Harmonization of clinical practice guidelines for primary prevention and screening: actionable recommendations and resources for primary care

Background Clinical practice guidelines (CPGs) synthesize high-quality information to support evidence-based clinical practice. In primary care, numerous CPGs must be integrated to address the needs of patients with multiple risks and conditions. The BETTER program aims to improve prevention and screening for cancer and chronic disease in primary care by synthesizing CPGs into integrated, actionable recommendations. We describe the process used to harmonize high-quality cancer and chronic disease prevention and screening (CCDPS) CPGs to update the BETTER program. Methods A review of CPG databases, repositories, and grey literature was conducted to identify international and Canadian (national and provincial) CPGs for CCDPS in adults 40–69 years of age across 19 topic areas: cancers, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, hepatitis C, obesity, osteoporosis, depression, and associated risk factors (i.e., diet, physical activity, alcohol, cannabis, drug, tobacco, and vaping/e-cigarette use). CPGs published in English between 2016 and 2021, applicable to adults, and containing CCDPS recommendations were included. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool and a three-step process involving patients, health policy, content experts, primary care providers, and researchers was used to identify and synthesize recommendations. Results We identified 51 international and Canadian CPGs and 22 guidelines developed by provincial organizations that provided relevant CCDPS recommendations. Clinical recommendations were extracted and reviewed for inclusion using the following criteria: 1) pertinence to primary prevention and screening, 2) relevance to adults ages 40–69, and 3) applicability to diverse primary care settings. Recommendations were synthesized and integrated into the BETTER toolkit alongside resources to support shared decision-making and care paths for the BETTER program. Conclusions Comprehensive care requires the ability to address a person’s overall health. An approach to identify high-quality clinical guidance to comprehensively address CCDPS is described. The process used to synthesize and harmonize implementable clinical recommendations may be useful to others wanting to integrate evidence across broad content areas to provide comprehensive care. The BETTER toolkit provides resources that clearly and succinctly present a breadth of clinical evidence that providers can use to assist with implementing CCDPS guidance in primary care. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-024-02388-3.


Background
Turning the tide on chronic disease is a major health system priority and integral to improving health outcomes, services, and costs.Seventy-three percent of Canadians 65 years of age and older have at least 1 of the 10 most common cancers and/or chronic diseases [1].Many of these could be prevented through management of modifiable risk factors and early detection through screening [2].
Primary care provides the first contact for patients in the healthcare system and therefore is an ideal setting to implement cancer and chronic disease prevention and screening (CCDPS) in Canada.Unfortunately, a substantial gap exists between clinical recommendations for CCDPS and actual practice [2][3][4][5][6].Due to a fragmented healthcare system and provider time constraints, implementation of guidelines tends to focus on recommendations for specific organ systems, medical conditions, or single risk factors [6,7].Initiatives such as the Canadian Cardiovascular Harmonized National Guidelines Endeavour (C-CHANGE) [8][9][10] and the Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care (BETTER) program [6,11] exemplify efforts to present compilations of highquality, evidence-based recommendations across multiple conditions in a way that is accessible and actionable by primary care providers (PCPs).
The BETTER program [12], with over 15 years of indepth study, has developed a novel, comprehensive approach to CCDPS in primary care based on the Chronic Care Model (CCM), which identifies essential elements needed to provide comprehensive, proactive care for patients with chronic conditions from health promotion to disease management [13][14][15].This approach introduces an enhanced role, the Prevention Practitioner (PP), typically undertaken by a clinician not responsible for ongoing care decisions or routine care.The PP works directly with patients to determine which CCDPS actions they are eligible to receive, and through a process involving shared decision-making and S.M.A.R.T. (specific, measurable, attainable, realistic, time-bound) goal setting, develops a unique, personalized "prevention prescription" with each patient [16].The evidence-based prevention prescription is rooted in harmonized, high-quality CCDPS guidelines and tailored to patients based on their medical history, risk factors, and family history.This cost-effective intervention has been demonstrated to improve uptake of CCDPS actions in urban primary care settings as compared to usual care [2] and similar improvements have been observed in rural and remote communities [17] and public health settings [18] across Canada.In this paper, we describe the rigorous process undertaken to synthesize and harmonize high-quality CCDPS clinical practice guidelines (CPGs) to update the clinical recommendations used in the BETTER program.This work was part of the Building on Existing Tools to Improve Cancer and Chronic Disease Prevention and Screening in Primary Care for Wellness of Cancer Survivors and Patients (BETTER WISE) project, a multi-provincial cluster randomized controlled trial (cRCT) [19].The results from the BETTER WISE trial, including patient-level outcomes to assess the effectiveness of the approach and qualitative findings describing the impacts of the global pandemic of coronavirus disease 2019 (COVID-19) on the trial and overall prevention and screening services in primary care, are reported elsewhere [20][21][22].We also describe the updated BETTER toolkit, a unique set of resources and tools aimed at supporting prevention of multiple cancers and chronic conditions in the primary care setting.Refinement of the toolkit was undertaken due to changes to the clinical evidence since its last iteration and to include new content areas informed by emerging evidence and feedback received from end-users.The BETTER toolkit informs the PP role and provides PCPs with accessible evidence-based clinical practice tools to address CCDPS.

Overview of the evidence review and CPG harmonization process
The process used to search, identify, appraise, synthesize, and harmonize CPGs for the BETTER program builds on our previous work [6,11], and involved the development of a compilation of robust CCDPS recommendations across the targeted conditions and risk factors while ensuring these were actionable and implementable in diverse settings across Canada.The clinical recommendations previously included were appliable to patients 40-65 years of age and encompassed the following areas: 1) cancers-breast, cervical, colorectal, lung and prostate; 2) chronic diseases -diabetes, cardiovascular disease, and obesity; 3) other conditions -depression; and 4) lifestyle risk factors -diet, physical activity, and alcohol and tobacco use.As described elsewhere [6,11], implementation science theories, models, and frameworks were used to inform the BETTER program and the approach undertaken to update the clinical evidence for the program to ensure that these recommendations were relevant, practical, feasible, and implementable in primary care settings.
The BETTER evidence review and CPG synthesis/harmonization process involved 3 main phases: 1) evidence review and identification of high-quality CPGs; 2) guideline synthesis and harmonization to standardize recommendations; and 3) refinement of the BETTER toolkit.These 3 phases were conceptualized within the Canadian Institutes of Health Research (CIHR) knowledgeto-action process model, a conceptual framework that depicts the process of knowledge translation as a continuous cycle with knowledge creation at the core and the activities related to "action" or application/implementation of created knowledge at the periphery [6,11,19,23].This model has been identified as an implementation tool that can guide the process of translating evidence into practice [24].This process culminated in the refinement and creation of knowledge resources and tools to support primary prevention and screening for relevant cancers and chronic diseases: the BETTER toolkit.Composed of clinical tools that succinctly and visually represent the clinical recommendations used in the program as well as a collection of accessible programs and resources available to providers and patients to support CCDPS efforts, the BETTER toolkit includes: a health survey, care paths for prevention and screening, a prevention prescription, a S.M.A.R.T. goals sheet, and bubble diagrams which provide CCDPS targets for patients at average risk.

Review of the literature
An evidence review involving a targeted search strategy developed by the Centre for Effective Practice (CEP) [25] (a non-profit independent knowledge translation organization based in Toronto, Canada,) was conducted for 19 topics related to CCDPS in the following areas: 1) cancers-breast, cervical, colorectal, lung and prostate; 2) chronic diseases -chronic obstructive pulmonary disease (COPD), diabetes, cardiovascular disease, hepatitis C, obesity, and osteoporosis/bone health; 3) other conditions -depression; and 4) lifestyle risk factors -diet, physical activity, alcohol, cannabis, drug, tobacco, and vaping/e-cigarette use.

Search criteria and search strategy
The search updated the previous evidence review, which was conducted in 2016 [6,11], and was limited to CPGs published in English between 2016 and 2021 focused on adults.Priority was given to Canadian guidelines (national and provincial -Alberta, Ontario, Newfoundland and Labrador, and Nova Scotia as these jurisdictions were engaged in the BETTER WISE project or actively implementing the BETTER program).Guidelines were excluded if they solely provided recommendations for diagnosis, treatment, or management of cancer, and not screening or prevention of cancer, or if they were not applicable to the primary care setting as the focus of the BETTER program is primary prevention and screening of cancer and chronic disease in primary care.
The 4-step search strategy used by the CEP to identify CPGs for each topic is described in Table 1.Specific details regarding the search strategies for each topic are provided in Appendix 1. Titles and abstracts of CPGs identified through this search were reviewed for relevance, and promising results were retrieved in full-text for further consideration.

CPG quality appraisal
Full-text guidelines underwent an initial quality appraisal using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Instrument, the purpose of which is to evaluate the process of CPG development and quality of reporting [26].To pass the initial quality check performed by trained reviewers at the CEP, a guideline had to include clear recommendations linked to levels of evidence and be based on a systematic review of the literature (items 7 and 12 in the "Rigour of Development" domain of AGREE II).CPGs that fulfilled these criteria were appraised independently by 2 reviewers using the full AGREE II, consisting of 23 items across 6 domains and an overall quality score, in preparation for Phase 2. These appraisals were subsequently reviewed by a lead expert reviewer and reconciled into a single score to provide an overall summary of the methodological quality of each guideline.
A review was also conducted to identify guidelines published by provincial organizations in the 4 jurisdictions of interest.Provincial guidance documents published between 2016 and 2021, regardless of whether or not they passed the "Rigour of Development" criteria described above, were included for review in Phase 2 because of their relevance to the local context, as the BETTER program was actively being implemented in these jurisdictions and we needed to ensure that the recommendations incorporated into the program would be actionable, accounting for regional differences.The recommendations from the included high-quality CPGs and key provincial guidelines were extracted into evidence tables for review in Phase 2, which also included each recommendation's level of evidence and the strength of recommendation, where available.

Phase 2: guideline synthesis and harmonization to standardize recommendations
The BETTER Clinical Working Group (CWG) was convened for 5 months (January to May 2022) to review the international and Canadian CPGs identified through Phase 1 and to integrate recommendations and resources for inclusion in the BETTER program (see Fig. 1).Members of the CWG included patients, health policy experts (regional, provincial, federal; government and non-government), PCPs, content experts (e.g., cancer, obesity, diabetes, lifestyle risk factors), and primary care and primary healthcare researchers who shared their perspectives to synthesize and harmonize the identified CPGs into clear, actionable recommendations.In this phase, the CWG was divided into 3 topic-review teams based on their area(s) of expertise: 1. Cancer team (5 members), focusing on breast, cervical, colorectal, lung, and prostate cancer; 2. Chronic disease team (10 members), focusing on cardiovascular disease, COPD, depression, diabetes, hepatitis C, obesity, and osteoporosis; and 3. Lifestyle risk factor team (4 members), focusing on alcohol, cannabis, drug, tobacco, and vaping/e-cigarette use, diet, and physical activity.
Topic-review teams worked independently to evaluate each recommendation within their ambit for clarity, actionability, and to determine if the recommendation could be operationalized in the primary care setting based on the following criteria: 1) focus on primary prevention and screening; 2) relevance to adults 40-69 years of age, the age group to which most CCDPS recommendations apply; and 3) applicability to primary care settings across different Canadian jurisdictions.Specifically, team members voted "yes" (i.e., include in BETTER), "no" (i.e., do not include in BET-TER) with rationale for any "no" votes clearly documented, and "maybe" (i.e., further discussion required).The topic-review teams presented their assessments to the larger CWG at scheduled meetings.Any disagreements or ambiguities were resolved through discussion until consensus for inclusion or exclusion was reached.In cases where multiple individual recommendations for a topic were endorsed for inclusion, these were combined, harmonized, and simplified when appropriate, through group discussion.Recommendations emerging from provincial guidance documents that did not meet the initial quality appraisal criteria were reviewed and harmonized alongside those derived from the high-quality CPGs to ensure that recommendations were actionable in different contexts.Most of these provincial recommendations were consistent with those already incorporated, though there were some regional differences.For example, provincial guidance differed in regard to the criteria that should be used to determine the appropriate screening modality for an individual at elevated risk for colon cancer, all of which were reasonable based upon the high-quality guidance.Any jurisdictional nuances, such as differences in frequency of screening, were captured and indicated in the harmonized recommendations.Across all topics, individual and family risk factors (e.g., genetics, preexisting medical conditions [personal or family], ethnic background) were incorporated to ensure that recommendations specific to high-risk and average-risk individuals were clear [11].
In Step 1, each topic-review team reviewed the international and national CPG recommendations identified through Phase 1 (see Fig. 1).As part of this first step, members were also asked to identify any high level international and national guidelines of which they were aware that were not included in their review.In Step 2, international and national clinical recommendations that reached consensus for inclusion were compared with provincial recommendations and policies to determine whether they were implementable in the 4 Canadian provinces of interest.For example, at the time of these discussions, the use of low-dose computed tomography (CT) scan for lung cancer screening, flexible sigmoidoscopy for average-risk colorectal cancer screening, and HPV testing for cervical cancer screening each varied among the different provinces.Any provincial clinical recommendations that differed from those already included and which were necessary to comply with a province's approach to CCDPS were accepted for inclusion, noting the specific relevance to that province.
Finally, in Step 3, the topic-review teams reviewed the tools and resources previously included in the BET-TER program [6,11] alongside new tools/resources that were identified through our search strategy.Teams reflected on the tools' clarity (i.e., use of unambiguous, understandable language), applicability (e.g., to diverse populations, patients 40-69 years of age), and clinical usefulness (e.g., for primary care settings and PPs).Validity was also considered for assessment tools (e.g., Patient Health Questionnaire 2-item (PHQ-2) [27] screen for depression, QRISK3 [28] cardiovascular disease risk calculator, and General Practice Physical Activity Questionnaire (GPPAQ) [29] screen for aerobic physical activity).Through this process, teams assembled updated, relevant, and useful clinician and/or patient-facing tools and resources to support the implementation of recommendations.

Phase 3: refinement of the BETTER toolkit
The final CPG recommendations selected for inclusion were synthesized and harmonized using succinct, clear, and actionable language while considering PCPs' and PPs' scope of practice, role in patient care, and linkages to community resources.These recommendations were then used to refine the existing BETTER toolkit to assist PCPs and PPs with the implementation of recommendations.The toolkit provides PCPs and patients with the tools and resources needed to: 1) evaluate the individual patient's risks for cancer and chronic disease, 2) identify CCDPS action(s) relevant to the patient, and 3) educate and prevent cancer and chronic diseases through a process of shared decision-making, resulting in a personalized 'prevention prescription' and actionable goals for the patient [11].

Search results and clinical recommendations
The titles and abstracts of 6,038 CPGs identified through the search strategy were reviewed for relevance to CCDPS and primary care settings.Of these, 243 guidelines were retrieved, considered in full-text, and underwent initial quality appraisal.CPGs that passed the initial quality appraisal and that were further assessed using the full AGREE II received an overall quality score between 0 and 7, where a higher score indicates higher overall quality, with 7 indicating a CPG of the highest quality [26].Thirteen percent of the CPGs assessed using the full AGREE II received an overall quality score of 4, 28% received a score of 5, 55% received a score of 6, and 4% received a score of 7 (see Appendix 3 for full AGREE II scores, including scores for overall quality).After excluding those that did not meet the inclusion or quality criteria, Phase 1 yielded 51 CPGs which provided current, relevant CCDPS recommendations for the general population (see Fig. 2).A summary of the search results is provided in Appendix 2.
Supplementary searches identified an additional 22 guidelines by provincial organizations in Alberta, Ontario, Nova Scotia, and Newfoundland and Labrador, which were also reviewed by the BETTER CWG in Phase 2. Discussions within topic-review teams and the larger CWG determined that 3 of the new topics proposed (COPD, hepatitis C, and drug use) did not have sufficient evidence for inclusion (e.g., lack of prevention and screening CPGs for the topic, focus on diagnosis, treatment, and/or management) and thus were excluded from the final recommendations, resulting in 16 topics included in the program -3 new: osteoporosis/bone health, cannabis use, and vaping/e-cigarette use.Notably, there were no CPGs published between 2016 and 2021 that met our criteria for inclusion on the topic of depression.The decision made by the CWG was to include a recommendation to screen for depression since this was already a part of the BETTER program.The final recommendations and resources/tools included in the BETTER program are presented in Tables 2 and 3, respectively.

Updates to the BETTER toolkit
The updated BETTER toolkit consists of clinical practice tools and resources that help assess patients, support patient education, shared decision-making, and self-management, including regional, provincial, and national resources that patients can access (via a provider or self-referral) to help them achieve their health goals.The BETTER toolkit includes:  2).Represented as care paths for each CCDPS topic, the maps are intended to help PCPs determine a patient's eligibility for CCDPS as well as appropriate next steps, including frequency of screening and recommended screening modality based on personal medical history, family history, and genetics.2. A patient survey, which captures a patient's detailed prevention and screening history, including lifestyle risks and family history.The survey contains validated tools (e.g., PHQ-2, GPPAQ) and documents patients' level of confidence and how prepared they are to make changes.3. The BETTER Bubble Diagrams (Figs. 5a and b), which are patient-and clinician-friendly representations of the BETTER prevention and screening maps with sex specific targets for patients at average risk.A blank version can be used as a patient-teaching tool to illustrate the patient's current health status and their risk factors for each 'bubble' to help guide the conversation.4. A prevention prescription (Fig. 6), which provides a summary of the patient's risk for cancer and chronic disease, their screening and prevention targets, and any follow-up actions that may be required.5.A goals sheet (Fig. 7) that summarizes the patient's personalized, self-directed, actionable S.M.A.R.T. goals.6.A compilation of regional, provincial, and national resources and tools for patients and PCPs to support implementation of CCDPS recommendations, inform patients, and support patients' health goals (Table 3).

Discussion
Improving CCDPS in primary care is crucial to reducing the burden of cancer and chronic disease and increasing the sustainability of the healthcare system.In this paper, we describe the development of a comprehensive suite of resources and harmonization of recommendations that support CCDPS in patients         Fig. 6 The BETTER prevention prescription CCDPS care maps with succinct, clear, actionable recommendations that translate clinical evidence to PCPs to inform patient care, a streamlined patient survey to capture a patient's prevention and screening history, and agenda setting tools to help set expectations for discussions with patients.The BETTER tools can be used at point of care to identify outstanding CCDPS actions and provide opportunities to address prevention and screening comprehensively, across many cancers and chronic diseases, with individual patients while considering their health goals, values, and preferences.Initiated by the 1995 Institute of Medicine report Setting Priorities for Clinical Practice Guidelines [30], several decades of investment have resulted in robust methods to create high-quality guidelines; however, to achieve intended outcomes, CPGs must be implementable in real-world practice.The BETTER program has demonstrated that nuanced clinical tools can be designed to facilitate decisionmaking between PCPs and patients across multiple chronic diseases and lifestyle factors [2,17,18].In this evidence Fig. 7 The BETTER goals sheet review, we extended our topic scope, included health policy makers and patients in the evidence synthesis process, and tailored the included clinical recommendations for implementation in 4 Canadian provinces.The BETTER program process, grounded in the intersection between clinical practice, health policy, and systematic evidence, addresses a needed step to ensure feasible implementation of CPGs.
We recognize that our approach has limitations.Our population of interest was limited to adults 40-69 years of age with a focus on CCDPS and related risk factors.However, we believe that our approach may be useful to extend the work to different age groups, secondary prevention, and chronic disease management.All guidelines included in our review were published between 2016 and 2021 and as a result, recommendations from recent research, including guidelines published following the COVID-19 pandemic, would have been missed.For example, while the BETTER toolkit was being refined, two Canadian CPGs relating to cardiovascular disease [9] and alcohol use [31] were published in 2022 and 2023, respectively.To ensure that the recommendations used in the BETTER program remained clinically relevant, a subset of the BETTER CWG reviewed the CPGs and decided to include their recommendations.This highlights the importance of periodically and consistently reviewing the existing evidence to ensure that clinical practice is informed by the best current guidance.Though the clinical guidance was tailored to 4 jurisdictions in Canada and may not be applicable to other global jurisdictions or Canadian regions, the national recommendations included are relevant to a broad Canadian audience, and the tailoring methods used may prove useful to others when incorporating guidance for use in their context.
We developed a structured approach to synthesizing and blending CPG recommendations for application into primary care settings as described in our previous work [6,11].The process involved members of the Clinical Working Group sharing their diverse perspectives during group discussions to reach consensus for inclusion, harmonization, and synthesis of clinical recommendations extracted from high-quality CPGs.Though this approach is novel and not as recognized as other methodological approaches, such as the Delphi Method, it may still be used to guide and inform others on how to incorporate current clinical guidance into practice.Lastly, members of the Clinical Working Group were not asked to declare possible conflicts of interest prior to their involvement in the evidence review process; however, they represented diverse groups (PCPs, other healthcare professionals, patients, health policy specialists, content experts, researchers) from 4 Canadian Provinces, many of whom are authors on this manuscript and who have declared any competing interests here.

Conclusions
The process used by the BETTER program to synthesize and harmonize international and Canadian CPG recommendations resulted in a suite of tools and resources to support CCDPS in primary care practice.This approach incorporates diverse perspectives of patients, PCPs, and health policy makers to ensure usability in real-world practice.Used together, the BETTER toolkit provides resources and tools that clearly and succinctly express the breath of high-quality clinical evidence that was synthesized into actionable recommendations to help inform patient care and enable primary care providers to address CCDPS comprehensively in their clinical settings.The methods used may be applicable to others contemplating integrating evidence across broad content areas in primary care to help facilitate comprehensive care.The updated BETTER toolkit is available to PCPs and interprofessional team members practicing in Canadian primary care settings through the BETTER program [12].

1 .
The BETTER Primary Prevention and Screening Maps (Figs. 3a and b, 4a, and b), depict the harmonized clinical recommendations included in the BET-TER program for adults 40-69 years of age (summarized in Table

Fig. 2
Fig.2PRISMA diagram *Guidelines reviewed in full text.Initial quality appraisal completed using two key items assessing 'Rigour of Development' in the AGREE II instrument (items 7 and 12).A score of 5 or more in these domains typically indicates that the criteria is satisfied, however, guidelines with domain scores of least a 3 were considered for further appraisal** Appraised using full, 23-item, AGREE II Instrument.An additional 22 provincial guidelines were identified and included for review in Phase 2

Fig. 3 aFig. 4 aFig. 5 a
Fig. 3 a The BETTER primary prevention and screening care map -cancer (front).B The BETTER Primary Prevention and Screening Care Map -Cancer (back)

Table 1
Four-step search process for high-quality clinical practice guidelines a The Canadian Partnership Against Cancer has ceased funding for the Cancer Guidelines Database and it is no longer available online 1) Topic-specific Databases: • Ontario Health: Cancer Care Ontario: https:// www.cance rcare ontar io.ca/ en/ guide lines-advice Canadian Partnership Against Cancer Guidelines Database a : https:// www.partn ershi pagai nstca ncer.ca/ work-with-us/ procu rement/ procu rement-bid/

Table 2
Summary of primary prevention and screening recommendations for adults 40-69 years of age Untested first-degree relative of a carrier of such a gene mutation OR o FH consistent with a hereditary breast cancer syndrome and estimated personal lifetime cancer risk > 25%OR o Women who received chest radiation (not chest x-ray) before age 30 and at least 8 years previously (e.g. as treatment for Hodgkin's Lymphoma) o AB -women meeting any of the criteria above should receive an annual MRI, mammogram, and clinical breast exam starting at age 30 • Consider referral to genetics if any of the following: women meeting any of the criteria above should be refered to the Ontario Breast Screening Program • For women with one or two first-degree relatives with invasive breast cancer, but who do not meet the criteria for referral to genetics or MRI screening: o Annual mammography starting 5 to 10 years younger than the youngest case in the family, but no earlier than age 25 and no later than age 40 o Annual clinical breast examination starting at age 25 o Personal and/or FH of ovarian cancer any age (epithelial) o Family member with BRCA1/BRCA2 mutation o High risk ethnicity (e.g.Ashkenazi Jewish, Icelandic) + personal and/or FH of hereditary breast and ovarian related cancers (breast, ovarian, male breast, pancreatic, prostate with Gleason Score ≥ 7) o ON -

Table 2
(continued) Adults at increased (high) risk should be screened as follows: o Single first degree relative with CRC at age ≥ 60 ▪ AB -FIT starting at 40 ▪ NL -FIT starting at 50 ▪ NS -FIT or FOBT or colonoscopy starting at 40 ▪ ON -Colonoscopy every 5 years or as directed starting at age 50 or 10 years younger than the youngest case in the family o Single first degree relative with CRC at age < 60 or two first degree relatives with CRC at any age ▪ AB -Colonoscopy starting at 40 or 10 years younger than the youngest case in the family (repeat as indicated) ▪ NL & ON -Colonoscopy starting at 50 or 10 years younger than the youngest case in the family ▪ NS -Colonoscopy every 5 years starting at age 40 or 10 years younger than the youngest case in the family o Single second degree relative with CRC diagnosis at age < 50 -colonoscopy starting at 50 (repeat as directed by findings) o Personal history of Crohn's, UC, FAP, HNPCC, LS -colonoscopy at discretion of GI o Carrier of mutation in LS gene or untested first degree relative of a LS mutation carrier -colonoscopy every 1-2 years starting at age 20-25 or 2-5 years younger than the youngest case in the family if that diagnosis was made at age < 25, whichever is earlier • Refer individuals with suspected LS to PCP to discuss genetics referral Of African, Arab, Asian, Hispanic, Indigenous, or South Asian descent o Obesity (BMI ≥ 30) or abdominal obesity (High waist circumference)

Table 2
(continued) Screen for lung cancer among adults ≥ 55 years of age with at least a 30 packyear smoking history, who currently smoke or quit smoking less than 15 years ago, with low-dose CT scan every year up to three consecutive years o ON -adults ≥ 55 years of age with at least a 20-year smoking history should be referred to PCP for referral to the Ontario Lung Screening Program • Screening should only be done in health care settings with access to screening resources, expertise in early diagnosis and treatment of lung cancer Nutrition/Diet Screening Recommendations [9, 33, 36, 47, 48, 68, 77, 78] • All adults: screen for healthy eating behaviours • Encourage Mediterranean-style diet with variety of vegetables, fruit, healthy proteins and unsaturated fats • Encourage limiting intake of refined sugar • In individuals at risk for type 2 diabetes encourage dietary patterns used to reduce risk of diabetes: Mediterranean-style, DASH, AHEI Obesity Screening Recommendations [79-82] • For individuals who have indicated willingness to discuss weight and after asking permission, screen all individuals with height, weight, BMI o For those with BMI ≥ 30 refer to PCP for discussion of root cause assessment, lifestyle, risk stratification with Edmonton Obesity Staging Scale, optimization of medications, and need for referral • Measure WC if BMI 25.0-29.9o For those with high WC refer to PCP for discussion of root cause assessment, lifestyle, risk stratification with Edmonton Obesity Staging Scale,

Table 2 (
continued) ACE Angiotensin converting enzyme, ACR Albumin to creatinine ratio, AHEI Alternate Healthy Eating Index, ARB Angiotensin II receptor blocker, BMI Body mass index, BRCA Breast cancer gene, CAD Coronary artery disease, CKD Chronic kidney disease, CRC Colorectal cancer, CVD Cardiovascular disease, CT Computed tomography, DASH Dietary Approaches to Stop Hypertension, DM Diabetes mellitus, DXA/DEXA Dual energy x-ray absorptiometry, eGFR estimated glomerular filtration rate, FAP Familial adenomatous polyposis, FBS Fasting blood sugar, FBG Fasting blood glucose, FH Family history, FIT Fecal immunochemical test, FOBT Fecal occult blood test, GI Gastroenterologist, GnRH Gonadotropin-releasing hormone, HAART Highly active antiretroviral therapy, HbA1c Hemoglobin A1c, HNPCC Hereditary non-polyposis colorectal cancer, HTN Hypertension, HPV Human papillomavirus, KD Kidney disease, LS Lynch syndrome, MRI Magnetic resonance imaging, NL Newfoundland and Labrador, NS Nova Scotia, ON Ontario, PCP Primary care provider, PHQ-2 Patient Health Questionnaire 2-item, PSA Prostate-specific antigen, PVD Peripheral vascular disease, SSRI Selective serotonin reuptake inhibitor, UC Ulcerative colitis, WC Waist circumference

Table 3
BETTER program resources and tools list