1. What is the role of the pharmacist in the ColonCancerCheck program?Pharmacists have an important role in helping Ontarians who do not have a health care provider to access screening for colorectal cancer by :

Dispensing program-branded FOBT kits to eligible unattached participants. Providing information about the importance of screening for colorectal cancer. Referring individuals at increased risk (family history of colorectal cancer in a parent, sibling or child) to the

ColonCancerCheck program at 1-866-662-9233.Pharmacists are not required to recruit eligible individuals to participate in the program.

2. What is an FOBT kit?A Fecal Occult Blood Test (FOBT) is an at-home test that looks for hidden blood in your stool. A FOBT is used to check for colon cancer. Test kits: Stool Guaiac Cards: • This is the most frequently used test kit. Stool is put on three cards and read at home or in a lab. Other types: • Some kits come with a special cloth to wipe after a bowel movement. The cloth is then tested for blood in the stool. • Some kits have a special test pad that you put in the toilet. The pad will change color if there is blood in the stool. These foods can change the results of your test.Three days before the test do NOT use: • Iron supplements • Aspirin (or Aspirin products) • Vitamin C supplements Do NOT test your stool if: • You are having your menstrual period • You have active bleeding from hemorrhoids • The stool sample touched the toilet bowl, urine, ortoilet cleaning products Be sure you have your FOBT kit and read the directions that come with the kit. • Red or rare meat • Turnips • Beets • Radishes • Horseradish • Artichokes • Mushrooms • Broccoli • Bean sprouts • Cauliflower • Apples • Oranges • Bananas • Grapes • Melon How to get ready for the test:Three days before the test do NOTeat: Results:You can read the results for some FOBT kits. Others tests are sent to a lab. If you have abnormal results, contact your health care provider right away. You may need a colonoscopy or sigmoidoscopy test. These are tests that use a camera to look inside the large intestine. Every kit is different. Follow the directions thatcome with the kit. • Read all instructions before starting the test!• Check the expiration date on the package. Do not use the kit if it is expired. • Store the kit as needed. It may need to be stored in the refrigerator. • Make sure you do all the steps in order. Do not skip steps! • If a step in the test needs to be timed, use a watch. Do not guess. • Record the results clearly so you can talk about them with your health care provider.

Normal:A normal test (no color change) means there was no blood in your stool at the time of the test. Normal test results are Abnormal: An abnormal test (blue color change) means there was some blood in your stool at the time of the test. Abnormal How the test is done:The test takes three days. You will get three small stool samples. One sample each day. Your test may have these steps: 1. You will use a cup from the kit to collect your stool. It is important that you catch it before it touches the toilet or urine. 2. You will use the spatula or brush that comes with your kit to collect a small amount of stool. Take pieces from different areas of the stool. 3. You will then put the stool on a card and store it in an envelope overnight to dry. 4. Flush the rest of the stool down the toilet. 5. Follow these steps for the next two days. 6. Once you have your three samples, you will read the results or have them sent to a lab. **If you are color blind, have someone else read the test results.

Risk factorsColorectal cancer is the third-most diagnosed type of cancer in Canada. There are a number of risk factors. It can be caused by family history or genes. Your lifestyle can also increase your risk.Ontario offers a free screening program to help protect people from this cancer. If you need treatment, your doctor will discuss the options with you.Learn more about colorectal cancerWhy you should screenWhen colorectal cancer is caught early:

most people (90%) recover fully after treatment your cancer is less likely to spread you may have more options to treat your cancer

When to go for screeningUse the tool to find out when you should get screened for colorectal and other cancers.Time to screen toolTypes of screeningColonCancerCheck is Ontario’s screening program for colorectal cancer. There are two screening tests:

Fecal Occult Blood Test (FOBT) colonoscopy

Learn more about the ColonCancerCheck programHow to join the ColonCancerCheck programIf you have a primary care provider:

you may receive a letter from ColonCancerCheck inviting you to enter the program your primary care provider (family doctor or nurse practitioner) may talk to you about

screeningIf you don’t have a primary care provider:

call Telehealth Ontario at 1-866-828-9213 to enter the program talk to your pharmacist — he or she can share information about the program and give you a

Fecal Occult Blood Test (FOBT) kit contact ColonCancerCheck directly by email or call INFOline at 1-866-410-5853 — ask about

the program and how to joinTake the Fecal Occult Blood Test (FOBT)Everyone between the ages of 50 and 74 should get this test every two years if their risk of cancer is average.How it worksIt’s a simple test that you can do yourself in your own home. You then send the test off by mail to get your results. You must complete and mail the kit 1 month before the expiry date.Before you take the test

Check the expiry date on your kit — you can find it at the bottom of the slide card inside the kit envelope.

If your kit is expired or expiring within a month: contact your health care provider about getting a replacement kit. If you don’t have a health care provider or have other questions, call INFOline at 1-866-410-5853.Don’t take the test if you also have any symptoms of colorectal cancer or you have blood in your urine. Wait three days after you stop bleeding if you’re:

menstruating bleeding from hemorrhoids bleeding from dental work

Get your FOBT test resultsColonCancerCheck will send a letter with your results to you and your health care provider. What happens next depends on your results:If your result is negative (-)ColonCancerCheck will send you a reminder letter in 2 years, when it’s time for another test.If your result is positive (+)It means there’s blood in your stool. This doesn’t always mean you have cancer. You’ll need to follow up with a colonoscopy to find out.If you have a health care provider, he or she should contact you to arrange the next steps.If you don’t have a health care provide, ColonCancerCheck will arrange for your follow-up care.If you don’t get your results within a monthContact your health care provider. If you don’t have a health care provider, call ColonCancerCheck directly at 1-866-410-5853.Get a colonoscopyA colonoscopy is an examination of the lining of your rectum and colon using a long flexible tube with a camera on the end. This test is for people with a higher risk of cancer. Your doctor may recommend this test if:

you have a positive FOBT result  a sibling, child or parent had colorectal cancer

Tips to reduce your risk maintain a healthy body weight be physically active reduce alcohol intake don’t smoke take calcium or folic acid supplements know your family history — if a close relative had colorectal cancer, you could be at increased

risk most importantly, get screened

3. Who is not eligible to receive an FOBT kit at a pharmacy?Please do not provide FOBT kits to individuals with the following :

Unexplained changes in bowel patterns Rectal bleeding Unexplained weight loss Urgent feeling to empty bowel

Those experiencing one or more of the symptoms described above may require medical attention and must be directed to seek appropriate medical care.Note: Individuals who regularly use the service of walk-in clinics (e.g. those who obtain monthly blood pressure medications from the same clinic) may obtain their FOBT kits from these clinics to facilitate provision of results and follow-up care.

4. how would you counsel an eligible patient?

1. What is the ColonCancerCheck program?In April 2008, the Ministry of Health and Long-Term Care and Cancer Care Ontario launched ColonCancerCheck, Canada's first population-based provincial colorectal cancer screening program. The goals of the ColonCancerCheck program are to reduce deaths from colorectal cancer through an organized screening program and to improve the capacity of health care providers to participate in comprehensive colorectal cancer screening.Organized screening programs like ColonCancerCheck provide important benefits including the ability to :

Invite individuals to participate in screening Remind individuals to be screened Track participants throughout screening and diagnostic processes Continually evaluate program quality and performance

2. Why screen for colorectal cancer?Colorectal cancer is the second leading cause of cancer death in Ontario. In 2011, an estimated 8,100 Ontarians were diagnosed with colorectal cancer and 3,250 died from the disease1. When caught early, there is a 90 percent chance that people with colorectal cancer will be cured, compared with only 12 percent if the cancer is detected at an advanced stage. Regular (repeated) screening using the Fecal Occult Blood Test (FOBT) for individuals aged 50 and older, followed by a colonoscopy for those with an abnormal FOBT, reduces deaths from colorectal cancer by 16 percent. But according to 2009-2010 data, only 27 percent of Ontarians aged 50 to 74 years completed an FOBT in the previous two years.3. What is the role of the pharmacist in the ColonCancerCheck program?Pharmacists have an important role in helping Ontarians who do not have a health care provider to access screening for colorectal cancer by :

Dispensing program-branded FOBT kits to eligible unattached participants. Providing information about the importance of screening for colorectal cancer. Referring individuals at increased risk (family history of colorectal cancer in a parent, sibling or

child) to the ColonCancerCheck program at 1-866-662-9233.Pharmacists are not required to recruit eligible individuals to participate in the program. Back to topScreening4. Who is eligible to receive an FOBT kit at a pharmacy?To be eligible to receive an FOBT kit from a pharmacist, an individual must meet all of the following criteria :

Aged 50 to 74 years Have a valid Ontario Health Card Does not have a health care provider (unattached individual) Not experiencing symptoms that may be indicative of colorectal cancer Be at average risk of developing colorectal cancer i.e. have no first-degree relatives (parent,

sibling, child) who have been diagnosed with colorectal cancer Have not had a colonoscopy within the past 10 years Have not completed an FOBT in the past two years Does not already have an FOBT kit and accompanying laboratory requisition at home

If a participant meets all criteria, the pharmacist can provide them with an FOBT kit. 5.  Who is not eligible to receive an FOBT kit at a pharmacy?Please do not provide FOBT kits to individuals with the following :

Unexplained changes in bowel patterns Rectal bleeding Unexplained weight loss Urgent feeling to empty bowel

Those experiencing one or more of the symptoms described above may require medical attention and must be directed to seek appropriate medical care.Note: Individuals who regularly use the service of walk-in clinics (e.g. those who obtain monthly blood pressure medications from the same clinic) may obtain their FOBT kits from these clinics to facilitate provision of results and follow-up care.6. What are the symptoms that may indicate colorectal cancer?During the early stages of colorectal cancer, there are often no symptoms. This is why screening is important. However, as colorectal cancer progresses, the following symptoms may occur :

A change in bowel movements Blood (either bright red or very dark) in the stool Diarrhea, constipation or feeling that the bowel does not empty completely Stools that are narrower than usual Stomach discomfort Unexplained weight loss Fatigue Vomiting

It is important to explain that these symptoms do not mean that an individual has colorectal cancer. However if an individual is experiencing one or more of the symptoms they must be directed to seek appropriate medical care from their health care provider. 7. What if an individual is under 50 or over 74 years of age and asks about colorectal cancer screening?The pharmacist should advise individuals who are under 50 or over 74 years of age that ColonCancerCheck recommends that asymptomatic average risk individuals aged 50 to 74 years of age be screened using the ColonCancerCheck FOBT every two years. This is consistent with clinical guidelines.The pharmacist should refer the individuals under 50 or over 74 years of age to the ColonCancerCheck website at ontario.ca/coloncancercheck or to his/her health care provider.8. What if the individual has had a colonoscopy within the last 10 years?Individuals who have had a colonoscopy within the last 10 years should not be screened using FOBT and should consult with their health care provider about the appropriate follow-up. If an individual no longer has a health care provider, please refer them to :

Health Care Connect at 1-800-445-1822 or ontario.ca/healthcareconnect; or  Telehealth Ontario at 1-866-797-0000.

9. What if the individual has a family history of colorectal cancer?People who have a first-degree relative (i.e., parent, sibling or child) with a history of colorectal cancer are at increased risk. For these people, a colonoscopy is recommended beginning at age 50, or 10 years earlier than the age at which their relative was diagnosed (whichever occurs first).Those at increased risk for colorectal cancer who do not have a health care provider should be referred to the ColonCancerCheck program at 1-866-662-9233. The ColonCancerCheck program can arrange an appointment with a health care provider who is willing to accept participants for referral to follow-up care.10. What if the individual already has an FOBT kit?If the individual currently has an FOBT kit, they should be encouraged to use the kit they already have.  Back to topResults11. How will participants who receive their FOBT kits from a pharmacist obtain their results?ColonCancerCheck assumes that any participant who received an FOBT from a pharmacist does not have a health care provider.Participants with normal (negative) test results, and participants who submitted kits that the laboratory was unable to obtain a result from (result was inconclusive or the kit was unable to be processed), will receive a letter from ColonCancerCheck informing them of their test result. Participants with abnormal (positive) test results will be contacted by ColonCancerCheck to discuss follow-up care. Participants who have not heard from the ColonCancerCheck program about their results within a month of completing the test should call 1-866-662-9233.12. Is the pharmacist who dispensed the FOBT kit responsible for follow-up care if a participant has an abnormal (positive) FOBT result?No, the pharmacist who dispensed the FOBT kit is not responsible for coordinating follow-up care if a participant has an abnormal (positive) FOBT result. ColonCancerCheck will contact the participant to discuss follow-up care.13. What does an abnormal (positive) FOBT test result mean?An abnormal FOBT result means that blood was found in the stool. The pharmacist should reassure the participant that an abnormal FOBT does not mean that they have cancer but it is very important that they receive follow-up testing. Research shows that 1 in 20 individuals with an abnormal FOBT will be diagnosed with colorectal cancer after undergoing a follow-up colonoscopy. 14. What if the participant’s first test is inconclusive (a result could not be obtained) or it was rejected for processing and the participant is requesting another kit?There are a number of reasons why a test may be inconclusive or rejected for processing. They include :

Missing lab requisition Mismatched patient information on the FOBT kit and requisition Missing name and/or date of birth on the FOBT kit All specimens expired (FOBT was received by the lab more than 21 days since samples were

collected)

FOBT kit has expired (i.e. the entire kit has exceeded the manufacturer’s recommended expiration date)

Test card is damagedReasons for an inconclusive result include :

No date of stool collection was written on the test card The sample was not applied to one or more of the windows on the test card or was on the

wrong side of the test card The sample was too thick or too thin A specimen expired (i.e. one specimen was received by the lab more than 21 days since the

specimen was collected) There were technical issues

If the test is inconclusive or rejected, the participant will receive a letter from ColonCancerCheck informing them that the test was not processed or that the test was inconclusive (neither positive nor negative). The participant will be directed to get a new FOBT kit, either from their health care provider if they now have one, or from a pharmacy or Telehealth Ontario if they do not currently have a health care provider. Pharmacists should re-assess whether the participant meets the eligibility criteria before providing another FOBT kit and ensure that they understand how to do the test correctly to avoid similar problems.15. What if a participant presents at the pharmacy asking about their results?Pharmacists will not have access to a participant’s test results. Participants will receive notification of their result through a letter from ColonCancerCheck. If a participant has not received their result after a month, they should be directed to contact ColonCancerCheck at 1-866-662-9233.Back to top Processes And Remuneration16. How can pharmacists obtain FOBT kits?For participants with a negative FOBT, the ColonCancerCheck program will send them a letter informing them of their results. They will also be reminded by the program to take the test again in another two years.For participants with a positive FOBT, the ColonCancerCheck program will arrange an appointment with a family physician to facilitate follow-up care which may include a referral for colonoscopy. A positive FOBT does not mean that the participant has cancer, as 10% of participants with a positive result in one window will have cancer.If a participant has not heard from the ColonCancerCheck program about their results within a month of completing the test, the participant should call 1-866-662-9233.17. Where can pharmacists get a laboratory requisition form fors FOBT?Pharmacists can obtain a laboratory requisition form from ColonCancerCheck Forms can be photocopied as required.Alternatively, the forms can be downloaded from ontario.ca under the "Forms" repository.  After choosing a language (English/French), click the “Forms” item, which is found under the "Resources" banner. Type the form number 4533-84 into the "Quick Search" window to find the form.18. What is the PIN (Product Identification Number) for the FOBT kit?The PIN for the FOBT is 93899960. 19. Where can pharmacists order more patient education materials?Patient education materials can be downloaded and printed from ColonCancerCheck, including the FOBT instruction sheet in English, French and 26 other languages. Materials in hardcopy can be ordered from Service Ontario at :

ServiceOntario under Publications and Health Programs Call 1-866-410-5853 Send an email to ColonCancerCheck@ontario.ca

20. What fees can pharmacists claim for colorectal cancer screening?Distributing an FOBT kit is a paid service for community pharmacists at a rate of $ 7.00.21. How does a pharmacist submit an FOBT claim?After the pharmacist has reviewed the requisition form for eligibility and completeness, an online FOBT claim can be submitted to the Ontario Drug Benefit (ODB) Health Network System (HNS). Software system changes are required.An FOBT claim for distributing the FOBT kit must be submitted to the ODB HNS with the following information:

Participant Gender “F” = female, “M” =maleParticipant Date of Birth YYYYMMDDParticipant Health Card # As noted on Health Card

Product Identification Number (PIN) “93899960” = FOBT PIN for kit distributionIntervention Code “PS” = Professional Care Service

“ML” = Eligibility established- Standard coverageCarrier ID “G” = ColonCancerCheck Plan Code

Pharmacist’s ID code Pharmacist OCP License #Colorectal Screening Fee – FOBT Distribution $ 7.00 22. What should pharmacists do with the FOBT requisition form?After submitting the online FOBT claim, pharmacists are asked to affix the prescription label on the FOBT requisition form and ensure completeness of the form prior to signing it. The prescription label provides details to the participating laboratory in case the information on the FOBT requisition form is unclear. You may be contacted by the participating laboratory staff to clarify details on the FOBT form or if the form is not completely filled out. ColonCancerCheck will use the information on the FOBT requisition form to send letters to participants informing them of their test result or to follow-up with participants who have positive test results.Note: The Pharmacy ID, as requested on the FOBT requisition form, is the unique identification number assigned to your pharmacy. It is the ten digit Canadian Pharmacists’ Association (CPhA) number for accredited community pharmacies that begins with “ON”. The FOBT kit must be provided to the individual together with the completed and signed requisition form. While not required, the pharmacy may retain a copy of the completed laboratory requisition form. Once the FOBT test is completed at home, the kit together with the requisition form may be dropped off at a participating laboratory or mailed to the laboratory in the pre-paid self-addressed envelope provided. Completed FOBT kits should NOT be returned to the pharmacy.23. What is inside the ColonCancerCheck FOBT kit?The ColonCancerCheck FOBT kit includes easy-to-read instructions, a test card, specimen collection sticks, privacy statement, a leak-proof envelope to protect the test card, and a pre-paid self-addressed return envelope.24. How often can colorectal cancer screening services be provided to the same individual?Individuals aged 50 to 74 years at average risk of colorectal cancer should be screened with FOBT once every two years. In the case where the individual has lost or damaged their FOBT kit, pharmacists can provide another kit and a new requisition form will need to be completed if the previous one is no longer available (e.g. lost or damaged).The Colorectal Screening Fee - FOBT Distribution is limited to a maximum of one claim submission per patient once every two (2) year period