Evidence of meeting #122 for Health in the 44th Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was women.
A recording is available from Parliament.
5 p.m.
Liberal
The Chair Liberal Sean Casey
I call this meeting to order.
Welcome to meeting number 122 of the House of Commons Standing Committee on Health.
Before we begin, I'd like to ask all members and other in-person participants—
5 p.m.
Bloc
Luc Thériault Bloc Montcalm, QC
Point of order, Mr. Chair
I'm not getting interpretation. The sound isn't loud enough. I've got the volume three quarters of the way up right now and I can't hear the interpretation.
5 p.m.
Bloc
5 p.m.
Liberal
5:05 p.m.
Liberal
The Chair Liberal Sean Casey
I call the meeting back to order.
Once again, welcome to meeting number 122 of the House of Commons Standing Committee on Health.
Before we begin, I'd like to ask all members and other in-person participants to consult the cards on the table for guidelines to prevent audio feedback incidents. Please take note of the following preventative measures in place to protect the health and safety of all participants, including the interpreters. Please use only the black, approved earpiece. The former grey earpieces must no longer be used. Please keep your earpiece away from all microphones at all times. When you're not using your earpiece, please place it face down on the sticker placed on the table for this purpose.
Thank you for your co-operation.
In accordance with our routine motion, I'm informing the committee that all remote participants have completed the required connection tests in advance of the meeting.
Pursuant to Standing Order 108(2) and the motion adopted on April 11, 2024, the committee is commencing its study of breast cancer screening guidelines.
I'd like to welcome our panel of witnesses.
We have, appearing as an individual, Dr. Michelle Nadler, breast medical oncologist and implementation scientist; representing Breast Cancer Canada, Kimberly Carson, CEO; representing the Coalition for Responsible Healthcare Guidelines, Dr. Shiela Appavoo, chair; and representing Dense Breasts Canada, Dr. Paula Gordon, volunteer medical adviser, clinical professor at the University of British Columbia.
To all of our witnesses, thank you for bearing with us. We had some technical difficulties and votes that caused the start to be delayed. We have resources until 6:30 eastern. That's when we will adjourn.
I understand Ms. Carson has another obligation that will require her to leave at 5:30, so we're going to start off the opening statements with Ms. Carson to make sure that we get it in.
Ms. Carson is here on behalf of Breast Cancer Canada.
Welcome to the committee. You have the floor.
5:10 p.m.
Kimberly Carson Chief Executive Officer, Breast Cancer Canada
Thank you.
Thank you very much for having me here and for the opportunity to speak on the important topic that this is.
My name is Kimberly Carson, and I'm the chief executive officer of Breast Cancer Canada.
Breast Cancer Canada is the only national organization that's clearly focused on funding breast cancer research, and we've been doing that since 1991. We advocate for more funding in breast cancer research and diagnostics and precision oncology, and certainly the task force recommendation on May 30 is of great concern to us.
Despite calls from patient advocates like me at Breast Cancer Canada and from health care providers and patients across Canada to lower the age of the systematic breast cancer screening program to 40, the task force remained with the guidelines of 50 to 75. Obviously, we have a number of research projects that go against this recommendation.
We believe that the screening should be lowered to a lower age because we know for sure that detecting it early saves lives. When it's detected early and it hasn't spread—it has not become metastatic—the five-year relative survival rate is close to 99%. Making that diagnosis at an earlier age and stage, and not delaying treatment, obviously increases the survival rate.
The other thing I would like you to consider is that there are many populations where the risk is even higher at a younger age, including Black and Hispanic women. For example, triple-negative is one of the more aggressive forms of breast cancer and tends to be at higher rates in Black and Hispanic women, and certainly younger, at 10% to 20% of the diagnoses. The other consideration is women with dense breasts, who are obviously more at risk with a delayed diagnosis and less chance of MRI screening.
All of this leads to a burden on the health care system.
There are steps we could take certainly to reduce that burden. An earlier diagnosis reduces the number of systemic treatments, the complexity of the treatments, the repercussions, the overtreatment with chemotherapy, surgery and radiation.
For patients who receive stage three or stage four therapy, their therapy will go on over a longer period of time and has a greater impact—greater disability—as opposed to women who would perhaps be diagnosed at a younger age and an earlier stage, where they could go back into the workforce or remain employed at the same time and continue to care for their families and contribute to society.
Certainly, earlier screening at the age of 40 is going to play a very important role for those health outcomes for our patients across Canada.
We also see some inequities in breast cancer screening. There are a number of provinces where the screening is at 50, which makes it inaccessible for women at a lower age, but then we see some provinces where they can self-refer into a program at a younger age.
The other thing I would add is that women need to be prompted and reminded that they're not health care professionals and it's certainly up to the task force to recommend the screening age.
The other thing Breast Cancer Canada would like to see is review in a more timely manner. There are new therapies and new novel treatments coming out. Right now, we're talking about mammography and screening, but in the future there will be things like blood tests and new technologies. We certainly would like to see that timing get a little quicker—at least once every two years—so that we would have the opportunity to take advantage of all of the new breakthroughs in technology that we have.
We have some amazing breast cancer researchers right here in Canada, and we should really be listening to what they have to say to help us provide that quality and equity across Canada and help to save more lives through breast cancer research.
Thank you very much for your time, and thanks for taking a moment to listen to me.
5:10 p.m.
Liberal
The Chair Liberal Sean Casey
Thank you, Ms. Carson.
Next is Dr. Michelle Nadler, breast medical oncologist and implementation scientist.
Welcome to the committee. You have the floor.
5:10 p.m.
Dr. Michelle Nadler Breast Medical Oncologist and Implementation Scientist, As an Individual
Thank you for the opportunity to present to the committee today, and thank you for taking the time to review an issue so important to women's health.
I'm a breast medical oncologist in Toronto. I speak with patients and their families about breast cancer every single day, and I see how this disease and its treatment impacts them. We are all committed to ensuring the best possible outcomes for women and for people with breast cancer.
My academic focus is in knowledge translation or guideline implementation. Through this work, I was invited to participate as a knowledge expert on the task force. The 2024 draft guidelines state as follows:
Breast cancer screening is a personal choice.
Women aged 40 to 74 should be provided information about the benefits and harms of screening to make a screening decision that aligns with their values and preferences. If someone in this age range is aware of this information and wants to be screened, they should be offered mammography screening every 2 to 3 years.
This information should be accessible and shared in absolute numbers. It should include how age, family history, race and ethnicity, and breast density (if known) may impact the benefits and harms of screening.
The task force invited four experts: a medical oncologist, a radiation oncologist, a radiologist and a breast oncology surgeon. There were two to three patient partners. All provided input on the three main systematic review questions: inclusion criteria for each study, outcomes of importance and protocols. Randomized trials and observational and quasi-experimental studies were included.
The task force investigated, among others, the following outcomes: breast cancer mortality, stage distribution and treatment morbidity. We often hear about the benefits of early detection. We are told that if we can find cancer earlier, there is less chance of death from breast cancer or less intensive therapies. It might be surprising, but early detection is not always necessarily an assurance of either of these. More and more, we know that the biology of disease or how aggressive the cancer is factors into prognosis.
Outcomes of harms, including additional testing showing no cancer and overdiagnosis, were also looked at. Overdiagnosis means the biopsy-proven detection of a pre-cancer or cancer that would otherwise never have caused the individual any symptoms or problems in their lifetime. This occurs for older women and is also well documented in younger women.
All studies that met inclusion criteria and additional studies submitted to the portal were reviewed by the evidence synthesis team. The team included two radiology experts and a GP-oncologist. All studies were rated for certainty, i.e., how likely they are to represent the truth, through something called the GRADE methodology. Once the data analysis was completed, the evidence was displayed to our working group, and we reviewed and discussed the data.
In key question three, the task force undertook a systematic review related to the values and preferences for women ages 40 to 74 for screening. This showed that the majority of women aged 40 to 49 felt that the harms outweigh the benefits for screening; however, members of the task force working group agreed that there is large variability in women's values.
The task force met separately to look at the evidence in totality, looking at all included study results and comparing them. One of the criticisms of the task force is that certain studies were not considered. It is normal in the scientific method of a systematic review to question why some results are outliers compared to others. This does not mean that they are dismissed. The task force cannot base its recommendation on only one or two studies; they must look at the evidence in totality.
Everything above that I have stated are the facts as I know them. To be clear, what follows is my personal opinion.
I think it is commendable to have guidelines state specifically that personal risk factors, benefits and harms should be clearly communicated to women to inform a decision and that the decision they make should be respected.
The alternative suggested by many critical of the task force is to systematically screen all women starting at 40. I have concerns that this is not respectful to the range of values that different women hold about the benefits and harms of screening. Some women will want to screen, and others won't. Both sets of values should be respected.
I went into this process with an open mind of what the data would demonstrate. I truly believe that the task force went into this with open minds as well. The science shows us that there are both benefits and harms to breast screening. In individuals not at high risk, there is equipoise and substantial uncertainty. There is more uncertainty than the public may think.
Sometimes science gives us an answer we didn't expect or we don't want, but we should still listen to it. In medical practice, when there is close equipoise or uncertainty, the best thing to do is have a shared discussion with each individual patient in front of us and respect their decision.
Thank you.
5:15 p.m.
Liberal
The Chair Liberal Sean Casey
Thank you, Dr. Nadler.
Next, representing the Coalition for Responsible Healthcare Guidelines, we have Dr. Sheila Appavoo. Thank you for being with us.
You have the floor.
5:15 p.m.
Dr. Shiela Appavoo Chair, Coalition for Responsible Healthcare Guidelines
Thank you for having me.
Honourable members of the health committee, thank you for convening this important study with such urgency.
I'm Dr. Sheila Appavoo, a general radiologist with an interest in breast imaging. I chair the Canadian Society of Breast Imaging's patient engagement working group. I also founded and chair the Coalition for Responsible Healthcare Guidelines.
I speak today about my serious concerns about the recent draft guidelines issued by the Canadian Task Force on Preventive Health Care regarding breast cancer screening, which recommend against screening women aged 40 to 49.
These guidelines stand in stark contrast to those provided by the U.S. task force, the Canadian Cancer Society and the majority of Canadian provinces, all of which have recognized the need to lower the screening age to 40. The Nurse Practitioner Association of Canada has also recently withdrawn its endorsement of the similar 2018 task force guidelines.
The task force decision not to routinely screen women aged 40 to 49 is biased. This stance was seemingly predetermined. The task force leadership indicated in the media in early May 2023 that there was no need to change the Canadian guidelines. This was before the evidence review began. Lo and behold, this prophecy was fulfilled almost exactly a year later.
How does the task force come to such different conclusions from the rest of the modern world? Without the context provided by the fulsome guidance of experienced content experts, they amplify harms, such as overdiagnosis and callbacks for additional imaging, and they minimize the benefits of early detection. One rarely hears the task force discussions mentioning the lives saved or mastectomies prevented by screening.
The U.S. task force has acknowledged and acted on the increasing incidence of breast cancer and racial disparities. Canadian research has found similar trends here at home, and the Canadian task force even acknowledges higher mortality in Black women in their forties, but fails them in its guidelines by begging off on a lack of evidence and abandoning common sense and the precautionary principle.
In every racial group except white women, breast cancer starts to peak in the forties, yet the task force makes little attempt to accommodate these groups. While acknowledging the influence of race, ethnicity, family history and breast density, the task force has minimized these important individualizing issues.
One of the misconceptions of the task force is that improved life expectancy is attributable to better treatment, with an implication that treatment is a substitute for early detection. This is problematic. Women with an early-stage diagnosis are far more likely to live out their full lifespan with less of the aggressive treatment, existential dread and generational trauma of a woman and her family dealing with a late-stage cancer diagnosis. Simply put, women with smaller, less advanced tumours tend to live longer and better-quality lives, and screened women tend to have smaller tumours than non-screened women.
It has been mentioned by some task force members that screening should be limited to control costs. This is a false economy. Screening is an investment, considering the cost of modern treatment. Work done by researchers in Ottawa has demonstrated that by screening annually from age 40 to 74, Canada would save around $460 million annually. The cost of treatment far outweighs the cost of screening. We cannot afford not to screen.
If instituted, the consequences of these new task force guidelines will be dire. Many young women will potentially pay with their lives. Most provinces and territories have recognized this and have allowed self-referral for women aged 40 to 49. However, the recommendation of a primary care provider is still the strongest predictor of whether a woman will actually go for screening. As long as doctors are being given the task force message that women in their forties don't need screening, many of those women won't get access.
By continuing to make the same recommendation that the task force has made since 2011, Canada's national guideline is falling further and further behind the provinces, other countries and expert recommendations. This has led to patchwork access for women across the provinces. Unfortunately, these guideline problems are not isolated to breast screening; they are part of a pattern seen in multiple other guidelines during the past 15 years of the task force's existence.
We must not allow these guidelines to stand as they are. We must have guidelines that are informed by the latest evidence and that truly serve the best interests of Canadians. With respect, looking at its record, we must dismantle and rebuild this task force.
Thank you very much for your attention to this issue.
5:20 p.m.
Liberal
The Chair Liberal Sean Casey
Thank you, Dr. Appavoo.
Finally, representing Dense Breasts Canada, we have Dr. Paula Gordon.
Welcome back, Dr. Gordon. You know the drill and you have the floor.
5:20 p.m.
Dr. Paula Gordon Volunteer Medical Advisor, Clinical Professor at University of British Columbia, Dense Breasts Canada
Thank you.
Honourable health committee members, the Canadian task force understates the benefits of screening, but they are obsessed with what they call the harms. They recommend against screening women in their forties, even though women aged 40 to 49 are 44% less likely to die of breast cancer if they have mammograms. They recommend against supplemental screening for women with dense breasts, even though many more invasive cancers would be found earlier if it were used.
I'll explain what they think the harms are. Even that term is misleading. They really are the risks or limitations.
The first is the anxiety women experience if they are recalled for additional tests after a screening mammogram and are not found to have cancer. Only about 5% of recalled women are diagnosed with cancer. That anxiety is real, but it's transient, and it pales in comparison to the anxiety a woman feels if she learns that she has an advanced cancer and that she faces the possibility of death or at least months of surgery, radiation and chemotherapy, which might have been avoided had her cancer been found earlier.
The task force gives false equivalence of this anxiety to delayed diagnosis and advanced cancer. The task force also disproportionately focuses on overdiagnosis. You just heard that this is the theoretical possibility in which a woman is diagnosed with cancer and is treated for it but dies of another cause sooner than her breast cancer would have killed her. For example, she may die of a heart attack sooner.
Overdiagnosis is much less common in younger women. They're less likely to die of other causes, and their cancers are more aggressive than are those in older women, so they grow and spread faster if untreated. In women in their forties who get breast cancer, breast cancer accounts for 91% of their deaths, but in women in their seventies, it accounts for only 48%.
Cancers do not regress if they're left untreated. They may grow quickly or slowly, but given time they will spread and kill. Doctors Wilkinson and Seely, working with Stats Canada, showed that after screening of women in their forties was stopped in response to the task force recommendations in 2011, the rate of metastatic cancer went up by 10% for both women in their forties and those in their fifties.
Overdiagnosis is only important if it leads to overtreatment. With current testing and rapidly advancing research on predicting how a given cancer will behave, oncologists can offer less aggressive treatment for some cancers, but if women choose not to be screened because of the task force's emphasis on overdiagnosis, they lose the opportunity to find their cancers early and save lives.
In their 2018 review, the task force said that the rate of overdiagnosis was 48%, based mainly on an old, flawed Canadian study that has been discredited. For the current review, overdiagnosis was 11% when that discredited study was included but only 6% when it was excluded. That 48% rate included in the decision tool created by the task force and used in shared decision-making may well have been responsible for countless deaths.
Screening is not perfect. Women should be told about the risks of being recalled and overdiagnosis, but they should not be discouraged from screening. Some members of the task force say that screening is less important because treatment is getting better, but it's not a contest. Screening and treatment are synergistic. Cancer can be treated more effectively and less aggressively when it's found earlier.
Of course, there are anecdotal studies of women with early cancer who didn't do well and women with stage three who did do well. However, it's like hearing stories about people who smoked all their lives and died at age 95 without developing lung cancer. Reliable data trumps outlier stories.
Some members of the task force claim that screening can't save the lives of women with rapidly growing cancers. That's not true. Stats Canada has shown that when triple negative cancer is detected at stage one, the five-year survival is 96%, but at stage four, it's only 7%. The stage of diagnosis does matter, and it's about more than just saving lives. Chemotherapy can often be avoided when cancer is found early. Most patients with stage one cancer don't need chemo. Most patients with stage two and higher do need it. The stage of diagnosis does matter.
Early detection also allows for less aggressive surgery—lumpectomy instead of mastectomy, sentinel lymph node biopsy versus axillary dissection. The traditional armpit surgery to sample lymph nodes leads to permanent swelling of the hand and arm in about one-third of women. The stage of diagnosis does matter.
To sum up, the science is clear: Screening finds cancer at a lower stage, improves the quality of life for women with cancer and saves more lives. The alleged harms are not reason enough to deny or discourage women from the opportunity for early detection. If screening is not offered starting at age 40, it will be inaccessible for many women. No one is going to force a woman to have screening, but she needs to have the choice whether to attend.
Thank you very much.
5:25 p.m.
Liberal
The Chair Liberal Sean Casey
Thank you, Dr. Gordon.
That concludes our opening statements.
We're now going to begin with rounds of questions starting with Ms. Goodridge, please, for six minutes.
5:25 p.m.
Conservative
Laila Goodridge Conservative Fort McMurray—Cold Lake, AB
Thank you, Mr. Chair.
I want to thank all the witnesses for being here today and providing their testimony.
This is such an important study. It's wonderful that we were able to get to it so quickly, especially in light of the updated guidelines coming out, which I don't believe hit the mark by any stretch of any imagination.
Dr. Gordon, as an expert in the field, do you believe women have the capacity and capability to decide for themselves whether or not to get breast cancer screening?
5:30 p.m.
Volunteer Medical Advisor, Clinical Professor at University of British Columbia, Dense Breasts Canada
Yes, I believe women are capable. It's patronizing for the task force to make a decision for women. If given the correct information, which is not currently in the decision tool, and given it in multiple different ways, women can make the decision for themselves. The task force plays down the benefits by using absolute numbers. They say how many women in 1,000 will benefit, for example, and they make it sound like there's not a big difference between one in 1,000 or two in 1,000. However, if you multiply that by the number of women in that age group in the country, you'll find there could be 400 to 600 fewer deaths every year in Canada if women in their forties were allowed to attend. I think women know what that means.
5:30 p.m.
Conservative
Laila Goodridge Conservative Fort McMurray—Cold Lake, AB
Thank you. I appreciate that.
My mom was diagnosed with breast cancer when she was 48 years old. She passed away from breast cancer at 49 years old, leaving behind four kids. I was the oldest, and that put a huge strain on all of us. If I were to have the same symptoms right now, the fact that I would have to argue with a doctor to try and get screening seems, to me, absolutely insane.
What are the benefits of early diagnosis, Dr. Gordon?
5:30 p.m.
Volunteer Medical Advisor, Clinical Professor at University of British Columbia, Dense Breasts Canada
With early diagnosis, women can have better treatment that's effective. They can have a lumpectomy, for example, instead of losing a breast with a mastectomy. The way they do the lymph node staging is also less aggressive. It's called a sentinel node biopsy. Compared to the traditional method, which left about a third of women with permanent swelling in their hand and arm, with the less aggressive sentinel node biopsy, the likelihood of lymphedema is as low as 2%. They can function much better if they can avoid chemotherapy, which is possible depending on the biology and the stage of the tumour.
For some women, having chemotherapy is the worst part of breast cancer, and to be able to avoid it is a huge benefit. Then they can go to work while they're being treated and continue to care for their children and, in some cases, look after aging parents. They're contributing to the economy.
5:30 p.m.
Conservative
Laila Goodridge Conservative Fort McMurray—Cold Lake, AB
Thank you.
I'm now going to ask a really broad question, and it's for all of the panellists, perhaps starting with Dr. Appavoo.
If you could write screening guidelines today, what would your screening guidelines be?
5:30 p.m.
Chair, Coalition for Responsible Healthcare Guidelines
As a matter of fact, I have notes on that.
5:30 p.m.
Chair, Coalition for Responsible Healthcare Guidelines
I have an opinion about everything.
What we want is to start at 25 to 30 asking a few questions of the women about family history so we know if that person needs to be on a high-risk channel to start with early in the game so that we're not finding out by accident they really should have been.... What is horrible is when we see women who get cancer and they're discovered with a late-stage diagnosis even in their thirties, sometimes even before they're eligible for screening, but once you talk to them you realize they had a really strong family history and they should have been getting screening all the way along.
Of course, I can't find my notes on this, but we would like to see annual screening from 40 until the person has under 10 years of life expectancy. That is shown, with modelling and with evidence, to save the most lives and to have the fewest treatment harms.
What we also would like to see is anybody who has dense breast tissue being offered supplemental screening with either ultrasound or MRI—most commonly ultrasound, but patients with very dense breast tissue should get MRI screening. In Europe, they're starting to do this.
That's about it.
5:30 p.m.
Chair, Coalition for Responsible Healthcare Guidelines
Dr. Gordon might have something extra to add there.
5:30 p.m.
Conservative
Laila Goodridge Conservative Fort McMurray—Cold Lake, AB
I see that Kimberly Carson has to leave.
Kimberly, could you perhaps provide us with your recommendations?