That's an excellent question.
That quote, or the background to that quote, is what stimulated all this work that I've done. In 2017, Health Canada had five reports of ALCL, and plastic surgeons knew that was far under-reported. The reporting to Health Canada is mandatory from manufacturers and if there's an adverse event, but it requires somebody to do that.
The other problem was that it was very difficult to find out how to do the actual reporting. I had colleagues who notified me of cases. They tried to report them to Health Canada, and that was very challenging in terms of the way you could do that.
I think part of the reason we were very successful in doing it was simply that I reached out to colleagues. If somebody heard of a case, I was able to contact them to get all the details of it, and I was able to keep very accurate information. Had a registry been in place that had easy reporting, I think the numbers would have been much more accurate early on.
It's still unclear. That's the difficulty with the Health Canada data. We asked them to share the data so that we could look at it, compare it with the data we have and see if there was overlap or double counting. They said they were not able to do that, so I have no idea how they get their data or how robust the data is.