High Risk Ontario Breast Screening Program FAQs for Healthcare Providers

As the referring primary care provider, it is your responsibility to:

• talk to your patient about their breast health and screening test options;
• refer only people who meet the High Risk OBSP eligibility criteria (Category A) or genetic assessment referral criteria (Category B) using the High Risk OBSP Requisition Form;
• ensure relevant supporting materials are submitted along with the referral to the High Risk OBSP; and
• ensure appropriate follow-up of abnormal screening results for your patients in conjunction with High Risk OBSP sites

Women, trans and nonbinary people ages 30 to 69 can get screened through the High Risk OBSP if they have a referral from their primary care provider, a valid Ontario Health Insurance Plan number, no breast cancer symptoms and meet criteria listed in Category A or B.

• Category A – Eligible for direct entry into the High Risk OBSP based on personal and family history. To fall under this category, at least one of the following criteria must be met:
  • Known carrier of a pathogenic or likely pathogenic gene variant (e.g., BRCA1, BRCA2, TP53, PALB2) that increases their risk for breast cancer
  • Have not had genetic testing, but have had genetic counselling because they are a first-degree relative of a carrier of a pathogenic or likely pathogenic gene variant (e.g., BRCA1, BRCA2, TP53, PALB2) that increases their risk for breast cancer
  • Previously assessed by a genetics clinic (using the IBIS or CanRisk risk assessment tool) as having a 25% or greater lifetime risk for breast cancer based on personal and family history
  • Have had radiation therapy to the chest to treat another cancer (e.g., Hodgkin lymphoma) before age 30 and at least eight years ago
• Category B – Genetic assessment required (i.e., counselling and/or testing) to determine eligibility for the High Risk OBSP. To fall under this category, at least one of the following criteria must be met:
  • An identified pathogenic or likely pathogenic gene variant that is associated with breast cancer risk (e.g., BRCA1, BRCA2, TP53, PALB2) in a close blood relative
  • A personal or family history of a cancer suggestive of a hereditary breast cancer syndrome

People with a personal history of breast cancer and/or breast implants may get screened through the High Risk OBSP if they meet program eligibility criteria.

The High Risk OBSP does not accept new participants over age 70. However, when participants already in the High Risk OBSP turn 70, the program will continue to screen them with mammography only every year until they are age 74.

High Risk OBSP sites do not send letters to people over age 74 about participating in the program. To continue screening through the High Risk OBSP, a referral is required from a primary care provider.

People with a personal history of breast cancer and/or breast implants may get screened through the High Risk OBSP if they meet eligibility criteria.

People with bilateral mastectomies are not eligible for screening through the High Risk OBSP.

As of July 1, 2022, nurse practitioners can complete and approve the High Risk OBSP Requisition Form. This requisition form is also an implied requisition for future magnetic resonance imaging (MRI) and image-guided biopsies, as appropriate.

Once the High Risk OBSP Requisition Form and relevant supporting material is received, the High Risk OBSP site will:

1. Arrange for screening for people who are eligible for direct entry into the program; or
2. Refer people on to genetic assessment (i.e., counselling and/or testing) to determine if they are eligible for the program.

The High Risk OBSP site will recall people annually if their results are normal. If screening results are abnormal, the High Risk OBSP site will arrange for follow-up testing.

Genetics clinics are responsible for completing genetic assessments to determine eligibility for screening through the High Risk Ontario Breast Screening Program (OBSP).

Risk assessments (using the IBIS or CanRisk risk assessment tools) should be completed by genetics clinics to ensure consistent and standardized care for everyone across the province. In addition to conducting the risk assessment, genetics clinics will provide genetic counselling to patients. This includes reviewing their breast cancer risk score, as well as discussions about genetic testing (if appropriate), personal risk factors, family history and options for screening and prevention of breast cancer.

As a primary care provider, you can help facilitate an accurate breast cancer risk assessment by completing the High Risk OBSP Requisition Form and providing relevant supporting documentation along with the referral.

When a person visits a genetics clinic, they meet with a genetic counsellor to review their personal and family history,  and discuss any implications to their health. Genetics clinics use the IBIS and CanRisk breast cancer risk assessment tools to determine if someone is eligible for screening through the High Risk Ontario Breast Screening Program. The IBIS and CanRisk risk assessment tools assess the probability of developing breast cancer, as well as the probability of carrying a pathogenic or likely pathogenic gene variant.

If a person is eligible for genetic testing, they will be offered the test. For this test, their blood is drawn and sent to a lab for processing. Once the lab results come back, the person returns to the genetics clinic to discuss their results and their risk mitigation options, if appropriate.

Staff at genetics clinics are trained to assess and counsel people who may benefit from screening through the High Risk Ontario Breast Screening Program (OBSP) based on their personal and family history. They are aware of the sensitive nature of this consultation and can support people through the assessment process. People who choose not to undergo a genetic assessment and do not meet the criteria for direct entry (Category A) into the High Risk OBSP will not be eligible for the program. Please refer to the High Risk OBSP Requisition Form for Category A criteria.

Genetics clinics are responsible for communicating genetic assessment results to patients and their primary care provider. Please note that wait times for genetic assessments vary across the province. If genetic testing was completed as part of the genetic assessment, it may take up to several months for someone to receive their results.

The High Risk Ontario Breast Screening Program site is responsible for communicating breast screening results to participants and their primary care provider.
 

Annual mammography and breast MRI, (or screening breast ultrasound if breast MRI is not medically appropriate) is the recommended standard of care for screening women, trans and nonbinary people in the High Risk OBSP because these two tests complement each other.

For people at high risk of breast cancer, screening with mammography alone has limitations. The addition of MRI is better able to find breast cancer (higher sensitivity) but is not as good as mammography in identifying people without breast cancer (lower specificity). As well, the quality of imaging produced by MRI is not affected by breast density.

Therefore, using a combination of mammography and breast MRI to screen participants in the High Risk OBSP helps to address the limitations of each test and identify more breast cancers than using mammography or breast MRI alone.