Evidence of meeting #123 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.
11:40 a.m.
NDP
Bonita Zarrillo NDP Port Moody—Coquitlam, BC
In my experience, what worries me the most is non-white women, women of colour and women who are more likely in their forties and fifties.... Knowing how hard I had to fight, I'm wondering how we are disadvantaging non-white women with this antiquated task force study.
11:45 a.m.
Professor of Radiology, Faculty of Medicine, University of Ottawa, As an Individual
The women who are more likely to present with advanced breast cancer are women of all races and ethnicities other than white. This is because the peak age at which they are diagnosed with breast cancer is their forties. They are not able to access screening programs in many parts of the country based on these guidelines and based on a lack of access to a family physician. This is, unfortunately, similar to what we see in some of the developing world, with advanced breast cancers presenting in these women at a 2.5 times higher rate than white women in Canada.
These guidelines are very harmful. That's why I would recommend that we reject them and start again.
11:45 a.m.
Liberal
June 13th, 2024 / 11:45 a.m.
Conservative
Laila Goodridge Conservative Fort McMurray—Cold Lake, AB
Thank you, Mr. Chair.
I want to thank MP Zarrillo for sharing. That touched me. There aren't a lot of topics that get me really teary. I'm generally a very strong person who can hide a lot of emotion, but on this subject, I don't hide a lot of emotion.
My mom would have been one of the 400 to 600 women who would still be alive today had more screening been available. My mom passed away at 49 years old. She was diagnosed with breast cancer when she was 48 years old. She left behind four little kids. I was the oldest, and I had to take on a lot of extra responsibility through her chemo, through her radiation, through her palliative stage and then, eventually, after her passing. This isn't something that I wish on anybody. This isn't something that I hope another person ever has to struggle with.
I am angry. I'm angry with the task force. I think these guidelines fail to recognize the value of the lives of women and their families and the fear they have created by saying that additional screening is somehow not valid.
I want to open it up to you, Dr. Seely. I really appreciated your piece. You talked about the fact that you're seeing more women pass away within one year of diagnosis. What do you think we could do, beyond what the guidelines have put forward, to make things better for the outcomes of women?
11:45 a.m.
Professor of Radiology, Faculty of Medicine, University of Ottawa, As an Individual
I'm so sorry for your loss. Probably every one of us has a member of our family...but it's even more potent when it's your mother.
As to recommendations, women should have a risk assessment for breast cancer, with informed and up-to-date tools to recommend what their next step should be, starting between the ages of 25 and 30. This is in alignment with the European guidelines and the American guidelines, which suggest that we should be thinking about breast cancer as early as 25 to 30. We should be recommending systematic screening starting at age 40. We should be allowing self-referral to a screening program. We have extremely good-quality screening programs in Canada.
This is what we would recommend. It is a woman's decision whether she wants to be screened or not. We know that participation rates are about 60%. They could be better, but we know that women in their forties are begging to be allowed a screening, to be allowed into the screening programs and to benefit from early detection. They want to live a healthy life and to be there for their children for many years.
Those are the major recommendations for young women. For women who are 74 years and older, life expectancy has changed and improved dramatically. We would recommend continuing to screen women older than 74 as long as they have a life expectancy of seven to 10 years, which is the majority of women in their seventies.
These recommendations align with international standards, and they are the ones we would recommend for Canadian guidelines.
11:50 a.m.
Conservative
Laila Goodridge Conservative Fort McMurray—Cold Lake, AB
Thank you. I really appreciate that. I've had a number of women in their seventies bring up their concerns about screening stopping at 74 for exactly the points you raised, so I think this is an important piece to make sure we involve.
I'm going to open this up to the Canadian Cancer Society.
What recommendation would you put forward, very succinctly? Do you think we should have a reversal of the guidelines that were just put forward by the task force?
11:50 a.m.
Advocacy Manager, Prevention and Early Detection, Canadian Cancer Society
It's a difficult question, but we have heard it all today. We need access for women in their forties, from 40 to 49. It's about working with them in the capacity that they have today to get there. There is a public consultation, and we are encouraging our community to be very much a part of it in hopes that it might make a bit of a difference. We've also requested that a report be published after to understand what has been heard from the public.
A concern is that we have been consulted in the past and our thoughts, considerations and the research that has been provided haven't always come through. We're hoping this will be different, but we're also cautious. We'll see.
11:50 a.m.
Director, Advocacy, Canadian Cancer Society
It's just to add that we requested the task force to consider high-risk and elevated-risk guidelines in the current review. That's something else we would be looking to see. It's important to know that these screening programs are for average-risk populations. We need separate guidance for those at elevated and high risk.
11:50 a.m.
Liberal
11:50 a.m.
Liberal
Sonia Sidhu Liberal Brampton South, ON
Thank you, Chair.
Thank you to all the witnesses for being with us.
My question goes to Dr. Seely.
Dr. Seely, I would like to start where we left off in the last meeting. We've briefly spoken about outreach to women across provinces. We heard shocking testimony that in some cases, women are left to their own resources. Sometimes they hear about the need to get screened from women's magazines, not from physicians.
What recommendation can you give to this committee about raising awareness among women about screening?
11:50 a.m.
Professor of Radiology, Faculty of Medicine, University of Ottawa, As an Individual
This is exactly the experience. We see a lot of barriers. For the reasons I mentioned earlier, The College of Family Physicians, which sees a lot of women in the more rural or remote communities, very much adheres to the Canadian task force guidelines. They have extremely busy practices. They're seeing all aspects of medical problems and they don't have the time to get informed, so they rely very heavily on the Canadian task force guidelines.
This is a recurrent theme. We have thousands of people across the country who tell us their family physician refused them screening in their forties, even though the task force does acknowledge that it should be an informed decision. They are simply following the final guideline to not recommend routine screening for these women. The biggest reason these guidelines are so harmful is that they will pose a barrier.
Once the guidelines recommend that a woman can self-refer—when she's 40 to 49—there are outreach programs occurring across the country in different screening programs. We have some programs with mobile vans or coaches that go to different underserved communities. We have screening programs in the Northwest Territories and in Yukon. We're trying to establish this now in Nunavut.
It is feasible, but the message of not recommending routine screening is the most harmful. That is really where we have to focus, to start.
11:50 a.m.
Liberal
Sonia Sidhu Liberal Brampton South, ON
Thank you.
My next question is about the American guidelines that were published on April 30. Could you talk to the committee about the methodology and the justification for using the recommendation for screening at the age of 40? I know you said it saves almost 2,600 lives, which is a lot of lives. Then we heard the testimony.
Dr. Seely, you mentioned a study done in Sweden on breast cancer imaging. Could you expand on the results and, overall, on the current European guidelines too?
11:55 a.m.
Professor of Radiology, Faculty of Medicine, University of Ottawa, As an Individual
Let me start with the American recommendations.
The U.S. preventive services task force, for their recommendations released earlier this year, started their methodology with the principle that they knew screening mammography was effective at reducing breast cancer mortality. They did not re-evaluate the old randomized controlled trials, recognizing that it had already been proven effective. They only looked at data from 2016 onward, and they included some of the up-to-date evidence showing the benefit of early-stage diagnosis with screening and the increased incidence of breast cancer in women in their forties. That was the basis.
They also looked at the evidence of the disparities among races and ethnicities that showed they were not able to access screening. That was one of the big reasons to change the guidelines to include women in their forties.
You had a question about Sweden, about the more recent observational trial. They were able to compare no screening...and then the trial initiated screening and compared the mortality from breast cancer. Once they initiated screening, they compared the women who did not participate in screening with the women who did participate. What they found was a 60% reduction in breast cancer mortality by comparing women who did not choose to participate in screening with those who did participate. It was a huge benefit in lowering mortality. This accommodated all the recent advances in treatment, and it showed that even for the same treatment of breast cancer, screen detection was associated with a marked improvement in breast cancer mortality.
11:55 a.m.
Liberal
The Chair Liberal Sean Casey
Thank you, Dr. Seely and Ms. Sidhu.
Next is Mr. Thériault.
You have two and a half minutes.
11:55 a.m.
Bloc
Luc Thériault Bloc Montcalm, QC
Thank you.
In an article in Le Devoir from May 30, 2024, the chair of the Canadian working group explains the difference between the recommendations of her group and those of her American counterpart, including the fact that the Canadian working group reviewed 82 studies on patient values and preferences.
To quote Dr. Thériault: “The majority of women in their 40s in these studies, when presented a scenario in line with our numbers (deaths prevented, the number of additional scans, etc.), do not want to be screened”. I find that rather surprising.
Do you think it is normal for value and preference studies to prevail when women's lives are at stake?
11:55 a.m.
Advocacy Manager, Prevention and Early Detection, Canadian Cancer Society
That doesn't align with what we're hearing in our community, as our cancer community is quite strongly advocating for access. It's also important to remember that the opportunity to screen is a choice, and women can decide not to be screened if it is not their preference and does not align with their values, especially knowing the risks and benefits.
It is fair to consider that in this very holistic approach, we're looking at mortality, we're looking at costs and we're looking at quality of life, which is also an important factor. There's a lot to look at here, but in developing our own recommendations, we took quite a holistic approach.
11:55 a.m.
Bloc
Luc Thériault Bloc Montcalm, QC
Thank you.
Dr. Seely, according to the working group that made the recommendations, the risks of excessive screening far outweigh the benefits. Risks include increased anxiety, unnecessary tests tied to overdiagnosis, such as biopsies.
Do you think that the overdiagnosis referred to in the studies we used is overblown?
11:55 a.m.
Professor of Radiology, Faculty of Medicine, University of Ottawa, As an Individual
Those are a couple of great questions.
The abnormal recalls—what they've called false positives—are vastly exaggerated, and our patients tell us they are so grateful when they get screened and are happy to return to screening. The majority of studies show this.
Overdiagnosis—the case of diagnosing a cancer that is not going to lead to death in a woman because she might die of another cause—is a small, acknowledged risk of screening. It is much less likely in a woman in her forties who has another 40 to 50 years ahead of her than a woman in, say, her eighties who might die of other causes. Saying this is a harm to prevent a woman from benefiting from early diagnosis is an exaggeration.
Noon
Liberal
The Chair Liberal Sean Casey
Thank you, Dr. Seely.
The last person to pose questions to this panel is Ms. Zarrillo. You have two and a half minutes.
Noon
NDP
Bonita Zarrillo NDP Port Moody—Coquitlam, BC
Thank you.
Dr. Seely, I'm concerned about the reality of discrimination in medicine. I'm wondering if a modernized, back-to-the-drawing-board approach to this task force would offset some of that discrimination.
Noon
Professor of Radiology, Faculty of Medicine, University of Ottawa, As an Individual
There are international guidelines that include experts and methodology expertise to produce guidelines. I know we're speaking about breast cancer, but we have colleagues who are outraged by the task force recommendations for prostate screening, lung cancer screening, cervical screening and a whole host of others.
The expertise is there. You must include people who understand the disease and who are aware of the up-to-date evidence in order to produce guidelines that will save lives and make a difference. We need to go back to the drawing board.
Noon
NDP
Bonita Zarrillo NDP Port Moody—Coquitlam, BC
I'll finish by asking Ms. Wilson Cull about those at elevated and high risk. Could inclusion of the recognition of elevated and high-risk parameters have an impact on breast cancer survival or breast cancer diagnoses in people? What impact would it have?