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.
6:05 p.m.
Liberal
June 10th, 2024 / 6:05 p.m.
Liberal
Sonia Sidhu Liberal Brampton South, ON
Thank you to all of the witnesses.
I would like to share the concerns about the findings of the task force. I'm glad that our witnesses are here with us to provide more clarity.
I would also like to follow up on my friend Ms. Vecchio's question.
Dr. Gordon, we can start with you, but any witness is welcome to add their feedback.
Earlier we heard about the importance of a primary care physician and their referral. Could the witnesses talk to this committee about the difference in the outreach to women across provinces and territories to inform them of the importance of the screening education campaign? Are there letters being sent out? Is there a notification system? Help us to understand.
6:05 p.m.
Volunteer Medical Advisor, Clinical Professor at University of British Columbia, Dense Breasts Canada
Every province does its own thing.
Our screening program in British Columbia was the first in Canada in 1988. When we started, all women got a letter of invitation on their 40th birthday, and women were allowed to attend annually starting at 40 and going all the way through. It has gradually deteriorated over the years. We're striving for mediocrity instead of being the leaders now in B.C.
Now there is no letter, so if a woman happens to have seen something in a women's magazine and asks her doctor, it will depend greatly on what her doctor says. Now a woman in B.C. does not need a requisition. She can self-refer as long as she has the name of a physician to give. Sadly, only 25% of eligible women in their forties are having screening in British Columbia.
We know of examples, and because I volunteer with Dense Breasts Canada, which deals not just with dense breasts but works to get equitable access to screening across the country, we know of so many cases, as you heard from Dr. Appavoo, when a woman asked and even begged for a requisition, and her family doctor said, “No. That's not what we do here. You don't need one until you're 50.”
I give credit to the task force. As you heard from Dr. Nadler, it has changed it a bit this year. It still says it doesn't recommend it, but it's made it much clearer, from what I've read so far, that if the patient wants it, she should have it and the doctor should give her a requisition. That was not as clear when the 2018 guidelines came out. It was in the fine print, further down in the article. We even know of patients in British Columbia, where they don't need a requisition, if a woman asks her family doctor, she might be told not to bother until she's 50.
6:05 p.m.
Liberal
The Chair Liberal Sean Casey
Thank you, Dr. Gordon.
I'm sorry, Dr. Nadler. We're well past the time. Hopefully, somebody will come back to this topic.
Mr. Thériault, you have the floor for two and a half minutes.
6:05 p.m.
Bloc
Luc Thériault Bloc Montcalm, QC
Thank you, Mr. Chair.
Dr. Nadler, the results of a scientific research study you participated in were published in 2022. In the publication, it states that obstacles to individualized breast cancer screening include knowledge of risk factors and risk assessment tools. It also mentions that doctors had difficulty identifying breast cancer risk factors outside family history, such as reproductive factors, ethnic origin or breast density, and that some doctors were lacking the skills to calculate overall breast cancer risk.
The draft recommendations of the Canadian Task Force on Preventive Health Care would suggest not routinely screening with mammography. The suggestion is that women should be given information on the benefits and harms of screening so that they can make decisions in line with their values and preferences.
In this context, do you think that doctors' lack of knowledge of the risk factors and risk assessment tools, as you mentioned in your research, can influence women's decisions and prevent them from making an informed decision?
6:05 p.m.
Volunteer Medical Advisor, Clinical Professor at University of British Columbia, Dense Breasts Canada
Are you addressing me?
6:05 p.m.
Breast Medical Oncologist and Implementation Scientist, As an Individual
Thank you.
It's important to note that a primary care provider can engage in shared decision-making with a woman without knowing the exact lifetime risk she has. That being said, it is important for a family doctor to assess a woman's risk factors—I agree with all the other experts here—because that primary care provider needs to know if that woman is even at an average risk. If she's at an average risk, these guidelines apply to her, and the guidelines say she should have a choice.
If the woman is at a higher than average risk, there is a completely separate screening recommendation that doesn't even fit within these guidelines. It is correct that some primary care physicians could use extra support in learning about risk factors and calculating lifetime risk, and separately, that is outside of the scope of these guidelines. Some of the work I do is in helping to create tool kits and support primary care providers to do this.
I think first and foremost, the most important thing is that one can still have a shared care discussion if one has determined that the woman is of average or slightly above average risk, which the task force clearly defines in these updated guidelines, and which is an improvement from the 2018 guidelines.
6:10 p.m.
Liberal
The Chair Liberal Sean Casey
Thank you, Dr. Nadler.
Thank you, Monsieur Thériault.
Next is Mr. Julian, please, for two and a half minutes.
6:10 p.m.
NDP
Peter Julian NDP New Westminster—Burnaby, BC
Thank you very much, Mr. Chair.
I appreciate all our witnesses being here.
Unfortunately, because of the time constraints, at the end of my two and a half minutes, I'll be moving a motion to adjourn.
I wanted to come back to Dr. Appavoo and then ask Dr. Nadler and Dr. Gordon the same question.
You mentioned in your testimony, Dr. Appavoo, that it is important to look to dismantle and rebuild the task force. Very clearly, the task force is not responding certainly to the needs of Canadian women or certainly to the needs of racialized women in the health care system.
How important is it to dismantle and rebuild it, and what should the steps be to actually accomplish that?
6:10 p.m.
Chair, Coalition for Responsible Healthcare Guidelines
Thank you for asking that.
Quickly, one of the reasons I think there should be a complete dismantling and rebuilding is that this problem is not just isolated to breast. Breast is sort of the tip of the iceberg. Multiple other screening guidelines in cancer and non-cancer fields have similar reactions from experts and are similarly concerning. As one gastroenterologist told me in an email regarding the colorectal screening guidelines, people are going to die.
Unfortunately, there is no accountability structure. Because it's at arm's length, there's no way to fix the guidelines that are wrong, and there's no way to update any sooner than they feel like updating, so we have guidelines sitting there that are very outdated, dating back to 2012 and 2013.
Ultimately, we can make any fix to any individual guideline we want, but the problem will happen again and again and again, because the problem is fundamental to the structure and the accountability of the task force. I think that, ultimately, there are many national and international guidelines that are well accepted. Experts in the fields can guide you to use a better guideline in the interim while we restructure the guidelines—
6:10 p.m.
Conservative
6:10 p.m.
Liberal
The Chair Liberal Sean Casey
We had a point of order just before you moved your motion, Mr. Julian.
Go ahead with your point of order, Ms. Goodridge. Then we're going to deal with the motion.
6:10 p.m.
Conservative
Laila Goodridge Conservative Fort McMurray—Cold Lake, AB
Thank you, Mr. Chair.
I appreciate the fact that the member wants to end our meeting early. Women's health is something that is greatly understudied in this country. We have an opportunity here with witnesses, and we have time for another round of questions, and this is absolutely inappropriate.
6:10 p.m.
Liberal
The Chair Liberal Sean Casey
Ms. Goodridge, that is absolutely not a point of order, and a motion to adjourn is not debatable, which is what you were trying to do through the back door.
Is it the will of the committee to adjourn the meeting?
6:10 p.m.
Conservative
Laila Goodridge Conservative Fort McMurray—Cold Lake, AB
I request a recorded division.
(Motion negatived: nays 10; yeas 1)
6:10 p.m.
Liberal
The Chair Liberal Sean Casey
Next up on the speakers list is Ms. Goodridge, please, for five minutes.
6:10 p.m.
Conservative
Laila Goodridge Conservative Fort McMurray—Cold Lake, AB
Thank you, Mr. Chair.
It's interesting. My initial anticipation as I read through the guidelines was how it was considered that women did not have the ability to make decisions and that somehow the feeling of anxiety trumped living. As someone who has dealt both with the anxiety of being sent out of my community and with getting additional testing as a result of dense breasts, the anxiety that really keeps me up at night is the anxiety of wondering whether I will live to see my children grow up, not the anxiety surrounding a test.
My question is for you, Dr. Gordon.
What advice would you have if you could draft new screening guidelines for Canada?
6:15 p.m.
Volunteer Medical Advisor, Clinical Professor at University of British Columbia, Dense Breasts Canada
First of all, I need to explain that it is well known that a percentage of women, perhaps around 10% plus or minus are going to be recalled. It is known that women are much less anxious if they're prepared ahead of time and if they're told that this could happen. It's most likely to happen on their first screening mammogram, because there are no priors to compare to. Women need to be told, just as they need to be informed about the possibility of overdiagnosis, so they're prepared.
For my wish list, I'll start with what Dr. Appavoo said, that all women should be assessed for risk early in life, perhaps at around the age of 30. Then all average-risk women who don't need to be screened younger because of increased risk would be able to start at 40. They should be able to self-refer without a requisition from their physician. They should be able to go annually, at least when they're premenopausal, because that's when hormones cause breast cancers to grow faster, and ideally annually until they don't have 10 years of life expectancy left.
We have loads of data to show that's how you save the most lives, the most years of life, and how you get to offer the least aggressive therapy.
Women should be told after they have their screening mammogram what their breast density is. We've only just now, after seven years of lobbying, finally got pretty much every province and territory on board to tell women their breast density. Up until 2018, no woman in Canada was being told their breast density. Why? We were told that it was because we were going to make them anxious.
When men have high blood pressure, we tell them they have high blood pressure because it's a risk and they need to know information about their own health. Women deserve to know their breast density because of the two associated risks.
From there, any woman with category C or D—those are the women with dense breasts—should have access to supplemental screening because, when a woman has dense breasts, there's a risk that her cancer might not be seen on her mammogram. That supplemental screening with either ultrasound or MRI can find many of those cancers.
Finally, women should be able to continue having screening beyond age 74 until their life expectancy is less than 10 years. For most women, that's age 80. At age 75, according to Stats Canada, a healthy woman has a life expectancy of 13 years, and at age 80, it's 10 years.
That's my wish list for screening.
6:15 p.m.
Conservative
Laila Goodridge Conservative Fort McMurray—Cold Lake, AB
Thank you.
I appreciate that you brought up extending it past 74. I had a number of women after I brought this forward who brought that to my attention, and it was something that was a constraint to them, especially when they were healthy.
Dr. Appavoo, we have an audience here today. We have people who are tuning in and paying attention to this health committee meeting. What recommendation would you have to the women who are listening?
I have about 30 seconds.
6:15 p.m.
Chair, Coalition for Responsible Healthcare Guidelines
My recommendation is to start screening at age 40. If you need a requisition from your family doctor, and your family doctor is reluctant to write the requisition.... I know that now the task force guideline states that women should be allowed to have screening if they want to. I know that a lot of doctors talk their patients out of it because of that overdiagnosis, anxiety and all these paternalistic ideas about why women shouldn't be screened, and they discourage it, and they talk their patients out of it.
Go in and don't let yourself be talked out of it. Make sure that you start at 40 and go every year, as Dr. Gordon says, during premenopause.
6:15 p.m.
Conservative
Laila Goodridge Conservative Fort McMurray—Cold Lake, AB
Thank you.
Now I would like to move a motion, Mr. Chair:
That, in relation to the committee’s order of reference of Wednesday, May 29, 2024, concerning Bill C-368, An Act to amend the Food and Drugs Act (natural health products):
(a) the sponsor be invited to appear during the first hour of the committee’s meeting on Thursday, June 13, 2024;
(b) other witnesses, to be proposed by the parties, appear during:
(i) the second hour of the committee’s meeting on Monday, Thursday, June 13; and
(ii) the first hour of the committee’s meeting on Monday, June 17, 2024;
(c) all amendments be submitted to the clerk of the committee no later than 4:00 p.m. on Friday, June 14, 2024;
(d) clause-by-clause consideration of the bill be taken up during the second hour of the committee’s meeting on Monday, June 17, 2024, provided that, at the later of the conclusion of that second hour or 5:30 p.m. that day, if the committee has not completed clause-by-clause consideration:
(i) all remaining amendments submitted to the committee shall be deemed moved;
(ii) each recognized party shall be allotted no more than five minutes for each of the remaining amendments and clauses;
(iii) the committee shall not adjourn until it has disposed of the bill; and
(e) the Chair and clerk be instructed to seek the House resources necessary to implement the terms of this motion.
I have a bilingual copy that I can circulate to members of the committee.
Thank you, Mr. Chair.
6:20 p.m.
Liberal
The Chair Liberal Sean Casey
Feel free to circulate it; however, the motion that you just presented does not touch the issue at hand and the committee has not been provided with 48 hours' notice. I therefore rule it out of order.