
• Only 10% (7 of 69) of CTs in Brampton have pap test participation rates at or above the 2010 target.
• In Mississauga, 27% of CTs (34 of 128) had participation rates under 65% and these are primarily located in central Mississauga along Hurontario St, south of Eglinton Ave, and in Malton to the northeast.
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WHAT DOES THIS MEAN?
While there are census tracts that are meeting the provincial target of 85% for pap test screening, there are many census tracts across the region below the provincial target, particularly in Brampton.
WHAT FACTORS ARE ASSOCIATED WITH CERVICAL CANCER SCREENING?
The factors associated with increased odds of pap test utilization across Peel census tracts include:
• Income o With every $10,000 increase of median household income, the
odds of pap test utilization increased by 4%. • Education
o With every 1% increase of post-secondary education within a census tract, the odds of pap test utilization increased by 1%.
The factors associated with lower odds of pap test screening include:
• Age o Compared to women aged 60 to 64 years, women in all other age
groups show lower odds of pap test utilization, ranging from those aged 20 to 24 years (72% lower odds) to women aged 50 to 54 years (19% lower odds). Pap test participation rates by age group are shown in Table 2.
• Recent immigrants (arrived within the past 10 years) o A 1% increase in the proportion of the population by census tract
who are recent immigrants was associated with a 1% decrease in the odds of pap test utilization.
• South Asian visible minority o A 1% increase in the proportion of the population by census tract
who identified as South Asian, was associated with a 1% decrease in the odds of pap test utilization.
Age Table 2 provides the pap test utilization and eligible population counts, and rates across Peel Region CTs from 2006 to 2008. The standardized rates show that pap test participation generally increased by five year age group up to ages 65 to 69, and that women aged 20 to 24 had rates 34% lower than women aged 60 to 64 years.
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Table 2 – Pap test Counts and Age-Specific Rates by Age Group across Peel Region Census Tracts (CTs), 2006-2008 Age Group (Years)
# eligibles receiving one or more pap
tests
Eligible population aged 20 to 69 years
Age-Specific Rate per 100,000
20-24 23,231 43,820 53,015 25-29 31,933 49,053 65,099 30-34 35,961 51,803 69,419 35-39 38,169 55,406 68,890 40-44 39,120 55,160 70,921 45-49 34,414 48,457 71,020 50-54 26,507 34,636 76,530 55-59 19,997 28,448 70,293 60-64 13,926 17,442 79,842 65-69 8,359 12,961 64,493
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COLORECTAL CANCER INCIDENCE AND SCREENING COLORECTAL CANCER INCIDENCE Colorectal cancer is one of the most common cancers among the Ontario population.3 From 2004 to 2007, Peel Region colorectal cancer standardized incidence rates (SIRs) were 0.8770 (p<0.001) and 0.8116 (p<0.001) for women and men, respectively, and both were significantly below the Ontario-wide rate.1 Within Peel Region CTs, 1,080 cases were observed among women from 2004 to 2008, and for men, 1,304 cases were observed. Maps 5 and 6 in Appendix B shows the colorectal cancer incidence rates for males and females once the effects of these covariates (such as age, income, education, immigration and visible minority group) are removed from the modeled estimates. WHAT DOES THIS MEAN?
While there is variation by census tract of colorectal cancer incidence, there are no census tracts in Peel that have a significant excess of new cases of colorectal cancer for either males or females after controlling for other related factors such as age, income, education, immigration and visible minority status. COLORECAL CANCER SCREENING There are two tests available to screen for colorectal cancer:
• Fecal occult blood tests (FOBTs) are recommended for persons without family history once every two years and are funded for persons aged 50 to 74 years by the ColonCancerCheck program, launched in 2008.4 FOBTs are also covered by OHIP.
• Colonoscopy/flexible sigmoidoscopy procedures are recommended for persons with family history of colorectal cancer once every five years may be recommended by the program. For colonoscopy/flexible sigmoidoscopy, no target rate is set because FOBT is the standard colorectal cancer screening procedure.
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Fecal Occult Blood Tests (FOBTs)
Colonoscopy/Flexible Sigmoidoscopy
Participation rates within Peel Region for these age-eligible populations within CTs are displayed in Maps 7 (for females) and 8 (for males) in Appendix B for the period from 2007 to 2008. FEMALES Among Peel Region females the overall participation rate for FOBT is 30.4%. • Only 2 CTs in Mississauga were
meeting the provincial FOBT screening target of 40%.
• Many CTs throughout Caledon, Brampton and Mississauga had FOBT screening rates that are 10% or more below the provincial target.
MALES Among Peel Region males the overall participation rate for FOBT is 24.8%. • None of the CTs within Peel are
above the provincial target for FOBT screening.
• The majority of CTs within Peel are below the provincial target for FOBT screening.
The participation rates for colonoscopy/flexible sigmoidoscopy are presented in Map 9 (for females) and Map 10 (for males) in Appendix B. The data are for five years, 2004 to 2008 inclusive, as one colonoscopy per five years is the recommended frequency. For colonoscopy/flexible sigmoidoscopy, no target rate is set because FOBT is the standard colorectal cancer screening procedure. Nevertheless, 40% was used for comparison. FEMALES Among Peel Region females the overall participation rate for colonoscopy/flexible sigmoidoscopy is 29.2%. • Some CTs with Peel are meeting a
40% screening target for colonoscopy/flexible sigmoidoscopy (north Caledon and south Mississauga)
• Within Brampton and Mississauga, the majority or CTs have colonoscopy/flexible sigmoidoscopy screening rates 20% or more below the 40% target.
MALES Among Peel Region males the overall participation rate for colonoscopy/flexible sigmoidoscopy is 24.4% for males. • A few CTs within south Mississauga
are meeting the 40% screening target.
• The majority of CTs within Brampton and Mississauga have screening rates 20% or more below the 40% screening target.
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WHAT DOES THIS MEAN?
Fecal Occult Blood Test The majority of males and females in Peel census tracts had FOBT screening participation rates 10 to 20% below the provincial target. Colonoscopy/Flexible Sigmoidoscopy Procedures Many of the census tracts in Peel for both males and females had colonoscopy/flexible sigmoidoscopy screening rates that were below the provincial target. WHAT FACTORS ARE ASSOCIATED WITH FOBT UTILIZATION FOR FEMALES?
The factors are associated with increased odds of FOBT screening for FEMALES across Peel census tract include:
• Age o Compared to women aged 60 to 64 years, women in the following
age groups had a lower odds of FOBT screening: 50 to 54 (46%); 55 to 59 (36%) and 70 to 74 (35%). Table 3 shows FOBT counts and rates by age group across Peel Region Census Tracts.
• Education o A 1% increase in the proportion of the population by census tract
who had post-secondary education was associated with a 1% increase in the odds of colorectal cancer screening using FOBTs.
• Long-term immigrants o A 1% increase in the proportion of the population by census tract
who are settled immigrants (in the country for 10 or more years) was associated with a 1% increase in the odds of colorectal cancer screening using FOBTs.
• Black visible minority o A 1% increase in the proportion of the population by census tract
who identify as Black was associated with a 1% increase in the odds of colorectal cancer screening using FOBTs.
The factors associated with lower odds of FOBT screening include:
• South Asian visible minorities o A 1% increase in the proportion of the population by census tract
who identified as South Asian was associated with a 1% decrease in the odds of FOBT utilization.
• “All Other” visible minorities o A 1% increase in the proportion of the population by census tract
who identified as “all other” visible minorities was associated with a 1% decrease in the odds of FOBT utilization.
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Age As shown in Table 3 age is associated with FOBT screening. FOBT utilization rates increased by age group up to age 70.
Table 3 - Female FOBT Counts and Age-Specific Rates by Age Group across Peel Region Census Tracts (CTs), 2007-2008 Age group (Years)
# eligibles receiving one or
more FOBTs
Eligible population aged
50 to 74 years
Age Specific Rate per 100,000
50-54 9,541 38,521 24,768 55-59 9,057 32,299 28,041 60-64 7,663 20,230 37,879 65-69 6,054 14,406 42,024 70-74 4,171 14,658 28,455
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WHAT FACTORS ARE ASSOCIATED WITH COLONOSCOPY/FLEXIBLE SIGMOIDOSCOPY UTILIZATION FOR FEMALES?
The factors are associated with increased odds of colonoscopy/flexible sigmoidoscopy utilization for FEMALES across Peel census tracts include:
• Education o A 1% increase in the proportion of the population with post
secondary education by census tract was associated with a 1% increase in the odds of colonoscopy/flexible sigmoidoscopy for colorectal cancer screening.
The factors associated with lower odds of colonoscopy/flexible sigmoidoscopy utilization for FEMALES include:
• Age o Compared to females aged 60 to 64 years, females in the following
age groups had a lower odds of colonoscopy/flexible sigmoidoscopy for colorectal cancer screening: 50 to 54 (47%), 50 to 59 (35%), 65 to 69 (6%) and 70 to 74 (43%) (see Table 4 for age group rates of screening).
• Immigrants o A 1% increase in the proportion of the population by census tract
who are settled immigrants (in the country for 10 or more years), or new immigrants (in the country within the past 10 years) was associated with a 1% decrease colonoscopy/flexible sigmoidoscopy for colorectal cancer screening.
• South Asian visible minorities o Within census tracts, a 1% increase in the South Asian visible
minority group, was associated with a 1% decrease in the odds of colonoscopy/flexible sigmoidoscopy for colorectal cancer screening.
• Black visible minorities o Within census tracts, a 1% increase in the Black visible minority
group was associated with a 1% decrease in the odds of colonoscopy/flexible sigmoidoscopy for colorectal cancer screening.
• “All other” visible minorities o Within census tracts, a 1% increase in the “all other” visible minority
group was associated with a 1% decrease in the odds of colonoscopy/flexible sigmoidoscopy for colorectal cancer screening.
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Age For both FOBT and colonoscopy/flexible sigmoidoscopy., women in Peel Region had much higher participation rates than men across all age groups. Table 4 - Female Colonoscopy/flexible sigmoidoscopy Counts and Age-Specific Rates by Age Group across Peel Region Census Tracts (CTs), 2007-2008 Age group (Years)
# eligibles receiving one or more
colonoscopy/flexible sigmoidoscopys
Eligible population aged
50 to 74 years
Age Specific Rate per 100,000
50-54 9326 38521 24,210 55-59 9188 32299 28,447 60-64 7603 20230 37,583 65-69 5161 14406 35,825 70-74 3745 14658 25,549
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WHAT FACTORS ARE ASSOCIATED WITH FOBT UTILIZATION FOR MALES?
The factors are associated with increased odds of FOBT screening for MALES across Peel census tracts include:
• Age o Compared to men aged 60 to 64 years, men in the following age
groups had a higher odds of FOBT screening: 65 to 69 years (12%) and 70 to 74 years (10%). Table 5 shows FOBT counts and rates by age group across Peel Region Census Tracts.
• Income o A $10,000 increase by census tract of the median income that was
below the average for Peel was associated with a 1% increase in the odds FOBT screening.
• Immigrants o A 1% increase in the proportion of the population by census tract
who are long-term immigrants (in the country for 10 or more years), was associated with a 1% increase in the odds of FOBT utilization. Census tracts with higher proportions of recent immigrants were also associated with slightly higher odds of FOBT utilization (!%).
The factors associated with lower odds of FOBT screening include:
• • • Age
o Compared to men aged 60 to 64 years, men in the following age groups had a lower odds of FOBT screening: 50-54 (38%) and 55-59 (25%).
Age As shown in Table 5, age is associated with FOBT screening. FOBT rates of screening increase by age group. Table 5 - Male FOBT Counts and Age-Specific Rates by Age Group across Peel Region Census Tracts (CTs), 2007-2008 Age Group (Years)
# eligibles receiving one or
more FOBTs
Eligible population aged
50 to 74 years
Age Specific Rate per 100,000
50-54 8,463 42,433 19,944 55-59 7,957 34,469 23,085 60-64 7,231 25,556 28,295 65-69 5,606 18,254 30,711 70-74 3,982 13,229 30,101
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WHAT FACTORS ARE ASSOCIATED WITH COLONOSCOPY/FLEXIBLE SIGMOIDOSCOPY UTILIZATION FOR MALES?
The factors are associated with increased odds of colonoscopy/flexible sigmoidoscopy utilization for MALES across Peel census tracts include:
• Education o A 1% increase in the proportion of the population with post
secondary education by census tract was associated with a 1% increase in the odds of colonoscopy/flexible sigmoidoscopy utilization for colorectal cancer screening.
• Income o A $10,000 increase of the median household income was
associated with a 1% increase in the odds of FOBT utilization for colorectal cancer screening.
The factors associated with lower odds of colonoscopy/flexible sigmoidoscopy screening include:
• Age o Compared to men aged 60 to 64 years, men in the following age
groups had a lower odds of colonoscopy/flexible sigmoidoscopy screening: 50 to 54 (40%) and 55 to 59 (22%). Table 6 describes screening rates by age group.
• Immigrants o Within a census tract, a 1% increase in the proportion of the
population who were recent immigrants (in the country within the past 10 years) was associated with a 1% decrease in the odds of colonoscopy/flexible sigmoidoscopy utilization for colorectal cancer screening.
• South Asian visible minorities o Within census tracts, a 1% increase in the South Asian visible
minority group was associated with a 1% decrease in the odds of colonoscopy/flexible sigmoidoscopy utilization for colorectal cancer screening.
• Black visible minorities o Within census tracts, a 1% increase in the Black visible minority
group was associated with a 1% decrease in the odds of colonoscopy/flexible sigmoidoscopy utilization for colorectal cancer screening.
• “All other” visible minorities o Within census tracts, a 1% increase in the “all other” visible minority
group was associated with a 1% decrease in the odds of colonoscopy/flexible sigmoidoscopy utilization for colorectal cancer screening.
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Age Table 6 - Male Colonoscopy/flexible sigmoidoscopy Counts and Rates by Age Group across Peel Region Census Tracts (CTs), 2007-2008 Age group (Years)
# eligibles receiving one or more
colonoscopy/flexible sigmoidoscopys
Eligible population aged
50 to 74 years
Age Specific Rate per 100,00
50-54 8194 42433 19,310 55-59 8238 34469 23,900 60-64 7305 25556 28,584 65-69 5302 18254 29,046 70-74 3684 13229 27,848
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PROSTATE CANCER INCIDENCE AND SCREENING
Prostate Cancer Incidence Prostate cancer comprised 30% of new cancers diagnosed in men in Ontario and Peel Region is below the Ontario-wide rate with a standardized incidence ratio (SIR) of 0.9964, but not significantly so (p=0.074).3 From 2004 to 2008, there were 3,425 new cases of prostate cancer registered within Peel Region. Map 11 in Appendix B portrays the residual prostate cancer SIRs from 2004 to 2008 once the effects of these covariates are removed from the modeled estimates. Region-wide, 95% of CTs (195 of 205) had incidence rates similar to the Peel Region average. There is no evidence of spatial clustering of excess prostate cancer incidence once age, income, education, immigration and visible minority status are accounted for. WHAT DOES THIS MEAN?
There are no census tracts in Peel that have an excess of new cases of prostate cancer after controlling for other related factors such as age, income, education, immigration and visible minority status. Prostate Cancer Screening While prostate-specific antigen (PSA) testing is available, it is not recommended or covered by OHIP and therefore PSA tests are not a reliable population-based indicator for screening.
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REFERENCES 1. Cancer Care Ontario. SEER*Stat Release 8 - OCRIS (May 2010) released
February 2011. Population Data Source: Pop Est Summary (Statistics Canada, Ontario Ministry Finance), Ontario Ministry of Health and Long-Term Care: IntelliHEALTH ONTARIO, extracted October 2010 (1986-2007). [cd-rom] Toronto : Cancer Care Ontario, 2011.
2. Cancer Care Ontario. About the Ontario Cervical Screening Program. [Online] Cancer Care Ontario, November 23, 2009. [Cited: February 16, 2011.] http://www.cancercare.on.ca/cms/One.aspx?portalId=1377&pageId=9536.
3. Cancer Care Ontario. Cancer in Ontario: Overview, A Statistical Report. Toronto: Cancer Care Ontario, 2010.
4. Cancer Care Ontario. Colorectal Cancer Screening. Colorectal Cancer Screening. [Online] Cancer Care Ontario, July 29, 2010. [Cited: February 15, 2011.] http://www.cancercare.on.ca/pcs/screening/coloscreening/.
5. Stratton J, Mowat DL, Wilkins R, Tjepkema M. A comparison of income disparities in life expectancy among immigrants and non-immigrants in the City of Toronto and Region of Peel. Chronic Disease in Canada. Submitted for publication, 2010.
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APPENDIX A DATA SOURCES The following data were used to describe the results in this report: CANCER INCIDENCE DATA Cancer incidence data are from the Ontario Cancer Registry (CCO, 2010) acquired in November 2010. Generally, the data for the recent period of 2004 to 2008 are quite complete. However, there is a lag in the mortality data incorporated into the OCR for the more recent time periods (2008 to present) for cancer cases diagnosed by Death Certificate Only (DCO). These cases represent a small portion of all cases (approximately 2%) and for consistency across all study years, DCO cases were excluded for this study. SCREENING DATA Screening data were obtained from the Institute for Clinical Evaluative Sciences, at Sunnybrook. Criteria for each cohort eligible to be screened varied, depending on the cancer under consideration, and are described in the complete Technical Report. Mammography participation data Mammography participation data for female breast cancer screening are from 2007 to 2008. Pap smear participation data Pap smear participation data for cervical cancer screening are from 2006 to 2008. Fecal occult blood test (FOBT) and colonoscopy and flexible sigmoidoscopy data Fecal occult blood test (FOBT) data for colorectal cancer screening are from 2007 to 2008; and, colonoscopy and flexible sigmoidoscopy (flex.sig.) participation data for colorectal cancer screening are from 2004 to 2008. The time periods are based on recommended frequency for the relevant screening procedure (e.g., once every two years for mammography). We did not distinguish between first (or prevalent) screens, and second or later (incident) screens. 2006 CENSUS DATA Data from the 2006 Census (short and long form data) were used for areal measures of income, education, immigration and visible minority status as a proxy for large groupings of ethnic groups. These variables were selected by Peel Public Health to investigate their associations with cancer incidence and screening. Previous work indicated that immigration has stronger associations, or is a confounding factor, for health outcomes than measures of socio-economic status (e.g., income) in Peel Region.5 Median household income was used as
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a measure of an area’s affluence. Educational attainment was measured using the per cent of the population aged 25 and above that had achieved post secondary graduation (college or university certificates, diplomas and/or degrees). Associations with immigration were measured using period of immigration, recent immigrants (arriving between 1996 and 2006) and established immigrants (arriving before 1996). Identification of ethnic groups can be complex – visible minority status was selected for several reasons: i) a lack of study power to examine an exhaustive collection of regional ethnic groups; ii) its use in a previous report on mortality and immigration5; and, iii) its groups aligned well with the primary ethnic groups in Peel Region -- persons of South Asian, Chinese and Caribbean origins.
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APPENDIX B MAP 1
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MAP 2
29
MAP 3
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MAP 4
31
MAP 5
32
MAP 6
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MAP 7
34
MAP 8
35
MAP 9
36
MAP 10
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MAP 11
