Health Committee on June 13th, 2024

[Kelly Wilson Cull]

Thank you very much.

I think you used the term “mixed messages”, and that's part of the challenge we're experiencing as a result of these guidelines. We have provinces and territories across Canada with different approaches to breast cancer screening. What that has inadvertently created is inequity: Where you live dictates what your breast cancer screening access looks like.

From the Canadian Cancer Society's point of view, we are urging all provincial governments to reduce access to systematic screening starting at age 40. We recognize that some provinces—I'm from Nova Scotia—have access to self-referral, for example, and have for some time, whereas provinces like Ontario have committed to rolling this out but aren't quite there yet.

Where you live shouldn't dictate your access to breast cancer screening in Canada. We want to ensure that there's an equitable approach. At this point, we know that provinces are taking their cues from the task force, so we need leadership and a strong infrastructure to ensure the provinces are getting the most accurate, up-to-date, comprehensive guidelines. Then they can make the right decisions for their constituents.

[The Chair, Liberal, Sean Casey]

Thank you.

Next we have Mr. Naqvi for six minutes, please.

[Yasir Naqvi, Liberal, Ottawa Centre, ON]

Thank you very much, Chair. I'll be sharing my time with Dr. Powlowski, if that's okay with you.

I want to thank all of the witnesses for being here, particularly Dr. Seely, whom I had the opportunity to meet a little over a year ago on precisely this issue. I'm thankful to her for the guidance that she gave me on the task force work.

Since that time, the issue of breast cancer and screening has become personal to me, as my mother was diagnosed with breast cancer. Although she's an older woman, it was screening that caught her cancer in its very early stages, and she's on an incredible journey of recovery and living her full life.

I must say that I feel very frustrated by the draft guidelines the task force has issued and I am thankful that this committee is doing the important work and listening to witnesses.

Dr. Seely, when we met, you spoke about a study you had done, I believe in 2023, that looked at how screening of women aged 40 to 49 impacted net survival. Would you be able to elaborate for us on some of the key findings and why you believe the screening age should be lowered to 40?

[Dr. Jean Seely]

Thank you very much, Mr. Naqvi. I'm sorry your mother was diagnosed, but I'm very grateful that she was screen-detected, because it's a very different diagnosis.

As noted, there is a geographic difference in screening programs in the country. Some women who live in the provinces of British Columbia and Nova Scotia are able to participate in screening programs, and others are not. We were able to look at over 55,000 women diagnosed with breast cancer in Canada over a 10-year period. What we could see is that the women who lived in a province where there was a screening program offered for women in their forties had a significant increase in the 10-year net survival of their breast cancer, which was on par with some of the chemotherapeutic agents we use for every woman diagnosed with a hormone receptor-positive cancer.

We found there was a significant decrease in breast cancer mortality for women living in the provinces that had screening programs. What we didn't know is how many women in those provinces were screen-detected, because that's not something we currently track. However, we could see a marked improvement. It correlated with a study we had done previously that showed the stage at which breast cancer was diagnosed was significantly lower—stage 1—if they lived in those provinces, compared to the ones that did not screen. It also had a benefit for women who were older, in their fifties, and increased improvement in their stage and overall survival.

[Yasir Naqvi, Liberal, Ottawa Centre, ON]

Very quickly, before I pass it on to Mr. Powlowski, I'll note that one of the cautions we hear is about false positives: If you lower the age, it may increase that particular incidence. Can you comment on that? Is that a misguided fear in this instance?

[Dr. Jean Seely]

The task force has called them false positives, which is not a correct term. We're not telling a woman when she's recalled from screening that she has cancer; we're simply telling her she needs some more imaging to identify if there's an abnormality. Over 94% or 95% of those turn out to be overlapping tissue. We're looking at a three-dimensional structure and showing it in 2-D, and it's something we can use to reassure a woman at that time.

We need to do biopsies, and about 1% or less are benign. This is a very well-tolerated procedure. I do biopsies all the time, and women tell me they would much rather have this kind of abnormal imaging test than have a delayed diagnosis of breast cancer. The women who have a delayed late-stage diagnosis are angry that they lost the opportunity to be screen-detected.

[Yasir Naqvi, Liberal, Ottawa Centre, ON]

Thank you.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

Dr. Seely, it seems like the task force ignored the advice of their own experts, which is, to me, very troubling. Could you start off by clarifying for us who is on the task force? What is their level of expertise?

[Dr. Jean Seely]

The working group of the task force was carefully selected to have no expertise in breast cancer imaging, diagnosis or treatment. I was invited to be an expert to the evidence review panel, which is the group that looks at the evidence and provides it to the working group to inform their recommendation.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

Can I interrupt you? Are you just supposed to compile the evidence, or are you supposed to be evaluating the evidence?

[Dr. Jean Seely]

For my job as expert adviser to the evidence review panel, we recommended the evidence. We put it into context. These are people who don't understand imaging. We gave a lot of recommendations and included the fact that the technology in those old trials was no longer used, but the working group overrode our recommendations and insisted to the evidence review panel that they must include those studies.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

Who is on the evidence review panel?

[Dr. Jean Seely]

On the evidence review panel are three different groups across the country. The one in Ottawa consisted of methodologists and epidemiologists whose methodology expertise is to analyze the evidence. That's who we were helping to advise.

The working group is separate, and we never directly interacted with them, but we could see their comments and their responses to the evidence review, which dictated the evidence that could be used.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Seely.

Thank you, Dr. Powlowski.

Mr. Thériault, you have six minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you, Mr. Chair.

I also want to thank the witnesses for their informative testimonies.

Dr. Seely, the working group recommends not proceeding with systematic mammography screening for women 40 to 49. This group emphasizes the informed choice of the patient, which involves an equally informed discussion between the patient and her doctor on the pros and cons of screening.

A study published in 2022 mentions that the obstacles to an individualized breast cancer risk assessment included knowledge of the risk factors and risk assessment tools. It also mentioned that doctors were having a hard time identifying breast cancer risk factors outside of family history, such as reproductive factors, ethnic origin or breast density. The study shows that some doctors lacked the skills to calculate the overall risk of breast cancer.

Do you not think that the doctors' lack of knowledge of risk factors and assessment tools can influence the informed decision that the patient should be making?

[Dr. Jean Seely]

Thank you for your question, Mr. Thériault

There are three factors to that answer.

One is that 80% of women in their forties who get breast cancer have no risk factors. This is why we don't recommend a risk-based approach to screening. We recommend systematic screening starting at age 40. We would miss too many cancers otherwise.

There is a second point, which is that there's a tremendous lack of family physicians. In Ontario, over two million people do not have a family physician. This poses a very big obstacle to getting access to screening and to having a discussion to allow them in.

Third, you mentioned a very good point. There is a lack of awareness of the risk factors. Even women who should be in high-risk screening are not advocated for to have screening earlier than age 40, when they should be in a high-risk screening program.

These are obstacles that the task force is placing with these recommendations, and they are going to accentuate the confusion and disparities we see, particularly among some of the racial groups and ethnicities I mentioned. It's a very important point.

[Luc Thériault, Bloc, Montcalm, QC]

I will ask a question that has not been asked yet during our meetings.

Every specialist and expert who comes to see us, including the representatives from the Canadian Cancer Society, tell us that there needs to be systematic screening between 40 and 49.

Why did the working group decide to set aside this advice? Is there a financial aspect, for better or worse, tied to that, even though I hear that this could save us a lot of money? What do you think? Why are these people insisting on this?

[Dr. Jean Seely]

It's a very difficult question to answer. We know there is a very strong anti-screening bias among the working group members.

Before the task force even began its work on this guideline, the co-chair publicly stated that she didn't believe there was any new evidence and didn't think the recommendations would change. Many of the other working group members are very strongly anti-screening, and they have already publicly published or commented on this.

I think it's about a lack of knowledge or lack of informed patient care. I am not sure if there are any other factors, but it's a good question.

[Luc Thériault, Bloc, Montcalm, QC]

That seriously catches my attention. Do you believe that the bias we talk about and that the working group talks about is very serious and harmful to women 40 to 49? What are we talking about when we talk about bias? This term comes up often during the study.

[Dr. Jean Seely]

I'm so sorry. I didn't really understand the question. If you're asking about the prejudice—

[Luc Thériault, Bloc, Montcalm, QC]

What is the bias? People say there is a bias associated with the screening. What is so biased? What is the nature of these biases when it comes to saving lives?

[Dr. Jean Seely]

The bias we see is the belief that treatment will resolve all breast cancers and is not dependent on stage. We've heard anecdotes that a patient at stage 3 might benefit from breast cancer treatment and do better than at stage 1. We have data that shows that is absolutely not the case. This comes from a belief based on a lack of awareness of all the data and a strong belief that treatment can solve anything. I see too many women dying within a year of their diagnosis of breast cancer.

That is exactly not our experience. It's an incorrect belief that chemotherapy will resolve and solve all the problems.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Thériault.

Next is Ms. Zarrillo, please, for six minutes.

[Bonita Zarrillo, NDP, Port Moody—Coquitlam, BC]

Thank you, Chair.

Thank you, Dr. Seely, for all your testimony today.

We've definitely seen a reaction from the community. We've seen a reaction from women, who have a hard time being believed on many things but certainly on their health. I hear your comments about going back to the drawing board. It seems like this study is perhaps antiquated and needs to be modernized.

Dr. Seely, I'm going to ask you about what special considerations you would want if this task force goes back to the drawing board, but before I do, I want to share my personal story.

I was diagnosed with breast cancer in my forties, and I think people forget that we have children. Most women who are diagnosed with breast cancer in their forties have children. My youngest was in grade 6 at the time, and I think some of the visceral response we've seen from the community is due to the fact that the task force didn't seem to consider what impact breast cancer has on the people who experience it.

It took me two years for my doctor to get me screened. You mentioned the supplementary screening. I have dense breasts, and in the end, the cancer was close to my pectoral muscle and needed an ultrasound to be found. It was lobular, not ductal, so it grew in sheets and could not be felt as a lump. I chose to have a double mastectomy because of the stress of not being believed for two years and then being at stage 2 before they found it. Having to tell my children was very difficult.

Terry Fox is from the Tri-Cities, where I am in Port Coquitlam. Their run is in Coquitlam, and every year the students of SD 43, our school district, do a Terry Fox run. To see your sixth-grader put your name after “I'm running for” is something I wouldn't want any woman to see.

I'm sorry; I'm upset today. I didn't think I would get upset.

I wonder if you could let us know what the new technologies are. What is the task force missing? What are the special considerations they need to remember when the government sends this back for reconsideration?

[Dr. Jean Seely]

Thank you so much, Ms. Zarrillo. I'm so sorry about your experience.

I hear this and see this almost every week, and you are not alone. There are many women like you, and we're here today to do a better job for women in their forties, when they are in the prime of their lives and are productive members of society and parents.

Breast cancer doesn't just affect a woman; it affects the whole family. It affects grandparents, spouses and children, and this is why we are working to change these guidelines.

These guidelines cause tremendous confusion, and unfortunately, even using the estimated number of one per thousand lives saved by screening but lost if you don't screen women in their forties in Canada, we estimate this translates into 400 to 600 women's lives lost per year. This has a huge impact on Canadian society.

The technology has improved dramatically. I mentioned the 20% to 40%. This is based on digital mammography, which we now use and is particularly better for women with dense breast tissue. We also need digital breast tomosynthesis, which is another technology shown to increase cancer detection rates by up to 40%. It is being used in multiple centres in the United States and is slowly being used in Canada.

Reducing cancer and diagnosing it at stage 1 are possible. We now know from randomized trials that we can screen women with dense breasts with an MRI and reduce their interval cancers by 80%. They are diagnosed at stage 1.

This is all the technology we can use to inform up-to-date evidence.