Health Committee on June 10th, 2024

[Kimberly Carson]

Yes. Thank you so much, Laila.

Obviously, Breast Cancer Canada would like to see the age lowered to 40 for all the reasons that both the doctors recommended. I think at the age of 40, although women can make up their mind, it is about that prompt. This is what we hear from the patients every day. They say they got the letter in the mail, or their doctor said they now qualify, and then they went and had that mammogram done. It catches something at a very early stage. We speak to those patient advocates on a daily basis and we hear that frequently.

In terms of providing them with the opportunity to be screened at the age of 40, and certainly profiled as to whether they should even be screened at a younger age because of family history, we would definitely be advocating for that and for asking the task force to please lower that age to 40.

Certainly, when we have more technology available in the future, we'll have a better opportunity to offer more technology and more treatment options for women at a younger age.

[The Chair, Liberal, Sean Casey]

Thank you, Ms. Carson and Ms. Goodridge.

Next we have Ms. Kayabaga for six minutes, please.

[Arielle Kayabaga, Liberal, London West, ON]

Thank you, Mr. Chair.

I also would like to extend many thanks to our witnesses.

Perhaps I can start with Ms. Carson, because I know she has to leave us soon.

In your opening remarks, you talked about Black and Hispanic women and the disparities in breast cancer and early screening for them. Do you think there's sufficient data available to be able to make any suggestions on practices for Black, Hispanic and indigenous women?

[Kimberly Carson]

I think there's a lot of research data. There is perhaps some shortage of some data in Canada due to the fact that we haven't always tracked ethnicity. We do now. Certainly, to the south of us there are a number of research studies. I would encourage the task force to take a look at those.

I think we need to pay more attention moving forward as well. We certainly see the risks in Black and Hispanic women at a younger age with certain types of breast cancer, the triple-negative, as I mentioned. I would like to see, as we were talking about earlier, the opportunity for women to have that profile done with their family doctor or their primary caregiver if they are at higher risk. Is there a family history? Are they at a higher risk because of the ethnicity as well?

Those all should be added in together. Perhaps even at the age of 30 they should be looked at.

[Arielle Kayabaga, Liberal, London West, ON]

Last year, in February 2023, a report came out, which I think the CBC reported on. The study found that members of Black communities were less likely to get screened for cancer. As a result, they have increasing mortality rates.

What are the best practices for making decisions about screening in situations where we know there's a community that is likely to have a higher rate of death because of less access to screening?

Perhaps Ms. Carson could quickly answer and then Dr. Gordon.

[Kimberly Carson]

Certainly.

I don't think they have less access to screening. I think we need to do everything to encourage every woman who has access to be screened. I also believe there should be an opportunity for women of Black and Hispanic descent to have a more in-depth review of their family history and the opportunity to be encouraged to screen.

Again, if we have the screening and detection lowered to the age of 40, would that catch more cases? Would they have that availability to say, oh, this something I'm supposed to get done at the age of 40 as opposed to waiting until the age of 50?

[Arielle Kayabaga, Liberal, London West, ON]

This is actually through a study that was released last year. It is proven that they have less access to screening.

I'll go to Dr. Gordon to see what she has to say. She looks like she has a lot to say on this.

[Dr. Paula Gordon]

Thank you.

The first point I want to make is about family history, as you've heard a couple of times. It's very important that everyone understand that—sit down for this one—85% of women who get breast cancer have no family history. Women are at increased risk if they do, but that's not the only risk factor. The other omission has been that Black, Asian and Hispanic women especially are at risk of developing cancer younger, but there are other groups who are at high risk, like Ashkenazi Jewish women.

The reason that mortality is so terrible in Black women is that they're at a much higher risk of getting these rapidly moving triple-negative cancers. For that reason, Black women are 40% more likely to die if they do get breast cancer.

Those are the aggressive, fast-moving cancers. The way to find them as early as possible is not only to do the mammogram every year, but if a woman has dense breasts—and that's more common in Black women—they should also get supplemental screening. Whether that's with ultrasound or MRI should depend on their actual risk level, which can be determined with online risk calculation tools that are easily accessible with just a few questions.

A Black woman with dense breasts and a family history is probably going to be at a high enough risk to justify not only screening her younger, but screening her more often and with better technology, like MRI.

[Arielle Kayabaga, Liberal, London West, ON]

Dr. Nadler, did you also want to add some comments?

[Dr. Michelle Nadler]

Thank you.

Just to clarify, the overall incidence of breast cancer in the Black community is less than average, but it does occur younger and the prognosis is poorer, as you said.

I also want to reach out to Laila and say that I'm absolutely so sorry that this happened to you. What we don't know is whether screening would have changed that outcome or not. We simply don't know. Screening helps some people, but it doesn't help everybody.

A second point—

[Arielle Kayabaga, Liberal, London West, ON]

Thank you.

I have a short amount of time, so I just want to get through some of my questions.

In December 2023, Dr. Anna Wilkinson told the committee “non-white women—Black, indigenous, Chinese, South Asian, and Filipina—have a peak age of breast cancer diagnosis in their forties, while white women have a peak age in their sixties”.

How and why are racialized women differently affected by breast cancer?

[The Chair, Liberal, Sean Casey]

Dr. Gordon, I'm sorry she didn't leave much time for a response. Be as concise as you can possibly be, please.

[Dr. Paula Gordon]

They're at risk because their cancers aren't found earlier because they're not screened starting at age 40. They deserve the same opportunity of early detection as Caucasian women. Everybody should be screened at age 40, but absolutely, racialized women deserve their cancers to be found as early as Caucasian women's.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Gordon.

Mr. Thériault, you have the floor for six minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you very much, Mr. Chair.

Dr. Gordon, we hear that overdiagnosis creates a lot of unnecessary stress, in addition to triggering other types of interventions, such as biopsies, that can sometimes complicate things. It's important to have an accurate measure of overdiagnosis to determine whether the benefits outweigh the harms.

Do you consider overdiagnosis to be a barrier to routine screening for women 40 to 49 years old?

[Dr. Paula Gordon]

You're quite right. Overdiagnosis is only important if it leads to overtreatment.

Overdiagnosis actually applies to real cancers. These are not false positive. These are cancers that have been diagnosed on a biopsy.

From that point, the patient is referred for care to a surgeon, to an oncologist or to a radiation therapist. Then her treatment has to be tailored to her. If that woman has advanced heart disease and her life expectancy is short, she will not be treated with the same aggressiveness as a young woman who's in very good health.

We have to screen to find the cancers. Then once we find them, the treatment is decided based on the individual patient, not only the characteristics of the cancer, but the patient's general health, how much treatment she can tolerate and how likely it is that the treatment is going to help her in the long run.

To say that we shouldn't screen because of overdiagnosis means we'll never find those cancers, even the ones that could be treated, even the more lethal ones, and especially the ones in younger women. As I explained, they're less likely to have heart disease and be at risk of dying of a heart attack, so if we do find their cancers, they tend to grow faster and they need to be treated. That's not overtreatment.

[Luc Thériault, Bloc, Montcalm, QC]

Do you think overdiagnosis has been overdiagnosed in the literature, Dr. Gordon?

[Dr. Paula Gordon]

There is confusion between overdiagnosis and what a false positive is. The term “false positive” is incorrectly used by the task force. It's pejorative to refer to something abnormal on a mammogram that needs additional tests as a false positive. Yes, 95% of those turn out to be negative and the patient is reassured that everything is fine. There's a big difference between that, which is not a cancer, and overdiagnosis, which is.

Overdiagnosis, as I said, is not a reason to deny screening to younger women. It's not even a reason to deny screening to older women, unless they're very sick. As long as a woman is healthy with a life expectancy of 10 years, it's reasonable to offer her screening because, if we can find a small cancer, sometimes it can be treated very easily, even with just a hormonal medication or a small operation—not do all the other stuff like radiation and chemotherapy. It's in the hands of the doctors who are treating her to use their skill to decide how much treatment to offer her.

[Luc Thériault, Bloc, Montcalm, QC]

The U.S. Preventive Services Task Force recommends screening starting at age 40 to save lives. It even indicates that 19% more lives could be saved. The Canadian task force, however, is sticking with age 50 and over.

How do you explain the differences in the analysis of research results? Are results in Canada so different from those in the U.S., Dr. Gordon?

[Dr. Paula Gordon]

First of all, the mortality reduction possible with screening depends on what kinds of studies you look at.

There's one kind of research called a randomized trial, where you have a control group and a study group. Then there's observational data. Screening has been under way in Canada since 1988. We know from observational data—not randomized trial data—that women in their forties are 44% less likely to die of breast cancer if they have screening. If you rely just on the randomized trials, which are now 40 to 60 years old.... They were done at a time when mammograms were X-ray film that we read on a light box. Now they're done digitally on computers with lots of enhancements that make them more accurate. If you look at just the randomized trials, the mortality reduction was only between 15% and 20%.

The task force this time included observational studies in addition to the randomized trials, using the grade system you heard about earlier. What they did is prioritize the older studies and downgrade the importance of the observational studies. In fact, if you look at all the observational studies, not just the Canadian one, you'll find that the mortality reduction from mammography alone is in the range of 53% fewer deaths. Yet, because of the task force's overemphasis on anxiety from recalls and overdiagnosis, they concluded that the harms of screening outweigh the benefits.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Gordon.

Thank you, Mr. Thériault.

Mr. Julian, go ahead, please, for six minutes.

[Peter Julian, NDP, New Westminster—Burnaby, BC]

Thank you, Mr. Chair.

Thank you to our witnesses.

I am looking at appendix A, which is a summary of the task force’s findings on the benefits and harms of breast cancer screening. I see a chilling absence of empathy. When you look at their own figures, they show that screening 1,000 people, ages 40 to 49, prevents one breast cancer death, while no screening means two people will die from breast cancer. In other words, the number of people per 1,000 who die from breast cancer would be cut in half. When you think of the number of Canadian women in that age group—not 1,000 Canadian women but 2.5 million—we're talking about saving, just by a rough calculation, over 3,000 lives. That's more than the number of people who died in the World Trade Center attack.

I simply don't understand this chilling absence of empathy, that a task force could put out these recommendations knowing that what they're doing is sentencing 3,000 Canadian women to death.

I thank all of our witnesses for their testimony today.

I want to start with you, Dr. Appavoo.

Does that sound right to you, the number of lives that could be saved if these task force recommendations were simply set aside and we started screening at 40?

[Dr. Shiela Appavoo]

Over the 10 years, absolutely.

In fact, the modelling calculations are between 400 and 600 per year. We talk about that being, if you can imagine, a jumbo jet full of women going down every year, based on the guideline recommendations not to screen.

You're absolutely right. I think there's an emphasis on using absolute numbers only from the task force. It actually states that they recommend only using absolute numbers, not saying, “You'd save 50% of your patients,” or “If I got breast cancer, I'd be 50% less likely to die if I were screening regularly.” They don't want us to say it that way. They want to say it as one in 1,000, because it makes it seem like a much smaller number.

Frankly, that's a manipulation technique, in my opinion. It is a well-known manipulation technique to try to control the narrative by controlling the way information is delivered.

I think both types of numbers should be used. In fact, I think more than those two types of numbers should be used.

You're absolutely right. For an individual woman who gets breast cancer—and it's very common, as we know—the benefit of mammography is huge. Most people don't get it. You can minimize it by talking about absolute numbers, but if you are that woman who gets it, it makes a huge difference to you.

It's just playing roulette not to screen. You're just hoping you don't get breast cancer, but if you do, you missed your opportunity.

[Peter Julian, NDP, New Westminster—Burnaby, BC]

Thank you for your answer.

I just do not understand how any person could sign what is a death warrant for thousands of Canadian women with such alacrity without any feeling at all. All the witnesses have been very clear about this. The primary people who are impacted are indigenous, Black, Asian, Filipina and Hispanic women. Is it systemic racism driving this? There is absolutely no justification for these recommendations when they know that thousands of Canadian women die as a result of these recommendations. What is it? Is it systemic racism that is contributing to them putting forward recommendations that are a death warrant for so many Canadian women?

[Dr. Shiela Appavoo]

I am reluctant to use the word “racism”, but sometimes you have to call a spade a spade. There is a systemic form of racism involved in over-weighting these ancient RCTs that were performed on a group, 98% of which were white women.

When you put those at the top of the evidence hierarchy or the top of the pyramid, you are systematically leaving out every other race. Women who are white have a peak in breast cancer in their fifties to sixties. Every other race that's not white gets their peak in their forties. In this question, we are specifically focused on women screening in their forties. Every race other than white has been excluded in their highest level of evidence. Yes, there's a systemic form of racism there.

I was dismayed to see in the guideline that they acknowledge there is a higher mortality rate for Black women. Black women have a slightly lower chance of getting breast cancer, but when they do, they are 40% more likely to die of breast cancer. They acknowledge that, but they put them in the average-risk category, which is the category where they don't get screened in their forties, or there's no strong recommendation for them to screen in their forties. You have this double whammy of people being more likely to die if they get breast cancer and being in a group that is under-investigated, understudied, so you have this systemic form of racism. I don't call it personal racism. I'm sure there's no intent to be racist, but if you disregard these racial imbalances in the research, then you have entered systemic racism.