FOR HEALTHCARE PROVIDERS

My CancerIQ is a suite of online cancer risk assessments created by Cancer Care Ontario to help Ontarians of all ages:

• increase their awareness of specific types of cancer
• better understand their cancer risk and protective factors
• for colorectal, cervical and breast cancer, learn when and how they should be screened

The risk assessments are based on existing algorithms developed through an extensive international consultation process involving clinicians and scientists. Scientists at CCO adapted the algorithms by using prevalence data from Ontario or, if no Ontario estimates were available, from Canada or another Canadian province.

Response messaging was developed by inter-disciplinary working groups at CCO that included epidemiologists, cancer science specialists, a registered dietitian and health promotion/communication specialists.

For each cancer, the algorithm calculates the relative risk of cancer compared to the general population. For most cancers risk was divided into three broad categories: lower than average, average, or higher than average. For some cancers, additional categories were added to reflect the strong impact of particular risk factors (e.g., having a genetic mutation for breast cancer or heavy smoking for lung cancer).

Because risk is calculated relative to the Ontario population and using methods specific to Ontario, risk categories assigned to users may differ from those obtained through other available online risk calculators.

Qualifiers on the site explain to users that results:

• are not diagnostic and cannot predict whether an individual will or will not develop cancer
• do not constitute medical advice
• are most accurate for those age 40 and over without a previous history of cancer
• are limited to current knowledge and user’s responses, so risk may change in the future

For each risk assessment, risk factors were included if one or more large expert panel of scientists that looked at the data concluded there is sufficient scientific evidence these factors are causes or probable causes of cancer. Most of these factors have been reviewed and are included in one or more of the following reports/report series:

• Cancer Risk Factors in Ontario: Evidence Summary, published by Cancer Care Ontario
• Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective, published by the World Cancer Research Fund (WCRF) and the American Institute for Cancer Research (AICR)
• IARC Monograph series on the Evaluation of Carcinogenic Risks to Humans, published by the International Agency for Research on Cancer (IARC)

In these reports the strength of the evidence for each risk factor is assessed and classified. Common categories and their associated criteria used by the WCRF/AICR and by IARC to categorize the strength of evidence are outlined below.

World Cancer Research Fund/American Institute for Cancer Research ¹

Convincing: There is strong evidence the risk factor causes a specific type of cancer. To be considered convincing, there must be evidence from more than one type of research study and from at least two independent cohort studies. These studies should be of good quality so it is unlikely the observed association is the result of random or systematic error or confounding. Furthermore, there must be evidence of a dose-response or plausible biological gradient (e.g., the greater the exposure, the greater the risk), as well as strong and plausible experimental evidence showing how exposure leads to the relevant cancer. Finally, there must be little or no heterogeneity (variance) in the relationship between the risk factor and the risk of cancer in different types of studies or in different populations.

Probable: To be considered a “probable” cause of a specific type of cancer, there must be evidence from at least two independent cohort studies or at least five case-control studies, no substantial unexplained heterogeneity between or within different types of studies or different populations, and there is evidence of the biological pathway by which the factor can lead to cancer. As well, studies used in making this judgment should be of high quality, making it unlikely the relationship is the result of random or systematic error or selection bias.

International Agency for Research on Cancer (IARC)²

Sufficient: A causal relationship has been established between exposure to the agent (risk factor) and human cancer at the target organ(s) or tissue(s). To be considered “established” the positive relationship must be observed in high quality studies in which chance, bias and confounding are unlikely to influence results.

Limited: A positive association between an exposure and cancer at a target organ(s) or tissue(s) has been observed in humans and a causal relationship is considered by the Working Group of the IARC to be credible. The evidence, however, is considered “limited” because chance, bias or confounding could not be ruled out with reasonable confidence.

In addition to these two criteria, the IARC classifies the strength of the evidence that an agent is carcinogenic. Criteria are:

Group 1: The agent is carcinogenic to humans: There is sufficient evidence in humans that the agent is carcinogenic for at least one target organ or tissue. In rare cases, an agent may be put in this category when the evidence of carcinogenicity is less than sufficient in humans but there is sufficient evidence in experimental animals and strong evidence in exposed humans that the agent acts through a relevant biological mechanism.

Group 2A: The agent is probably carcinogenic to humans: There is limited (i.e., some but not sufficient) evidence of carcinogenicity in humans but sufficient evidence in experimental animals. In some cases, an agent may be put in this category when there is inadequate evidence of carcinogenicity in humans but sufficient evidence in experimental animals and strong evidence of a biological mechanism that also operates in humans. In rare cases, an agent may be put in this category solely on the basis of limited evidence in humans but it shares the same biological mechanism as a class of agents for which one or more members have been classified in Group 1 or Group 2A.

For each of the included risk factors, the relative risk of cancer has been estimated. The relative risk represents the size of the association between different levels of exposure to the risk factor and the related cancer. These numbers were identified and agreed upon by a large group of scientific experts based on the available current science.

Risk calculations in the Cancer Risk Assessments were adapted to reflect the proportion of the Ontario population exposed to each of the included risk factors (i.e., the prevalence). Wherever possible, prevalence estimates were obtained for each sex separately from population-based surveys or studies and the most recent data available were used. If Ontario estimates were not available, estimates for Canada or another Canadian province were used.

Risk categories assigned by My CancerIQ are relative to the population of Ontario and uses Ontario-specific data and cut-offs, as determined by the expert working group of CCO. Other online cancer risk calculators may use data from other populations or studies or use different cut-offs to determine risk level. As a result, outcomes may vary between different calculators.

Where screening is recommended, the information is based on the best available evidence and reflects the guidelines of:

• ColonCancerCheck, an evidence-based, province-wide, population-based colorectal cancer screening program. For more information, visit the CCO website or read the 2010 Program Report.
• Ontario Breast Screening Program (OBSP), a province-wide, evidence-based and organized program for screening average and high-risk women for breast cancer. For more information, please refer to the CCO website or the 2011 Ontario Breast Screening Program report.
• Ontario Cervical Screening Program (OCSP), an evidence-based, organized, province-wide program that promotes screening women for cervical cancer, one of the most preventable forms of cancer. For more information, please refer to the CCO website or read its 2012 program report.

For other forms of cancer, recommendations are based on diagnostic pathways developed for and by Cancer Care Ontario by leading experts in the field.

Links to outside websites and resources were chosen by Cancer Care Ontario to help Ontarians obtain more information or advice. Websites were chosen that:

• Are operated by Canadian governments or not-for-profit organizations
• Conform to the Honcode Code of Conduct for health information on the Internet, or provide evidence of conforming to similar principles of providing balanced, evidence-based information to support and not replace the doctor-patient relationship.
• Are transparent in their purpose and funding and post the means by which they protect the privacy of users
• Wherever possible, provide resources in both official languages

Completing a risk assessment will:

• educate your patients about cancer, cancer screening (if appropriate), and their own cancer risk and protective factors
• encourage patients to engage with their healthcare providers and to start dialogues on cancer prevention and screening
• motivate your patients to make healthy behaviour change

At numerous points throughout the risk assessment, users are encouraged to share their risk assessment report with their doctor, nurse practitioner or public health nurse. These primary care providers are positioned as the preferred source of information on cancer prevention and screening.

Encouraging your patients to complete one or more cancer risk assessment can:

• provide a means (the cancer risk assessment report) by which patients can document information (e.g., lifestyle risk factors or family history) to share with you
• help to open the door to productive dialogues on cancer prevention and screening
• educate your patients on appropriate cancer screening practices (CCO’s evidence-based screening guidelines for colorectal, cervical and breast cancer)
• by linking patients to high-quality resources, support patients in making healthy lifestyle changes (e.g., physical activity, healthy eating, smoking cessation)

The My CancerIQ site addresses:

• cancer-specific risk and protective factors
• for colorectal, cervical and breast cancer, evidence-based screening guidelines

Through links on the site, users have access to high-quality, bilingual resources providing:

• general cancer information (e.g., the Canadian Cancer Society)
• information and interactive resources for behaviour change (e.g., EatRight Ontario)
• information on screening (Ontario Breast Screening Program, Ontario Cervical Screening Program, ColonCancerCheck Program)

My CancerIQ does not discuss cancer diagnosis, treatment or recovery. Although messages are tailored to reflect users’ responses to assessment questions, personal medical information or advice is not provided.

We take patient privacy seriously. If patients sign up to receive email updates we will never share their email addresses with third parties.

Patients’ answers are retained while they take an assessment but will be deleted as soon as they end their browser session. Patients may choose to save, email or print their results, but these data will not be stored anywhere on our servers and we will not be able to see them.

Patients who complete our customer satisfaction survey will not be asked for any information that could be used to identify them and their answers.

For more information on how we keep patient information safe, please refer to our Legal & Privacy page.

Learn more about CCO’s collection of users’ assessment answers

The recommendations reflect evidence on alcohol consumption for each specific type of cancer and only that cancer.

The Low Risk Drinking Guidelines were developed from estimates of the relative risk of those who drink, compared to non-drinking men and women, of premature all-cause mortality, as well as mortality from 16 well-established causes associated with alcohol consumption, including stroke, motor vehicle accidents, and some forms of cancer.

In 2014, the Canadian Centre on Substance Abuse, in collaboration with the Canadian Cancer Society, released an advisory on cancer and alcohol. To reduce the risk of developing cancer, the daily and weekly limits should be lower than those recommended in the Low Risk Drinking Guidelines. Specifically, alcohol consumption should be limited to less than one drink a day for women and two drinks a day for men.

Visit the Helpful Links page to see sites recommended to your patients.

No, the algorithm is too complex to offer in a print version.

Visit CCO’s Primary Care page to find out about our resources for primary care practitioners.

• Downloadable Primary Care Quality Improvement Toolkits
• Register for Screening Activity Reports
• Breast Screening Guidelines Summary
• Colorectal Screening Guidelines Summary
• Drug Formulary
• Managing Symptom, Side Effects & Well-Being

An extensive list of resources for primary care providers, including screening and referral guidelines, colorectal cancer follow-up guidelines and symptom management and palliative care resources can be found here.