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Show notes

  • Colon Cancer Screening
    • Colon cancer screening is conducted in Ontario with the Fecal Immunochemical Test (FIT). The test detects microscopic blood in the stool.
    • An abnormal FIT leads to a colonoscopy which can detect colon cancer or polyps before they turn into cancer.
  • Screening tests
    • A screening test is used to test populations that are at average risk for a disease. It is difficult to design a screening test, because they have criteria.
    • A good screening test targets an important condition with a detectable preclinical phase, accurately identifies disease, is safe and acceptable, leads to an effective intervention, and (most importantly) improves meaningful patient outcomes while minimizing harms such as false positives, overdiagnosis, and unnecessary treatment.
  • Changes to the FIT
    • On July 1, 2026, the Ontario government lowered the eligibility age for people to access publicly funded colorectal cancer screening from 50 to 45.
    • At the same time, they change labs from LifeLabs to In-Common Laboratories (ICL), which did not have the same ability to communicate the results digitally, as was previously done.
    • The lack of digital communication was replaced with faxed results. This means that:
      • Results do not integrate with family physicians’ digital inboxes;
      • Electronics flags and red highlighting of abnormal results are not available;
      • Front-office staff, which are typically not involved in digital communications, must manually review the results;
      • Digital reminders in physicians’ Electronic Medical Records (EMRs) are not updates - a considerable issue since many family physicians have over 2000 patients each. This increases the risk of missed future screening;
      • Increased risk of delayed or missed diagnosis of colon cancer, which ultimately increases the risk of morbidity and mortality (disease and death) from colon cancer in Ontario;
      • Batch faxes: faxes with multiple patients on the same page, which increases the risk of communication errors; and
      • Patients being informed by letter of possible colon cancer before their physicians have been informed.
    • The SGFP Advocacy Campaign
      • In addition to the above, the timeline was extremely short: primary care partners were not informed until 70 days before the go-live date.
      • That digital integration was not made a condition of the lab contract and how this is a structural gap in program design as well as the lack of primary care input at the design level.
      • That this is at odds with Ontario Health’s own Patients Before Paperwork commitment. In that Ontario Health initiative, Ontario, in 2023 made a major commitment to “axe the fax,” including eReferral and centralized intake / care coordination.
      • Ontario has said that to mitigate this risk, front-line office staff should be vigilant in looking for the faxes. 
      • This is another example of the medical system relying on front-line practitioners plugging the gaps in the system and how this contributes to physician burnout, which can deprive communities of an important resource.
  • If Ontario’s healthcare system had a Safety Management System (SMS), a risk analysis would have been conducted
    • At a minimum a proper SMS that included proactive safety measures would have identified the risk that the transition created.
    • In this case, the FIT test has not changed but more people are being screened, so an analysis of whether the increased risks of delayed and missed diagnosis were counterbalanced by overall less morbidity and mortality for screening more people a few months earlier, would have been conducted.
    • This is a balancing of the risk of early implementation with poorer communication standards compared to the risks for those aged 45 to 49 who wouldn’t be screened until the proper communication standards had been achieved. The analysis would have to show that more lives / harm would be saved with early implementation compared to the number of lives lost.
    • We saw an example of this kind of analysis conducted by the HSSIB in Ep 9 - Unintentionally Retained Surgical Sponges - Part II.
  • Risk management in mature safety management systems
    • Key elements of risk management:
      • identifying hazards (things that could cause harm) (e.g. poorer communication standards leading to increased risk of delayed or missed colon cancer diagnoses)
      • assessing the risks (the likelihood of a hazard causing harm and how much harm may be caused) (e.g. estimate the number of delayed and missed diagnoses of colon cancer)
      • putting in place risk controls as appropriate (e.g. delaying the transition until the same communication standards are in place)
      • documenting the management decisions
      • reviewing the risk controls (an iterative process)
    • Within risk management there is not an expectation to eliminate all risk, but to reduce risks to ‘as low as reasonably practicable’ (ALARP). This requires risk to be balanced with efficiency.
    • “The decision process begins with a presumption that the risk reduction measure should be implemented. It would only be deemed reasonable not to implement the risk reduction measure if it would be ‘grossly disproportionate’ to the benefits that would be achieved. An extreme example is that spending £1m to prevent 5 staff suffering bruised knees would be considered grossly disproportionate”
    • Meaning the government-of-the-day bears the onus to show that the risks and the costs were considered.
  • Safety management systems improve efficiency and safety
    • A safety management system and risk analysis is not a hoop to jump through or a bureaucratic process: it is a process that guides decisions to make them not only safer, but more efficient, ultimately leading to cost savings.
    • In this case, considerable time and expense has been required to mitigate the risks caused by the reversion to faxes. Many meetings, use of front-office staff, etc.
    • For those unfortunate Ontarians that have delayed or missed colon cancers, the healthcare system will spend enormous sums of money caring for them. The costs of one colon cancer surgery on the system alone would likely pay for the time it would have taken to conduct a proper risk analysis, not to mention the agony and hardship for the family of that person.
    • Dr. Barber wonders whether the current  system of issuing FITs to patients, rather than, for example, having them available at the pharmacy, would improve uptake of colon cancer screening.
  • Safety Intervention Worth Mentioning: Section on General and Family Practice (SGFP) Advocacy Campaigns
  • Section on General and Family Medicine website: SGFP.ca 
    1. Chair’s Letters (how Adam and Amir first discovered this issue)
    2. Policy content
    3. Advocacy tools
  • Who can do what tomorrow?
    • Policymaker / government / regulator: Take heed of the issues presented here and work quickly to at least restore the level of communication of FIT tests in Ontario to what it was previously. In the future, perform a risk analysis.
    • Primary Care Offices and Practitioners: Tell your Member of Provincial Parliament (MPP) of the difficulties and risks to the patients you’re treating. Advocate for system change. In the meantime, ensure office staff know what to look for.
  • Other resources
    1. Ontario Medical Association (OMA) - Advocacy group for Ontario physicians (The SGFP is a section of the OMA)
  • Random recommendations
    1. Dave:
      1. Wheat Kings bakery in Kingston, Ontario.
      2. The Tragically Hip’s Wheat Kings song about the wrongful conviction of David Milgaard, whose story was recently showcased on CBC’s See You in Court podcast.
      3. TV show Lioness, which follows a team of female CIA operatives.
    2. Kevin:Dungeon Crawler Carl book series by Matt Dinniman.
    3. Adam: Neil Pasricha’s 45 Things I (Almost) Learned as I Turn 45
    4. Amir: TV show Abbott Elementary

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