Health Committee on Feb. 12th, 2024

[The Chair, Liberal, Sean Casey]

I call this meeting to order.

Welcome to meeting 101 of the House of Commons Standing Committee on Health. Today's meeting is taking place in a hybrid format pursuant to the Standing Orders.

I have a few comments for the benefit of members and those participating online.

You have interpretation available to you on Zoom. You have the choice at the bottom of your screen of floor, English or French. Those of you in the room may already know this: You can use the earpiece and select the desired channel. For those online, please bear in mind that screenshots or taking photos of your screen is not permitted.

In accordance with our routine motion, I'm informing the committee that all remote participants have completed the required connection tests in advance of the meeting.

Pursuant to Standing Order 108(2) and a motion adopted on May 16, 2022, the committee is resuming its study of women's health.

I'd like to welcome our panel of witnesses and thank them for their patience while they awaited democracy to run its course so that we could be here.

Appearing as individuals, we have Dr. Gillian Hanley, associate professor, department of obstetrics and gynaecology at the University of British Columbia. Dr. Hanley is appearing by video conference, as is Dr. Jessica McAlpine, professor and division head, division of gynecologic oncology at UBC.

Representing Ovarian Cancer Canada, we have Tania Vrionis, chief executive officer, and Valérie Dinh, regional director for Quebec.

Representing the Society of Gynecologic Oncology of Canada, we have Dr. Shannon Salvador, president-elect.

Thank you all for taking the time to appear today and for being generous with your time in awaiting our arrival.

Each of you will have five minutes for an opening statement, and we're going to begin with you, Dr. Hanley. You have the floor.

I don't mean this Dr. Hanley—

[Some hon. members]

Oh, oh!

[The Chair, Liberal, Sean Casey]

You'll get your turn.

Dr. Gillian Hanley, you have the floor.

[Dr. Gillian Hanley, Associate Professor, Department of Obstetrics and Gynaecology, University of British Columbia, As an Individual]

Good afternoon. Thank you very much for inviting me to speak with you today.

My name is Gillian Hanley, and I am an associate professor in the department of obstetrics and gynecology at the University of British Columbia and a tier 2 Canada research chair in population-based gynecological and perinatal outcomes.

I am also a member of the Gynecologic Cancer Initiative, along with Dr. McAlpine. The GCI is an interdisciplinary network of patients and family partners, clinicians and scientists who are all working across gynecological cancer disease sites, across institutions and across disciplines, with the goal of reducing death and suffering from gynecological cancer by 50% by 2034.

This is an important goal, since in this year alone, 12,000 Canadian women, transgender men and non-binary people will be diagnosed with a gynecological cancer. Gynecological cancers include cervical, endometrial, vulvar, vaginal and ovarian cancers, and they represent 10% of cancer deaths in women.

Importantly, funding for gynecological cancer does not reflect this disease burden. The Canadian Cancer Research Alliance has calculated that there has been a 60% higher investment per case in breast cancer research than in gynecological cancers. This disparity increases to a 270% higher investment in breast cancer when the numbers are based on cancer-related deaths. Thus, both national focus and dedicated investment are needed in this important area.

Despite these challenges, Canadian researchers have made important strides in understanding, treating and preventing gynecological cancers. There are many areas in gynecological cancer in which Canada is world-leading, including ovarian cancer prevention, which is the focus of my research.

Despite tremendous international effort, there is no effective screening method for ovarian cancer. Symptoms generally do not arise until the disease is in advanced stages, at which point five-year survival rates are well below 50%; thus, we have focused our efforts on preventing ovarian cancer.

There are five distinct types of ovarian cancer. Seventy per cent of ovarian cancers and 90% of deaths from ovarian cancer are from the high-grade serous type. Approximately 20 years ago, we discovered that most high-grade serous cancers arise in the Fallopian tube and not on the ovary, as was previously believed. Fallopian tubes connect the ovaries to the uterus, but they play no known role post-childbearing. This is not true of ovaries, which produce endogenous hormones that are important for women's long-term health. Thus, taking the opportunity to remove the Fallopian tubes during other gynecological and pelvic surgeries while leaving the ovaries behind has been a ground-breaking ovarian cancer prevention approach.

In 2010, our team in British Columbia launched the world's first population-based ovarian cancer prevention program. We recommended that salpingectomy, the removal of both Fallopian tubes, be performed at the time of hysterectomy, the removal of the uterus. We also recommended removal of Fallopian tubes rather than ligation or having one's tubes tied for permanent contraception. Recognizing that approximately 80% of ovarian cancers occur in people who have no genetically increased risk, we based this prevention effort not on risk for ovarian cancer but rather on opportunity. Hence, we called it opportunistic salpingectomy. We are taking an opportunity provided by another surgery to also conduct this important ovarian-cancer prevention strategy. This is now recommended practice in nine countries worldwide, including Canada. Through research, we've demonstrated the safety and feasibility of opportunistic salpingectomy, and in 2022, we provided the first evidence that removing Fallopian tubes does significantly reduce risk for ovarian cancer.

Despite these compelling data, a recent assessment of the pan-Canadian practice of Fallopian tube removal demonstrated considerable variation in uptake outside of B.C. The study estimated that between 2017 and 2020, nearly 80,000 Canadians received a tubal ligation or hysterectomy without Fallopian tube removal, representing a missed opportunity to stop ovarian cancer from developing and translating to a possible 1,000 future cases of ovarian cancer that could have been prevented.

My recommendations today are to increase the funding for gynecological cancer research to accurately reflect the burden of these cancers on Canadians and to target funding to groups that are multidisciplinary and working across cancer disease sites and institutions to make the fastest and most meaningful progress. We also recommend putting a focus on funding for implementation science to ensure that important research advances are available to Canadians and that the federal government consider engaging in communication strategies targeted to patients and clinicians to help get these important research advances to all Canadians.

Thank you very much.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Hanley.

Next is Dr. McAlpine for five minutes.

Welcome to the committee. You have the floor.

[Dr. Jessica McAlpine, Professor and Division Head, Division of Gynecologic Oncology, University of British Columbia, As an Individual]

Thank you very much. Thanks for the opportunity to be part of today's session.

I'm a surgeon, scientist and professor at UBC. I spend half of my time in surgery and seeing patients with gynecological cancers and half in translational research.

You have heard from my colleagues about the disparity of funding for gynecological cancers, and you will hear more. I'm extremely grateful to federally supported funding initiatives, such as the Canada research chairs, and institutions like CIHR, without which many of the discoveries you'll hear about today would not have been possible. However, the competition for research funding has soared, and actual funding available, particularly for multidisciplinary team projects and clinical trials, is increasingly difficult to obtain. We're at risk of losing our reputation in Canada of being innovative, creative leaders changing the landscape of gynecological cancer care. We're at risk of appearing irrelevant if the scientifically validated initiatives that we generate are not actually implemented and delivered to Canadians in a timely fashion.

I'm going to share one example of proven research advancement that was homegrown in Canada, an example of where we need to do better about ensuring equitable access for all Canadians.

Endometrial or uterine cancer is the most common gynecological cancer. Globally, it is increasing in both incidence and mortality, and it's on a trajectory to be the second most common cancer that women—including gender-diverse, trans and non-binary individuals—are likely to develop in their lifetimes. Despite these statistics, there has been little research, attention or funding related to endometrial cancer. It receives about a fifth of what prostate and breast cancer research receive.

Beginning about 10 years ago, we recognized that the way endometrial cancers were being categorized and subsequently managed was not working. There was little consensus between expert pathologists and their diagnostic reporting, meaning that a patient could get a completely different diagnosis from two different pathologists, directing them, for example, to six months of radiation or chemotherapy or to no treatment at all.

Clearly, this way of managing it was unacceptable. Our team worked to change this. We identified key molecular features in endometrial tumours that could be determined by simple methods that are achievable in most hospitals already. Within five years, we created a system that could consistently classify tumours and form molecular subtypes. They could identify which patients were most likely to have their disease recur and which patients were most likely to have an inherited cancer syndrome, and they could determine which treatments worked best.

Our classification system was adopted by the World Health Organization in 2020, and it was immediately implemented into international treatment guidelines. It is now considered the standard of care globally.

What is tremendously frustrating is that despite the international recognition, molecular classification is not uniformly available to patients across Canada. Even in British Columbia, where we developed this tool, it took two years for us to assure free testing for all endometrial cancer patients. In Canada, we have centres where they may actually have to wait eight to 10 weeks for their results. They may have to send their tissue out of province to get molecular testing. Molecular testing may never even be discussed with patients. Essentially, endometrial cancer has had one of the worst examples of health care inequities of any cancer. Our team is passionate about changing this.

My call to action is to first work to ensure that scientifically proven, value-added initiatives in prevention, diagnosis, screening and treatment of gynecological cancers are available to all Canadians. This could be by supporting provinces, for example, to fund molecular testing for endometrial cancers across Canada. We must change the current reality in this country that how you are treated depends on where you're diagnosed and must instead ensure equity for all.

Second, I call for increased funding for gynecological cancers, particularly funding for clinical trials and to support multidisciplinary team research, where it's been so successful in identifying important changes needed in clinical care. We've all witnessed what this government's rapid, impactful and successful communication actions could do in the recent COVID crisis. This proves that federal government initiatives on health communication are possible and can be effective.

I look forward to seeing what we can achieve in these initiatives for the prevention and treatment of gynecological cancers in Canada, and I commit to working hard with you to create these changes.

Thank you very much.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. McAlpine.

Next is Ovarian Cancer Canada. I understand you have a joint statement, Ms. Vrionis and Madam Dinh. The next five minutes are all yours.

[Tania Vrionis, Chief Executive Officer, Ovarian Cancer Canada]

Thank you, Mr. Chair.

Thank you, honourable members.

On behalf of Ovarian Cancer Canada and all Canadians affected by ovarian cancer, I want to thank the House of Commons Standing Committee on Health for conducting this important women's health study and for inviting us to appear as witnesses.

Eight women a day are diagnosed with ovarian cancer in Canada, with 75% of those being diagnosed as late stage. Ovarian cancer's five-year survival rate is only 44%. Four out of the eight women diagnosed today will not be here in five years.

There is no screening test. There is no definitive diagnostic test. There are few treatment options available. Women deserve better.

My colleague and I will be highlighting for this committee three of the challenges and associated opportunities regarding this disease from prevention to diagnosis to treatment.

The most effective way to impact ovarian cancer incidents and outcomes now is through prevention. While some believe that the Pap test screens for ovarian cancer, this is not the case. There is no screening test for this disease.

With an estimated 20% to 25% of ovarian cancers known to be hereditary, identifying those at risk through genetic testing and offering preventative or risk-reducing options will have a significant impact on saving lives now.

Ovarian Cancer Canada and our partners have revealed gaps and inequities regarding access to genetic testing including but not limited to regional variations in criteria and wait times, under-representation of individuals of Asian or indigenous origin, and racialized and ethnic individuals being less likely to be referred for genetic testing and more likely to receive inconclusive genetic test results.

We must maximize and optimize the identification of individuals at increased risk for ovarian cancer through timely and equitable access to genetic testing to stop ovarian cancer before it starts.

[Valérie Dinh, Regional Director, Quebec, Ovarian Cancer Canada]

A timely ovarian cancer diagnosis begins with access to primary care. Ovarian cancer is known to be difficult to diagnose because of its vague and unspecific symptoms. While access to primary care is essential to timely diagnosis, some 6.5 million Canadians don't have a family doctor, and a third of them have been waiting for treatment for over a year. However, that's not all. Primary health care providers also need to be able to recognize symptoms of ovarian cancer and order the right tests so that patients are referred to a treatment centre and receive a formal diagnosis.

To obtain a timely ovarian cancer diagnosis, Canadian women must have access to primary care, and physicians and nurses must be equipped to recognize and respond appropriately to the symptoms of ovarian cancer.

With few exceptions, the treatments offered haven't changed much since the 1990s. The same methods are used to treat patients, namely surgery and chemotherapy. Unfortunately, these methods are ineffective in the majority of cases. Despite this, investments in ovarian cancer research lag behind investments in other cancers.

Ovarian cancer is a unique disease with unique challenges. Research on ovarian cancer hasn't had the same breakthroughs as research on many other types of cancer. Traditional research funding mechanisms haven't led to significant progress in the field of ovarian cancer. That's why Ovarian Cancer Canada and the ovarian cancer research community have proposed a new model that allows scientists to work closely together and build on the progress of their colleagues to accelerate and facilitate progress. In 2019, the Canadian government made a bold decision to invest $10 million in Ovarian Cancer Canada to fund this new research model.

[Tania Vrionis]

While $10 million may be a relatively small investment, it is enabling us to build a highly focused national research engine for ovarian cancer. We were also able to leverage the federal government's investment and attract more than $4.5 million in additional funding from research partners and two provincial governments, building in total a $14.5-million research program.

In just five years, Ovarian Cancer Canada has yielded an impressive return on the federal government's investment, fuelling research in six provinces resulting in five transformative clinical trials, 13 innovative preclinical studies and 25 projects on ovarian cancer model development, allowing scientists to test and identify more novel treatments in new ways.

In addition, we will soon be funding two translational clinical research projects that are aimed to improve and expand treatment options for women with ovarian cancer. We are now on the cusp of bringing new treatment strategies to Canada.

For ovarian cancer to be preventable, curable and ultimately eradicated, the federal government must continue and increase its investment in innovative, highly focused, comprehensive national research into this disease.

Ovarian Cancer Canada is leading the way in propelling crucial breakthroughs from the bench to the bedside faster. This work must be prioritized to change the trajectory of ovarian cancer in this country.

Ovarian Cancer Canada applauds the government's commitment to women's health.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you both.

Last but not least, Dr. Salvador, welcome to the committee. You have the floor.

[Dr. Shannon Salvador, President-Elect, The Society of Gynecologic Oncology of Canada]

Thank you. Good afternoon, Mr. Chair, committee members and fellow witnesses. I'm very honoured to be here before you to present before this committee.

I'm a practising gynecologic oncologist at the Jewish General Hospital in Montreal, and I am also the president-elect of the Society of Gynecologic Oncology of Canada, also called GOC.

GOC is a non-profit organization created 40 years ago as a forum for medical professionals to highlight issues in women's cancer care across Canada to help correct the disparities in cancer care access and to improve equity in research funding for new treatments.

Historically, women's cancers have been orphaned from the traditional cancer care models, so in the 1970s the gynecologic oncology subspecialty was created to care for women with cancers of the Fallopian tube, ovary, uterus, cervix, vulva and placenta. Unfortunately, these cancers have long been, and often still are, deemed a women's issue. Funding for clinical care and research has not kept pace with other more common cancers, such as colorectal, breast or lung cancers. Among all surgical cancer specialities, gynecologic oncology is uniquely comprehensive. Diagnosis, surgery, systemic treatments, surveillance and palliative care are all done by one physician.

GOC has identified three major concerns that need to be addressed swiftly to improve women's cancer care in Canada. First is the backsliding of performance in our prevention of cervical cancer. Second is the rise in incidence and death rates from endometrial cancer and the need for dedicated funding for endometrial cancer research. Third is the need for funding to train health care professionals dedicated to gynecologic oncologies as we start to form our multidisciplinary teams.

A report was published in November 2023 by the Government of Canada with the Canadian Cancer Society on Canadian cancer statistics. It identified cervical cancer as the fastest-growing cancer in women, with incidence rising at a rate of 3.7% per year since 2015. Frankly, to me this is shocking, because women should have easy access to effective cervical cancer prevention strategies in Canada.

Primary prevention via vaccination against the human papillomavirus, or HPV, is offered to school children in every province, as well as to women up to the age of 45, and it has been available in Canada since the 1990s, yet there are decreasing vaccination uptake rates in our population. HPV is the primary cause of cervical cancer as well as vulva, anal and throat cancer. GOC strongly recommends nationwide campaigns to increase the awareness of the burden of HPV and to help increase those vaccination uptake rates. There's also secondary prevention via screening through HPV and pap testing. Unfortunately, our most vulnerable populations are in locations that do not have an organized province-wide screening program yet, or easy access to health care professionals who offer screening, leading to disparities in identification and treatment of these precancerous cervical lesions.

We need to support for better provincial-based screening programs for cervical cancer in areas that are not on track to reach our goal of cervical cancer elimination, either through improved access to health care professionals providing screening or through access to HPV self-testing, as offered in some countries and as currently being highlighted in British Columbia.

Second, the same cancer statistics report also identified a worrisome trend of increasing incidence of mortality in endometrial cancer. This can be attributed both to our aging population and to an increase in obesity rates in Canada, which have very strong risk factors for this cancer. We need to increase the numbers of funded gynecological oncology positions in locations that have unequal access to specialized care, as well as access to operating room facilities and robotic surgery to accommodate the rising numbers of these women's cancers.

To support gynecologic cancer research, GOC has created something called the “communities of practice” forums. These forums have facilitated Canadian-based research teams such as the ones run by Dr. McAlpine and her team to collaborate nationally. However, dedicated research funding for endometrial cancer is rare, and we would benefit greatly from specifically earmarked allocations of funds.

Finally, there is a need to increase funding to train other health care professionals in gynecologic cancers in the field of medical oncology, radiation oncology, family medicine and nursing as we grow our multidisciplinary teams to provide holistic patient-centred care. Having more of these specially trained care providers, especially in remote locations, will greatly improve the ability of our patients to receive ongoing care closer to home.

GOC remains deeply committed to improving research opportunities, advocating timely access to health services and being a strong voice for women's cancer care in Canada.

We look forward to working with the HESA committee and other voices at the table to find solutions to these concerns.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Salvador.

We will now begin with rounds of questions, starting with the Conservatives for six minutes.

Mrs. Vecchio, go ahead, please.

[Karen Vecchio, Conservative, Elgin—Middlesex—London, ON]

Thank you very much, Mr. Chair.

I would like to begin by thanking all the women who are here today.

To Tania specifically, I assume you work with many of the doctors we see on today's panel.

[Tania Vrionis]

We do, absolutely.

[Karen Vecchio, Conservative, Elgin—Middlesex—London, ON]

You mentioned you received $10 million in research dollars, which then increased by $4.5 million through your leveraging of that money.

Would you be working with groups and women like these to do that research?

[Tania Vrionis]

Absolutely. We're very strong partners with GOC. Certainly we do some work with our prevention task force friends on the screen there as well. One of the things we're most proud of at Ovarian Cancer Canada is our ability to work across the country, build these collaborative teams and participate in those.

[Karen Vecchio, Conservative, Elgin—Middlesex—London, ON]

Thanks so much.

I want to go online to Dr. Jessica McAlpine, and thank you very much for this information.

You indicated molecular features. When you're doing this, sometimes you don't need to have radiation and chemotherapy, which, for many people suffering from cancer, end up being the most drastic pieces they have to go through in how they are dealt with after surgery.

First of all, when you're trying to detect cancers such as cervical cancer—things that get diagnosed later on—how long does it take to start diagnosing people and getting them into these types of programs in which they might be able to look at things like this molecular piece you're talking about?

[Dr. Jessica McAlpine]

Cervical cancer, first of all, has probably a two-year lag period between pre-cancer and advanced cancer, with all those opportunities to either prevent it with vaccinations and screening, as Shannon Salvador mentioned, or to intervene and cure it. There are great opportunities there.

The endometrial cancer I was talking about is one that might present with spotting. It very much depends on the molecular features of that tumour and whether it is a cancer confined to the uterus and cured by surgery alone or is identified by that molecular feature and definitely needs more treatment because of a very high risk of recurrence.

In knowing that, there are opportunities to intervene and cure, and there are opportunities to spare treatment just in those two examples.

[Karen Vecchio, Conservative, Elgin—Middlesex—London, ON]

That's fantastic. Thank you so much.

I want to move over to Dr. Salvador.

We're talking about genetic testing when looking at breast cancer. We're talking a lot about the fact that for those high-risk groups here in Canada, maybe we should be doing it 10 years earlier. I think those are some of the things we heard—the probability at 50 or 40.

When it comes to cervical cancer, how do you ensure genetic testing is done?

[Dr. Shannon Salvador]

Do you mean for cervix cancer itself?

[Karen Vecchio, Conservative, Elgin—Middlesex—London, ON]

Yes.

[Dr. Shannon Salvador]

It's not genetically related.

[Karen Vecchio, Conservative, Elgin—Middlesex—London, ON]

For genetic testing, you were talking about some of the cancers that would be in women's organs. What would be genetically seen? If we see that with breasts, what would we see in those reproductive organs?

[Dr. Shannon Salvador]

For the reproductive organs, ovarian cancer is the strongest. It's related to the BRCA mutations we also see in breast cancer. This is where we have an opportunity to intercede for a lot of women. If we know they have family members who have a BRCA mutation, they can go ahead and get themselves tested.

Again, this is an opportunity to intercede earlier for women.