What solutions could help more people get screened for cancer?

Early cancer detection is key to good patient outcomes. But it’s not always easy to get screened — particularly if you live in rural and remote areas.

Late-stage cervical cancer is a punishing disease. Symptoms can include bleeding, vaginal discharge, fatigue and pain in the lower back, pelvis and legs. But the worst thing about it may be the survival rate: Less than 20 percent of women diagnosed with late-stage cervical cancer live five years or longer.

Catch it early, though, and your prospects are much better: The five-year survival rate is more than 90 percent. That’s why screening programs, some of which can detect the virus that causes cervical cancer even before cancerous cells have appeared, are critical, says Annemarie Edwards, vice president, strategy and innovation at the Canadian Cancer Society (CCS). Early diagnosis of cancer — whether it’s cervical or any other type — leads to more timely and effective treatment. “Screening saves lives,” Edwards says.

But for many Canadians, cancer screening isn’t easy to access. The growing primary care crisis in Canada has left an estimated 6.5 million people without a family doctor, which means tests that can be easily administered as part of a routine appointment are missed. As a result, many cancers aren’t detected until debilitating, late-stage symptoms emerge that send patients to hospital. One recent Ontario study found that more than a third of cancer patients had visited an emergency department within the three months leading up to their diagnosis, likely as a result of cancer symptoms.

In remote and rural areas of Canada, the barriers to screening are even greater, says Kami Kandola, chief public health officer for the Northwest Territories. Communities there are often too small or inaccessible to have medical clinics, and where facilities do exist, staff are often oversubscribed and under-resourced. Emergencies like disease outbreaks or plane crashes can shut down screening appointments indefinitely. As a result, less than 50 percent of eligible NWT women have typically undergone screening for cervical cancer.

“We want to diagnose early,” says Dr. Kandola. “But it’s not easy. We need to find ways to make more screening happen.”

Barriers to cancer screening

About six million Canadians live in areas considered remote or rural, where it can be challenging to access cancer screening. In some cases, the barriers stem from lack of resources and infrastructure: Screening programs for breast cancer, for instance, usually require expensive mammography machines and trained technicians who know how to use them.

And even when a community has the necessary equipment, other issues may prevent residents from booking appointments, notes Edwards of CCS. Rural communities tend to have older, less mobile populations, she says, and average incomes are lower — and work often more precarious, which means residents may be loath to miss work for a screening appointment.

Other impediments exist too, particularly in Indigenous communities, where institutional health care is often viewed with mistrust because of the racism many have been subjected to in hospitals and health clinics. So it’s critical to find innovative new ways to enhance and expand screening, Edwards says, citing examples like mobile clinics and at-home test kits, which can be used to screen for cervical and colorectal cancer. “Outcomes are worse if you don’t detect cancer early,” she says. “That’s what’s really driving the urgency.”

Spotting cancer early on

Technological solutions offer a lot of promise, Edwards says, since they can be deployed in remote areas, often with limited staff and equipment.

Canadian tech companies Oxford Cancer Analytics and mDetect, for instance, are using emerging technology to develop tests that can detect cancer “biomarkers” from a blood sample. Called liquid biopsies, screening tests like these could eventually eliminate the need for specialized medical equipment and be administered by a broader range of health practitioners.

Bodily fluids like saliva and urine can also be used to detect signs of some cancers, and at the University of British Columbia’s “Breathomics Lab,” researchers are working on a screening test for lung cancer that operates like a “breathalyzer,” using a sample of patient’s breath to search for signs of the deadly disease.

Other startups are working on ways to help remote and rural communities make the most effective use of limited resources. Toronto-based Linda Lifetech, for example, has developed a contactless, smartphone-based device that uses an infrared sensor to look for heat patterns and blood flow that indicate cancerous tumours. Patients who show signs of possible cancer can then be moved to the front of the line for mammograms, ultrasound or further testing.

Self-administered tests like those used for cervical and colorectal cancer represent a big step forward for screening programs, which are developed and administered by provincial governments. Cervical cancer self-tests offer benefits that go beyond convenience — they detect the risk of cancer even earlier than the PAP test screening method still used in some provinces. While PAPs identify the abnormal cells associated with cancer, the self-test swab kit looks for the HPV virus that causes it — ideally, before any abnormal cells have even formed.

And because self-test kits are easy to use, the NWT Cancer Program plans to incorporate them into an initiative to help boost cervical cancer screening rates in three remote regions of the territory. Eligible women will get a test kit delivered to their door, and if the program succeeds, participation rates will move closer to the 90 percent target (by 2030) established by the Canadian Partnership Against Cancer.

Virtual care offers benefits too, Edwards says. While screening can’t be administered remotely (yet), online sessions can be used to inform patients of the importance of screening, and remind them when due for a test.

From infobots to inflatable colons

New solutions are useless, however, if people don’t know about them. To boost participation in screening programs, it’s important to find innovative ways to raise awareness. NWT public health staff have used a giant inflatable colon to call attention to their colorectal screening initiatives in multiple communities. (Earlier this month, the colon was sent to Lutselk’e, a fly-in Indigenous community). “It is so big you can walk through it,” says Catherine Dixon, NWT’s cancer care manager, smiling at the memory. “People love it.”

The eye-catching display also helps staff address public misconceptions about the cancers themselves: Dixon recalls one woman at an event saying that she’d urge her husband to get tested. “I had to tell her that she could get colo-rectal cancer, too.”

In southern Ontario, Niagara Folk Arts Cultural Centre developed a program that used “multicultural community kitchen events” to raise awareness of the importance of colorectal cancer screening. Meals served at the events featured dishes that are part of a healthy diet, and diners heard presentations about screening programs, delivered by members of their community — trained medical professionals who served as “health ambassadors,” says Edwards. The Niagara program was the winner of a challenge sponsored by CCS that was created in partnership with MaRS to find innovative ways to boost screening rates. Runner-up Flemingdon Health Centre incorporated a tech-based solution: A bot that mines EMR systems and contacts eligible residents to advise them they’re due for a screening.

The most important thing, however, is that solutions are flexible and community-driven, says Edwards. “What works in one place may not work in another.”

One-size solutions don’t fit all

That’s especially true for Indigenous communities, who can be wary of a health care system in which care providers may operate with unconscious bias. Tragic incidents like the death of Joyce Echaquan, an Atikamekw woman who died in a Quebec hospital in 2020 after being subjected to racist remarks by hospital staff, undermine trust in institutional programs, including cancer screening, says Lisa Richardson, an Anishnaabe doctor who serves as associate dean, inclusion and diversity, at the University of Toronto’s Temerty Faculty of Medicine.

“It’s not that Indigenous people don’t want to get screened,” Richardson says, “but they find it hard to trust the system.” In some cases, she adds, the problem may be simply that they don’t have a doctor, since full-time medical professionals are rare in many Indigenous communities. As a result, they can’t get a screening referral.

To help overcome barriers like these, Richardson has helped develop screening events designed for Indigenous people that include walk-in access. Conducted through Ganawishkadawe: The Centre for Wise Practices in Indigenous Health at Toronto’s Women’s College Hospital, the events feature Indigenous cultural programming and are led by Indigenous people.

Ultimately, the best screening programs are designed by the communities themselves and involve local leadership, says Peter Hutchinson, assistant professor in Indigenous Studies at UBC. Hutchinson is currently working with several Métis settlements in Alberta to develop a plan to increase HPV screening. But rather than impose ideas on the communities, he’s starting with conversations with elders and youths to determine what might work best. “Indigenous people need to be the decision-makers.”

In the end, solutions need to come from the communities themselves, says Dr. Kandola. “We want more people tested early and diagnosed early,” says Dr. Kandola. “But you can’t just tell someone here to hop on a bus and go get screened. It won’t happen.”

The Canadian Cancer Society and MaRS has launched the Rural & Remote Community Cancer Screening Challenge to identify and support community-designed solutions. Find out more here.

Photo credit: Northwest Territories Health and Social Services Authority