Health Committee on Jan. 31st, 2012

[The Chair, Conservative, Joy Smith]

Good morning, everyone. We have a quorum, so we're going to start right on time, pursuant to the order of reference of Friday, December 9, 2011, in regard to Bill C-314, an act respecting the awareness of screening among women with dense breast tissue.

We are going to have our witnesses until 10 a.m., when we will suspend for about a minute just so Mr. Brown can take his place on committee. Then we'll do the clause-by-clause.

Our first witness, for a ten-minute opening statement, will be Mr. Brown.

Welcome. Congratulations on your bill, Mr. Brown.

[Patrick Brown, Conservative, Barrie, ON]

Thank you, Madam Chair. It's great to have the bill here at the health committee.

It's my pleasure to present some opening remarks about Bill C-314. I want to explain to the committee the genesis of the bill and why I think this is an important initiative to take up.

Over their lifetimes, one in nine women will be diagnosed with breast cancer. According to the Canadian Cancer Society, over 23,000 Canadian women will be diagnosed with breast cancer this year alone. Sadly, over 5,000 of them will lose their lives in this very difficult fight.

In the part of the country I come from, the city of Barrie, health care is of the utmost importance, as it is in most cities. When I was thinking about the type of private member's bill I could undertake, I thought that something in the health care field would be appropriate given the interest that exists in my community.

Every year we have a CIBC Run for the Cure, an annual breast cancer fundraiser, and the incredible numbers who gather to stand up and raise funds and build awareness of the fight against breast cancer always astonish me. There are always thousands and thousands who participate. Right now in Barrie we're also building a regional cancer centre to service all of Simcoe-Muskoka, and battling breast cancer obviously is going to be a key component of that new service.

I consulted the health care community in Barrie and asked what types of initiatives we could undertake to further broaden our health services. A number of issues were identified, but one initiative identified on which we can certainly move the yardstick forward was breast cancer screening. That's the genesis of this bill. I spoke with some of the top doctors and health care administrators in my riding and also with individuals from the Ministry of Health here in Ottawa, and I believe this is a means by which we can make a positive contribution in regard to breast cancer.

I feel that it is important not only for women but for all of us to be aware of the fact that screening for breast cancer can save lives. Providing women with accurate information about screening is critically important and will ultimately help them make the decisions that are right for them. That is the essence of Bill C-314.

Breast cancer is more easily treated--and in most cases curable--when found early. Dense breast tissue is one of the top risk factors for breast cancer. It is important for women to be informed of this. This can be done when they are screened for breast cancer by a mammogram. Women who have dense breast tissue should also know that potential cancer may not be detected because it cannot be seen on a mammogram and therefore cannot be diagnosed by radiologists. It appears white on mammograms and therefore is more challenging to detect.

What Bill C-314 will do is highlight the importance of being informed and of working with the provinces and territories through the national screening program in order to ensure that women receive this information. For many women--especially young women, who have a higher incidence of dense breast tissue--having this information is essential to the decision-making process. This knowledge will provide them with the tools they need to make personal health care decisions. Women who are informed that they have dense breast tissue may need to go for a different type of screening, such as an ultrasound or an MRI. Possible cancers may be deciphered more readily by a specialist using this type of diagnostic testing.

We are fortunate in Canada to have screening programs for breast cancer. Our provinces and territories deliver these programs to detect breast cancer early, before it has spread, so that treatment can be started. Providing more information through these programs will further help women and their doctors make well-informed decisions regarding breast cancer screening.

Through this piece of legislation, targeting dense breast tissue is one of the means by which I believe we can make a tangible difference in the fight against breast cancer. We all know too many loved ones, friends, and even colleagues on the Hill who have been touched by cancer. Through this bill, I believe we will make a positive step forward for individuals who unfortunately have to fight breast cancer.

Think of that overall number of 23,000 people every year in Canada who face breast cancer--believe it or not, both men and women--and of the 5,000 of them who pass away. If even a small percentage of them can have early detection through proper screening, it will make a huge difference.

There has been incredible progress in the fight against breast cancer in Canada. With survival rates up into 80%, it's an accomplishment for our country, but we can do much better. We're at 80% today, but with early diagnosis, with more effective screening, I believe the sky is the limit in terms of the survival rate levels we can achieve here in Canada.

I appreciate that the health committee is looking at this today. That's my brief introduction to what this bill is about. I hope that it can receive favourable support from the health committee and that when this becomes legislation we can all have paid a positive contribution into enhancing health care in Canada.

[The Chair, Conservative, Joy Smith]

With the committee's permission, is it okay if I ask Mr. Brown a quick question before he leaves?

[Some hon. members]

Agreed.

[The Chair, Conservative, Joy Smith]

Okay.

In your presentation, you were saying that mammograms cannot always catch breast cancers that are there. Often women are referred for mammograms. How do women know that they do have dense breast tissue? How do they know that a mammogram is not sufficient? Where is that point of decision-making made so that they know to go to the right place? They may go to a mammogram thinking that they're cancer-free and they're not.

[Patrick Brown, Conservative, Barrie, ON]

Therein lies the challenge with the screening in Canada right now. Thank you, Madam Chair, for that question, because I think it's very appropriate, Joy. It speaks to the inadequacy in screening.

Mammograms are great for many females, but for many Canadians they don't work. That's why if a female has dense breast tissue the physician or the health care worker who is performing the screening can provide that advice. Under this suggestion, they would inform the female that they have dense breast tissue and that they should, if they feel it's appropriate, engage in additional screening. That's not part of the screening protocol right now.

[The Chair, Conservative, Joy Smith]

Thank you, Mr. Brown.

I'll suspend for just one minute so that the committee can begin their questions. We'll suspend....

Yes, Ms. Davies.

[Libby Davies, NDP, Vancouver East, BC]

Just on a point of order, are we going to question Mr. Brown? Or how does that happen? Do we get to ask him questions about his bill?

[The Chair, Conservative, Joy Smith]

Certainly you could, of course. Would you like to...?

[Libby Davies, NDP, Vancouver East, BC]

Yes. I have a couple of questions.

[The Chair, Conservative, Joy Smith]

Okay.

First of all, Mr. Brown, if you don't mind, I'm going to ask the other presenters to make their presentations, and then I'll ask you to go back with the people during the question period. I'd just like to hear all the presentations first.

[Patrick Brown, Conservative, Barrie, ON]

Okay.

[The Chair, Conservative, Joy Smith]

Thank you, Mr. Brown.

Could I ask the other witnesses to come up, please? We would like to begin the ten-minute presentations.

We have with us Cathy Ammendolea from the Canadian Breast Cancer Network. She is chair of the board of directors.

From VIP Breast Imaging we have Tina Ureten, founder and president. I believe Tina will be speaking. Susan Quinn-Mullins and Feather Janz are both here as representatives today.

Will you be doing the full ten-minute presentation?

[Dr. Tina Ureten, Founder and President, VIP Breast Imaging]

I will share with Susan.

[The Chair, Conservative, Joy Smith]

If you're going to share, be mindful that I am very strict with the time. You have ten minutes, so just watch your timing.

[Dr. Tina Ureten]

Okay.

[The Chair, Conservative, Joy Smith]

We also have with us Mr. Bruce Cole, as an individual. Welcome, Mr. Cole.

We will begin with the Canadian Breast Cancer Network.

[Cathy Ammendolea, Chair of the Board of Directors, Canadian Breast Cancer Network]

Madam Chair and everyone, good morning.

I'm very pleased to be invited to speak here this morning on behalf of the Canadian Breast Cancer Network and to offer our support for Bill C-314, an act respecting the awareness of screening among women with dense breast tissue.

The Canadian Breast Cancer Network is the only national survivor-driven and survivor-focused organization in the breast cancer sector and is the voice of breast cancer survivors in Canada. We represent the concerns of over 225 partners and member organizations across Canada, as well as those of all Canadians affected by breast cancer and those at risk. CBCN's main goals are to improve access to quality breast cancer care for all Canadians and expand the influence of breast cancer survivors and families in all aspects of the breast cancer decision-making process.

It is estimated that over 23,000 women will be diagnosed with breast cancer this year and that over 5,100 of them will die from the disease. The Canadian Breast Cancer Network supports efforts made by the federal government to help women make decisions that will increase their chances of survival. As a breast cancer survivor myself, I know first-hand the importance of education and awareness around screening and treatment of breast cancer.

We are pleased to support this bill, as it encourages the use of existing programs to increase awareness, to determine gaps in information, to improve information and education to women undergoing breast cancer screening, and to address the challenges of screening with dense breast tissue. We encourage any pan-Canadian efforts by the federal government, as this will ensure that all Canadians have equal access to breast cancer programs, therapies, and services.

We applaud the efforts brought forward by the member for Barrie in Bill C-314. We would like to see a more clearly defined approach for implementing this bill that will ensure the desired outcomes are met. The member for Saskatoon—Rosetown—Biggar mentioned that there is currently a tool available through the Canadian breast cancer screening initiative to assist in decision-making pertaining to breast cancer screening. She indicated that this tool--“Information on Mammography for Women Aged 40 and Older”--will be revised to include breast density information. While we believe this to be a beneficial step, we would like to see additional mechanisms in place, clearly outlined, to indicate how this bill proposes to ensure that it meets its objectives.

One of the mechanisms the Canadian Breast Cancer Network would like to see clearly identified is an increased awareness and education for practitioners around screening women with dense breast tissue. The practitioners play an integral role in educating the patients and helping to recommend the appropriate type of screening that would most benefit those with dense breast tissue.

The Canadian Breast Cancer Network agrees that patient education and awareness are imperative when trying to provide necessary information to women being screened with dense breast tissue. We do, however, echo the concerns of the member for Vancouver Centre and the member for St. Paul's: while we want to see increased awareness around the issue, we need to ensure that we are not increasing anxiety in this population.

We are pleased with the federal government's continued commitment to work with the provinces through the Canadian breast cancer screening initiative and to provide education and awareness to Canadians through the Canadian Partnership Against Cancer.

The member for Scarborough—Rouge River identified recommendations the Canadian Breast Cancer Network has put forward that will make a difference for Canadian women. We would like to highlight how they relate to breast cancer screening for women with dense breast tissue.

While there are now more digital mammogram machines available across Canada, we need to continue to ensure that we invest in state of-the-art technology. Digital mammograms and MRIs are some of the diagnostic tools that are available to help address the challenges of screening women with dense breast tissue. We urge the federal government to continue to invest in new technologies to help Canadian women.

Currently there are no established or travelling screening facilities available in Nunavut. The federal and territorial governments must work together to establish a screening program for Nunavut that includes technologies that will address the needs of women with dense breast tissue.

In closing, the Canadian Breast Cancer Network would like to add our support for this bill, and we are encouraged that the federal government is taking a step in the right direction. However, we need a commitment from the government that this bill will be implemented in a timely manner in ways that will benefit women fighting this disease.

On behalf of the Canadian Breast Cancer Network, I would like to thank the committee for this opportunity to speak here this morning. Thank you.

[The Chair, Conservative, Joy Smith]

I want to thank you for being here.

We'll now go to Ms. Tina Ureten.

[Dr. Tina Ureten]

Madame Chair and dear members of this committee, I would like to thank you for this opportunity.

I support the Breast Density Awareness Act because I believe this act will provide very important information for Canadian women with regard to their breast health. This act can help save lives and can prevent advanced stages of the cancer.

When we talk about breast density, we are referring to the percentage of glandular tissue versus fatty tissue. That's just an explanation of breast density. Glandular tissue consists of milk-producing cells.

Breast density affects quite a large percentage of women, regardless of age and race. Women with dense breasts have five to six times more risk of having cancer. However, women are not informed after having mammograms as to whether or not they have dense breasts. That's why this act is so important.

Dr. Norman Boyd, a leader in breast cancer research at Princess Margaret Hospital, says, “Cancer turns up five times more often in women with extremely dense breasts, signalling the importance of a risk factor rarely discussed with the patients. It has been ignored to an absolutely unbelievable degree.” A poll in 2010 showed that 95% of North American women don't know their breast density. Less than one woman in ten over age 40 was informed by her doctor about breast density issues.

The important facts behind breast density are that 66% of pre-menopausal women and 25% of post-menopausal women have dense breasts. Women whose breast tissue density is over 75% have five to six times more risk of having cancer. Cancer originating from dense breasts is more aggressive, and breast density is one of the strongest predictors of failure of mammography screening programs.

It's obvious we need an adjunctive screening tool to screen dense breasts. It needs to fulfill WHO's criteria for screening. Since the mid-1970s researchers have been looking for the role of ultrasound as a screening tool. All of the results show very promising numbers for screening dense breasts after mammograms. Some authors of studies have even suggested that ultrasound should be the initial imaging used for younger women.

There is a table in your handouts. It shows how over 52,000 women were screened using mammogram and ultrasound. In the end, 186 cancer cases that were missed by mammograms were diagnosed through ultrasound. That's a significant number.

We have two different types of ultrasound these days. One is general ultrasound. We call it hand-held ultrasound. Those machines are used for general purposes. They are good. They save lives. They improve quality of life because they catch the cancer in the early stages, and they also save the cost of treating patients at the advanced stage, but they are very operator-dependent and time-consuming.

They came up with new machines. They are designed just for screening breast tissues, and they are called automated 3-D whole breast ultrasounds. These machines are really fast. They provide high-resolution three-dimensional images. They eliminate the human factor, and the radiologist can see the slices of the whole breast, so if there are multicentric cancers, they can see them in one image. Of course the sensitivity is much higher than that of the hand-held ultrasound, and they are reliable for following up with the survivors.

As my conclusion, I will say that Canadian women definitely need to be informed and educated about breast density. They are supposed to know what other tests are available for them.

The life-saving strategy should be catching the cancer in the earliest possible stage. We can't prevent this disease yet, but early diagnosis saves lives. Ultrasound is capable of detecting dense breast tissues, but automated 3-D ultrasound is a better tool for that purpose. Of the cancers detected by ultrasound, 93% are in the early stage and easier to treat.

As my recommendations, I will say we definitely need a standard mammography reporting system nationwide. We need to educate women. We need to educate health care providers. Women should know about their breast density after they go through a mammogram test. Also, they have to be informed about supplementary tests. Advanced technology with higher sensitivity should be used for effective screening and early diagnosis, and timely action for the changes is necessary before we lose many more lives.

Thank you for your attention.

[The Chair, Conservative, Joy Smith]

I'd like to thank you, Doctor. That was a very insightful presentation and gave us a much better understanding of this issue. So thank you very much.

We'll now go to Ms. Quinn-Mullins.

[Susan Quinn-Mullins, Representative, VIP Breast Imaging]

Thank you, Madam Chair, and thank you to the committee for allowing me to provide you a patient's perspective. I'm not going to take too long, because Dr. Ureten has already outlined things.

I am a breast cancer survivor with dense breast tissue. I had two instances when I actually had small areas on my right breast. One was a non-cancerous nodule and another one was DCIS, which is a sort of pre-cancerous stage. So I actually was someone who was very breast-aware and also did know that I had dense breasts. That was something that kind of came up in conversation. What I didn't know was anything about the risk factors, about what having dense breasts meant. This was a term like many other terms that are kind of thrown around when you have a diagnosis.

I was actually very religious with mammograms, as anyone who's been through this experience was, and in March 2007 was very relieved when my mammogram came back as clear. Then I felt a lump in my breast in August 2007, so four months later. An ultrasound at that point revealed that I had a fairly large tumour that was nestled between cysts and sort of sat in that dense breast tissue and obviously hadn't shown up on the mammogram.

Despite regular attention to my breast health, I was diagnosed with stage 3A breast cancer, locally advanced breast cancer. To quote my oncologist, the tumour was “a little bit larger than we'd have liked it to be”, and unfortunately it had also spread to my lymph nodes. As importantly—and as you've just heard—it was a very aggressive cancer. My next year was about a mastectomy, chemotherapy, radiation, and 15 months of Herceptin. Without Herceptin, to be quite honest, I wouldn’t be here today, because the cancer was that aggressive.

I believe my tumour was there in March 2007. And though I can never know for sure, I believe it would have been smaller, it probably would have been contained, and my survival odds would be better. Had there been a protocol for women like me with dense breasts that included ultrasound as part of my routine follow-up, perhaps my journey would have been different. Even today, as a survivor with dense breast tissue, ultrasound is not part of my annual follow-up because it's not part of the generally accepted protocol. I believe that's very wrong.

I can only tell my story, but I have heard many similar stories from other women, as I facilitate a monthly peer support group in Burlington, Ontario.

We need to educate women and health care professionals about the increased risks faced by women with dense breast tissue. We need to provide better tools for monitoring those of us who are facing those risks. Breast density is a serious issue. As you have heard, it affects all women, regardless of race and colour. We know that we are in fact at higher risk of getting cancer and that the cancer will be more aggressive.

Please, I would ask the committee on behalf of all breast cancer survivors to support this bill and ensure that this information does get out at the provincial and territorial level.

Thank you for listening.

[The Chair, Conservative, Joy Smith]

Thank you so much. We're so glad of the outcomes that we see before us today.

We'll now go to Mr. Cole.

[Bruce Cole, As an Individual]

Thank you, Madam Chairman.

I would like to thank Mr. Patrick Brown for asking me to speak to the Standing Committee on Health regarding Bill C-314, an act respecting the awareness of screening among women with dense breast tissue.

My mother passed away from breast cancer at age 72. Up until then I had heard of breast cancer but did not take much notice. I really took notice when my wife was diagnosed with breast cancer at age 36 and passed away at 40, leaving children aged 17, 15, and 13. Her family had no history of this terrible disease.

Family and friends have spoken to me on many occasions regarding this terrible disease, and I have been able to help and guide individuals through their tough times.

Since my wife passed away from breast cancer, I have been involved with the Canadian Breast Cancer Foundation as a donor and volunteer. Among other important parts of its mission, the foundation provides reliable, evidence-based information to help women make informed decisions about their breast health. I was fortunate enough to attend the world forum on breast cancer last June in Hamilton.

If Bill C-314 is passed, it will help to improve the quality of information provided to women as part of Canada's organized breast screening programs. This will help raise women's awareness about breast density and its implications for their health. If we could identify women with dense breast tissue, they could be monitored with regular breast cancer screening, and we would be in a position to detect and treat breast cancer earlier, when health outcomes, survival rates, and quality of life are usually better.

Collaboration and information sharing is essential between the Public Health Agency of Canada and the provincial and territorial governments through the Canadian breast cancer screening initiative. Let's enhance this sharing of information to benefit women's health. The passing of Bill C-314 would enhance knowledge and understanding of breast density screening, follow-up, and women's health outcomes.

The existing breast cancer screening programs in Canada differ somewhat province by province and from territory to territory. To improve women's health, the organized breast cancer screening programs should be uniform, offering all Canadian women access to the same services wherever they live.

Breast density increases a woman's chances of developing breast cancer. A woman with dense breasts has a three to six times greater risk of breast cancer than a woman who does not have dense breasts. Breast density is higher in younger women who have not gone through menopause. Given this, the women who most need our attention are those in the 40 to 55 age group.

Breast density is diagnosed by mammography. It cannot be diagnosed by touch. A woman's first mammogram will indicate whether she has dense breasts. For women diagnosed with breast density, regular screening by digital mammography or MRI as part of an organized screening program is recommended. Research shows that digital mammography is more effective than screen-film mammography at detecting breast cancer in dense breast tissue. Digital mammography is gradually replacing screen-film mammography in Canada.

Further research is required to better understand the biology of breast density and its role in the development of breast cancer. Further research is also needed to define measures of breast tissue density, optimal imaging modalities, and the frequency of screening.

Knowing about breast density is an important part of a woman's overall breast awareness. If multiple members of a woman's family have been diagnosed with dense breasts, she is encouraged to speak to a health care provider about having a mammogram to assess for breast density.

Women in their 40s, women who are 50 years plus and have not gone through menopause, and women with clinically diagnosed dense breasts are encouraged to ask to be referred to a facility with digital mammography to assess breast density and for regular breast cancer screening.

My wife was 40 when she passed away from breast cancer. She did not have access to the screening technology and knowledge that we have today. I ask you to consider Bill C-314 as a way to raise women's awareness about breast density, how it increases breast cancer risk, and the importance of screening to diagnose breast density and to monitor the breast health and breast cancer risk of women with dense breasts.

I thank the committee for letting me speak today.

[The Chair, Conservative, Joy Smith]

I thank you very much for that.

We've come to the end of our witness presentations at this time. I would like to ask Mr. Brown if he would be so kind as to join us, because I know there are some committee members who want to call on his expertise to answer questions. Thank you.

We're now going to go into a seven-minute Q and A. We will begin with Ms. Davies.