 At
the end of January, the Ontario government unveiled
North America's very first universal colorectal cancer
(CRC) screening program. Though there's been some squabbling
over how the program has been set up, by and large the
province's doctors are thrilled that more money is going
into the struggle against Canada's #2 cancer killer.
But the plan has once again brought
the issue of access to screening methods, particularly
colonoscopy, to the fore. Just one week after the announcement,
a study of over 12,000 Ontarians showed that where a
colonoscopy is performed and especially who's performing
it greatly affect patient outcome. And yet no one —
not the province, nor the college, nor any of the associations
— has any authority over either of these critical
factors.
HIT
OR MISS
The provincial screening program will give hospitals
$200 million over five years in hopes of boosting Ontario's
currently dismal screening rate of 10-15%. All citizens
over 50 should get a fecal occult blood test (FOBT)
every two years, and anyone with abnormal results, or
a family history of CRC, will automatically be sent
for a colonoscopy.
Dr Linda Rabeneck is a well-respected
gastroenterologist and senior investigator with the
Cancer Quality Council of Ontario who was intimately
involved in the development of the CRC program. She's
also the lead author of the study, published in the
January edition of Gastroenterology, that for
the first time established the rates of new or missed
colorectal cancers after colonoscopy. Certain patients,
she concluded, are more likely to have their cancers
go undetected — namely women, older folks, those
with diverticular disease and those with right-sided
tumours. But she also found cancer was more likely to
be overlooked if the colonoscopy is performed in an
office setting — by an internist or an FP —
than if it's performed in hospital by a gastroenterologist
or a surgeon. "This has been very important for us in
terms of the provincial initiative," Dr Rabeneck says,
"because it shows there's something going on in the
office delivery of colonoscopy that's clearly different."
As a result, patients screened
under the provincial initiative won't be sent to any
of the growing number of free-standing endoscopy clinics
in the province. "At least in the beginning, we're not
going to because we believe that if hospitals get more
funding, they can handle the volume of patients we expect
to see," Dr Rabeneck says.
HAVE
TIMES CHANGED?
But for the physicians operating those clinics or performing
colonoscopies in their office, the insinuation that
their work is slipshod is not only unfair — it's
counterproductive. "I don't think these findings are
reflective of current practices or expertise in clinics,"
says Dr Michael Gould, a founder of the Ontario Association
of Gastroenterologists. Dr Iain Murray, who opened a
free-standing endoscopy clinic in 2003 to improve access
for his patients, agrees. The findings, he says, are
based on historical data collected between 1998 and
2002. "A lot of the new clinics I believe are doing
a better job than when this was looked at," he says.
Dr Gould, who also performs colonoscopies
in his office, says excluding clinics from the provincial
screening program does the population of Ontario a disservice.
"I think this [reasoning] delays the development of
quality clinics outside of hospitals. It's just not
a good use of hospital resources to do outpatient average-risk
screening," he says. As it stands now, patients in his
part of the province can wait anywhere from three to
eight months for a colonoscopy. "It's unreasonable to
tell patients they have a positive stool test and then
tell them they have to wait for a colonoscopy," he says.
"But I don't think it makes sense to give preferential
access to in-hospital screening at the expense of patients
who are in pain and have already been waiting for six
months either."
FREE
FOR ALL
At the same time, both Drs Gould and Murray agree that
Dr Rabeneck's study highlights a very real problem.
"There are no licensing requirements for physicians
performing endoscopies, and no operating guidelines
to open facilities like ours," says Dr Murray. "There
should be."
Dr Rabeneck says that could very
well be the reason why some colonoscopies performed
at such facilities aren't up to par. "In a hospital,
there are certification requirements for the physicians
performing the procedures, standards related to infection
control and to monitoring patients — and people
there to make sure we adhere to those standards," she
explains. "That's not regulated in a clinic. While some
might very well be adhering to them, others we think
may not be."
As it turns out, anyone with a
licence can, in theory, perform a colonoscopy. According
to the Royal College of Physicians and Surgeons of Canada,
gastros and surgeons are the only ones for whom endoscopy
is a core procedural skill, but the time dedicated to
it in their training varies by program and individual
resident.
So while the consensus seems to
be that gastros and surgeons are the best people for
the job, there's absolutely nothing barring an internist
or a general practitioner from setting up colonoscopy
shop in their office. "It's up to the physician to look
at their training and evaluate if performing a colonoscopy
is within their scope of practice," explains Kathryn
Clarke, a spokesperson for the College of Physicians
and Surgeons of Ontario (CPSO).
No one wants to name names, but
it's clear that many specialists in the province feel
there are a few bad apples ruining the reputation of
the bunch. "I think it's a very mixed bag, unfortunately,"
says Dr Murray. "There are many that do a very good
job, others that don't." He's seen some botched colonoscopies
first hand, he says, and though he admits it's hard
to say how much training or experience is enough, he
feels somebody needs to decide. "It would certainly
be nice if there were a quality assurance program,"
he says. "It would take a change in infrastructure to
reach the appropriate standards, and there's really
no incentive at all to do that right now."
THE
BOTTOM LINE
Guidelines and standards are being written. The CPSO
released a rigorous set of guidelines and facility standards
for independent health facilities (IHFs) in March, and
a similar document is being developed by Cancer Care
Ontario's Program in Evidence-based Care (PEBC). But
physicians opening up clinics are under no obligation
to get an IHF licence, and the PEBC document will only
cover those procedures done within the CRC screening
program, and therefore, only those done in hospitals.
Even if they did cover physicians practising in free-standing
endoscopy clinics, they are merely recommendations —
unless there's a complaint lodged with the CPSO, no
one has any authority to enforce them. "With increased
attention to these issues, we anticipate that there
will be a raising of the bar," says Dr Rabeneck.
Despite all the politicking and
red tape, Dr Gould says we shouldn't lose sight of the
bottom line — colonoscopies do save lives. "Over
10 years, 30,000 people may have died unnecessarily
because we couldn't get a program together," says Dr
Gould. "We have the means, and the desire to do that
now." In the meantime, Dr Murray says FPs should refer
their patients to individual clinicians they know and
trust, rather than clinics where they have no idea who
will be performing the colonoscopy. If the patient is
having the procedure directly, without consultation
before hand, that is probably a bad sign," he warns.
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