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.
5:55 p.m.
Liberal
The Chair Liberal Sean Casey
Thank you, Mr. Julian.
Thank you, Dr. Appavoo.
Next is Ms. Vecchio for five minutes.
5:55 p.m.
Conservative
Karen Vecchio Conservative Elgin—Middlesex—London, ON
Thank you very much, Chair.
I want to go back to Dr. Appavoo.
We know that many Canadians don't have doctors. It's about 25% in the city of Ottawa, from what I understand.
When a woman goes to her doctor—if she has a GP—what is it that ignites getting something done? Do they have to ask for it? Must there be a referral? Is there a screening where they actually look at the family history? What does screening really look like at stage one?
5:55 p.m.
Chair, Coalition for Responsible Healthcare Guidelines
It varies from province to province.
For example, in Dr. Gordon's province of B.C., women in their forties don't need a requisition to screen. They can go and screen, but they're not necessarily encouraged to screen, whereas there's probably.... If it's similar to Alberta, you have about 60% of women in the target age group—so 50 and up—who will screen.
In the 40 to 49 age group, about 20% of those women will screen. They're allowed to self-refer, but their doctors don't push them to do it. When I say push, I mean encourage them, have the discussion or just say, “You should do this, if you want.”
In other provinces where.... I think in Ontario you have to have a requisition to screen. In Alberta, you do at 40, as well, if you want to screen. It requires that the family doctor be motivated to want to screen that patient. The family doctors very often—not all of them—take strong leadership from the task force. If the task force is saying not to screen, the doctor is going to say not to screen.
Time after time.... I work with a patient engagement group for the Canadian Society of Breast Imaging. Several, if not most, of the patients on the panel had asked for a screening mammogram at 40 and were told that, no, they didn't need it, that the task force said they didn't need it, and then within a few years, they showed up with a late-stage cancer.
June 10th, 2024 / 5:55 p.m.
Conservative
Karen Vecchio Conservative Elgin—Middlesex—London, ON
We know that, in certain sections, if a woman has not borne a child or has not gone through a full pregnancy, that may be one of the reasons or may be one of the screenings. To me, it just seems so simple for stage one. You sit there and think about how you haven't had a child yet or haven't nursed, so perhaps screening before 40 or screening after 40 would make sense.
That's why I'm thinking that it could be such a simple thing if you're just able to go through it at the very first step, because we know of the full-term pregnancies....
You said, or it could have been Dr. Gordon, that 85% of women do not have a history of breast cancer in their family. When we're looking at trying to do this testing, what kinds of things would they be looking at? Is it a blood test for screening, or would they be looking at a genetic issue?
5:55 p.m.
Chair, Coalition for Responsible Healthcare Guidelines
Our recommendation is that everybody screen at 40 because your biggest risk is being female. Then the second biggest risk is getting older. It's very difficult to predict.
There are some people you have a better chance of predicting, such as if they have a very strong family history or if they've had radiation to the chest before 30. There are some people for whom you know you're going to have to work harder and get them into MRI. You're going to have to dig a little deeper and make sure that you really screen them hard.
However, the average woman walking around without a family history is still at risk for breast cancer, and because that is the vast majority of women, that is also the vast majority of breast cancers.
5:55 p.m.
Conservative
Karen Vecchio Conservative Elgin—Middlesex—London, ON
Thank you so much.
I'm going to Dr. Nadler because, to me, all of the work that you've done here is what we're questioning today. We're saying to look at these guidelines because not everybody agrees with them.
I want to come back to you and ask you specifically whether there is anything that is done when you're talking about this—knowing, for instance, if a person hasn't had a child.... Is there something that would initiate some sort of screening for anybody under the age of 50 if they've not yet had a child?
5:55 p.m.
Breast Medical Oncologist and Implementation Scientist, As an Individual
The task force recommendations say that any woman who is 40 is eligible for a mammogram as long as she is informed, and they actually say that if she's informed and would like a mammogram starting at 40, she ought to have one.
The task force does not control access. If across Canada we need to open up access, then the task force guidelines would be fine with that, as long as women are informed.
5:55 p.m.
Conservative
Karen Vecchio Conservative Elgin—Middlesex—London, ON
I absolutely appreciate that.
Dr. Nadler, we know, though, that here in Ontario, for instance, you would need to have some sort of referral.
6 p.m.
Breast Medical Oncologist and Implementation Scientist, As an Individual
You won't anymore, not as of the fall of this year, fall 2024.
6 p.m.
Conservative
Karen Vecchio Conservative Elgin—Middlesex—London, ON
Are there any provinces where you still need a referral, or are they all referral-free now so that you can go directly and have breast screening?
6 p.m.
Breast Medical Oncologist and Implementation Scientist, As an Individual
I believe there are still two or three that require referrals, but that could be changed. It is not the mandate of the task force to control access to care.
6 p.m.
Breast Medical Oncologist and Implementation Scientist, As an Individual
The task force's mandate is that women be informed.
I'm sorry. Go ahead.
6 p.m.
Conservative
Karen Vecchio Conservative Elgin—Middlesex—London, ON
No, I absolutely agree with you.
You only have four seconds—I'm sorry—but with regard to informing people, what does that education look like if we're saying that guidelines are somewhat different?
6 p.m.
Breast Medical Oncologist and Implementation Scientist, As an Individual
Do you want me to answer, or is there no time?
6 p.m.
Conservative
6 p.m.
Breast Medical Oncologist and Implementation Scientist, As an Individual
Thank you.
All of the best available evidence on communication does suggest to communicate in absolute numbers. For example, there was a scare many years ago where we thought that the oral contraceptive pill doubled or increased the risk of a blood clot by 100%, but really, it took it from about one in 7,000 to two in 7,000.
I don't think we would ask family doctors to use that 100% increase in blood clots from a birth control pill. We would ask them to give the absolute numbers so that women can make their own informed choices. Whatever choice they make about screening—informed in absolute numbers—should be respected, and however the access wants to be for that, the task force doesn't mind so long as the woman is informed.
6 p.m.
Liberal
The Chair Liberal Sean Casey
Thank you, Dr. Nadler.
Next we go over to the Liberals with Madam Brière.
I understand that you're going to be sharing your time with Ms. Sidhu.
You have the floor, Madam Brière.
6 p.m.
Liberal
Élisabeth Brière Liberal Sherbrooke, QC
Thank you, Mr. Chair.
Thank you to all of our witnesses.
I will be speaking to Dr. Gordon.
According to the expert committee, more cancer does not mean there needs to be more screening. We should be focusing on why it has become more prevalent.
Do you not think we could do both, that is, screen for cancer while finding out why it's more prevalent?
6 p.m.
Volunteer Medical Advisor, Clinical Professor at University of British Columbia, Dense Breasts Canada
If I understand your question, you're asking why breast cancer is getting more common in younger women. I don't think anybody knows the answer.
One that was proposed that seems to make sense to me was, especially during the pandemic, there was greater consumption of alcohol. We know that alcohol is a carcinogen and is related to breast cancer risk as well as risks of other cancers.
For another example, we don't know why women are starting to menstruate younger. We know that lifetime exposure to estrogen is a risk factor for breast cancer, and women who start their periods younger and go through menopause later are at a higher risk for breast cancer. We've certainly seen that the age of onset of periods has become younger. It's not uncommon for girls as young as nine to get their periods now. It used to be that age 12 to 13 was the most common average.
I'm not an expert in this subject, but I've read that maybe it's because the girls who are young now, women my age, hopefully didn't smoke and drink during their pregnancy like our mothers did, and they're much better nourished. Maybe that's why they're starting their periods earlier, and maybe that's contributing to increasing rates of breast cancer.
There's a bunch of theories out there. At the end of the day, I don't think anybody really knows why it's happening.
6 p.m.
Liberal
Élisabeth Brière Liberal Sherbrooke, QC
Thank you.
Dr. Appavoo, we know that, starting at age 40, women who have been given the information can decide to be screened. However, we know that not all women have a family doctor. That's the case in Quebec, at least.
Do you think that's a barrier to accessing screening?
6 p.m.
Chair, Coalition for Responsible Healthcare Guidelines
If I understand your question, you're asking if not having a doctor is an obstacle to access. That's absolutely the case, especially in provinces where you need a requisition to get the screening mammogram.
In Alberta, fortunately, we've moved it down to age 45 when they get invited and can self-refer, but if you want to get in at 40, you need a requisition at least for the first one. If you don't have a doctor or if your doctor believes the task force and does not want to write a requisition, there's a big barrier right there. Yes, that's a huge barrier for a lot of women.
6 p.m.
Breast Medical Oncologist and Implementation Scientist, As an Individual
Just to clarify, if that family doctor followed the guidelines, they should refer for screening. Guideline care is to respect a woman's choice.