Health Committee on June 16th, 2015

[Dr. Natasha Leighl]

To follow up on that, as I think we've already heard from the Canadian Cancer Society team, in addition to smoking cessation, assessing for a risk from radon and radon exposure and measures to decrease asbestos and other workplace exposures I think are very important.

You are absolutely right. There are other factors. Family history is important. I think this is the challenge for researchers. If, with your help, we can screen those at highest risk and really change the burden of this disease, the next step for us is to try to focus on those patients with family histories. Can we get a better understanding similar to what we have in breast and ovarian cancer, colon cancer, and some of these other family syndromes?

We've already learned that there are some specific gene abnormalities. For example, this EGFR gene that I mentioned can be hereditary. Once we are able to target the largest population of those at risk, I think we can then take a systematic approach at looking at these other risk factors, particularly in the never-smokers and people with no apparent risk. I think it's a huge area of research interest, and yes, family history and potentially genes are related to lung cancer risk.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

How much time do I have, Chair?

[The Chair, Conservative, Ben Lobb]

You have 30 seconds.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

Thirty seconds? That's enough to ask a short question.

We're talking about smoking. In the home where I grew up, nobody smoked, but every smoker who came to our home smoked at home. Therefore, people of my generation were all exposed one way or the other to second-hand smoke. Do you have any comment on this?

[Rob Cunningham]

For non-smokers, second-hand smoke exposure causes lung cancer. That's one of the reasons why we need to continue efforts to reduce exposure to second-hand smoke as part of the overall effort to combat lung cancer.

Also, once cancer is detected, it's very important, as part of excellent treatment, to provide smoking cessation assistance. Whether a person with cancer smokes or not affects their survival rate. The 2014 U.S. Surgeon General's report had an extensive evidentiary review for the first time of how important not smoking is to cancer survivorship.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

Should people of my generation get tested at a certain age?

[Dr. Natasha Leighl]

As I think you'll hear from Stephen Lam, I think people of certain generations should be assessed for their lung cancer risk. If your risk is high enough, you should be considered for a lung cancer screening program. We do have the knowledge and the expertise here in Canada across the country to conduct outstanding life-saving lung cancer screening. I really hope that it's one of the things this group can help us develop.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Mr. Easter.

[Wayne Easter, Liberal, Malpeque, PE]

Thank you, witnesses, for your presentations.

I can tell you that these statistics—80% more women die from lung cancer than from breast cancer and 200% more men die from lung cancer than from prostate cancer—were shocking to me. Those are shocking facts based on the publicity out there on breast and prostate cancers.

With regard to one of the key causes of lung cancer, smoking, how are we doing in Canada? I'm from Prince Edward Island and I see more young people smoking than I did a few years ago. I have no statistics or anything. I don't know. How are we actually doing especially in terms of young people smoking? One of the things I hear is that flavoured tobacco products are in fact potentially enticing youth to smoke. What's your view on that?

[Rob Cunningham]

We are making progress at reducing youth smoking but a lot of work remains to be done. Every month more teenagers begin smoking. It's not just cigarette smoking. It's also these flavoured products. There are also cigarillos, water-pipe tobacco smoking, and smokeless tobacco. I know that in P.E.I. a bill has just been introduced to ban flavoured tobacco. Six provinces have done that. You know, we would support a ban on all flavoured tobacco including menthol across Canada. We have a lot more work to do. There are still 37,000 Canadians dying each year because of smoking and 5.7 million Canadians who smoke. There's a whole range of measures that can be taken. Australia has plain packaging as do Great Britain and France. Ireland will have it next May. Funding to Health Canada for its efforts to reduce smoking among youth can be increased. There are cessation programs and enforcement. It's a comprehensive approach. We're making progress, but a lot more remains to be done.

[Wayne Easter, Liberal, Malpeque, PE]

I think the reality is that if you can target young people and prevent them from starting to smoke, that's where the efforts have to be made. I look back to my own time in school, in high school, when if you didn't smoke, you were on the wrong side of societal favour. That's changed immensely, but I still see too much of it.

You're basically suggesting that we ban menthol and flavoured tobacco products, and I know they've moved on that in my province.

On early detection, you mentioned that there is a screening program in place in the United States. What has the experience been under that program? Do you have any idea of the cost? We have a public health care system here, so you have to look at the cost as an investment more than just as a cost. Can you comment on that?

[Dr. Natasha Leighl]

Sure. I might start since I might have been the guilty party who introduced that.

This is where Canada has the potential advantage over the U.S. The U.S. has not formalized a program, but it is paying for screening, which is covered as a Medicare benefit. So whether or not you organize a program depends on the centre that's offering the screening. Screening can be offered in your local community centre or you could have a van that goes around and offers screening. You don't necessarily have to tie outcomes, to cost-effectiveness, to quality, and to smoking cessation. What we've tried to do with CPAC, the Canadian Partnership Against Cancer, and the lung cancer framework is to set something up so that we are able to track statistics and outcomes. We are able to measure how many of the population at risk were able to get in, to actually have screening adherence rates, and also to tie this to smoking cessation.`

In terms of cost-effectiveness for the large U.S. randomized study, where no matter how early you found the cancer there was still a mortality benefit to treating it, the incremental cost-effectiveness ratio, which is a measure of benefit compared to cost was—and forgive me since I'm approximating here—somewhere between $83,000 and $86,000 U.S. per quality-adjusted life year gained. I'm happy to provide the committee with a reference and the paper for that. However, that is in the U.S. health care system. The way they have done that differs from the way our pan-Canadian study was done and from the way the framework is proposing that we do screening. So, cost-effectiveness estimates from Ontario from ICES that were commissioned by Cancer Care Ontario are as low as $43,000 or less per quality-adjusted life year. Again, depending on the interval of screening and the level of risk, your cost effectiveness impact can really change. So, yes, it will cost money. Could there be a way to introduce cost-effective screening by choosing your population and the follow-up? Yes, we think there is something within a reasonable estimate of cost-effectiveness.

[Wayne Easter, Liberal, Malpeque, PE]

Coming back to the early detection, what can be done both federally and provincially to enhance early detection? I hear too many stories. In fact, I was talking to a husband this morning whose wife had died and who had waited for a year before she could get into our hospital system. Would it have made a difference? We don't know.

What can be done to enhance the early detection, and operations if needed, in these kinds of matters from a policy perspective at the governmental level?

[Dr. Paul Wheatley-Price]

I think it may be best to ask that question again in the next hour when Dr. Stephen Lam will present from British Columbia.

About a year and a half ago we started some discussions with MP Lizon and Senator Ogilvy and some physicians across the country about screening programs in the populations that the federal government is responsible for. We're just starting to put together a proposal for a screening program among veterans. Dr. Lam is really the person who can give the most detail about that.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Mrs. McLeod.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Thank you, Chair.

First, before I start, thank you to the witnesses.

Also, as the other committees are winding down, I do want to say to my colleague, Mr. Lizon, who's been very passionate about this issue, and to all the health committee, that from what we're hearing I think this is a very important issue for us to spend a little bit of time on and, hopefully, in the next Parliament this work can get picked up and maybe there will be some significant movement forward.

It's interesting, because you talked about the 96% who really didn't have much of a clue about radon, and I am embarrassed to say I am probably one of them. Then my colleague was talking about Sparwood. I guess they did a research study there, which is a terrible place in the country in terms of radon levels. Then we looked in the interior of British Columbia, but I saw that Kamloops has lots of clay, so I guess I'm okay.

Could you talk a little bit more, because I think it's important for the blues of this meeting, about that whole issue around radon, radon testing, and mitigation measures.

[Dr. Robert Nuttall]

Yes, I can take that one.

In our Canadian geology, basically we sit on a whole bunch of rich natural resources, one of them being uranium. Uranium contributes most of the emissions of radon gas. We have geology maps that target where we have areas of high uranium and areas where we don't. Those give you a good proxy to areas that have high radon levels, but one of the major points, though, is really around how your house is built.

You can be in an area with low levels of uranium, but still some uranium, and if your house is poorly built, over time those levels are going to accumulate. You can be in an area with low levels of uranium, but your home, because of the way it's built, will have high levels of radon, whereas you can be in an area that has high levels of uranium, but your house is a good build. A lot of the building codes have a radon mitigation strategy, and there are sump pumps that you can put into your basement so that the air that comes in is vented out—anything coming up from the ground gets vented out. Even if you just open your windows, you can actually get a lot of the radon circulating and moving out.

That's really where it's important. We need to have all the homes tested. Even if the geological map of your area shows that it's a low uranium area, your home itself could have high levels of radon. You can't even look at your neighbour's house. Your neighbour could have a nicely built house that doesn't have much in the basement, has good ventilation, and has low levels of radon. It's very important to target those homeowners and get that individual testing.

There are strategies, though. We did use the Health Canada survey. They sent out 18,000 radon test kits across the country. They found regions that have a lot of homes with high levels of radon, more than you would expect. We can use that. The Canadian Cancer Society, the Canadian Lung Association, and Health Canada are doing targeted strategies in those areas. The interior of British Columbia is one area. There are some areas in Manitoba. Those are communities where there are strategies. You can do it on a community-by-community basis. Sometimes you have to choose the communities you go into first. You can use geological maps or these radon maps.

What we're really focused on is that if we had everybody testing their homes, with 100% test rates and we knew exactly what to do, then we would need people to take action. Some people might cite.... The test itself is relatively inexpensive. Some charities offer it for free. It could be $30 if you buy it from a hardware store. The cost is from what you need to do to get rid of the radon. It could be a simple cost: you need a professional to come in and really look at it. The cost of mitigating it is a potential barrier, but because we have so few people doing it, we don't know how much of a barrier it is right now. The Canadian Cancer Society and our offices are trying to get as many homeowners testing regardless of where they live.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

So the test is a simple kit. Who is able to analyze the results and look at the home? Is it a home inspector who is pretty good at coming in if you have some worrisome results?

[Dr. Robert Nuttall]

There are actual professional radon mitigators. Health Canada provides a directory of all the licensed mitigators across the country.

For our work and what we do, if people come back with a test result of over 200 becquerels per cubic metre, we direct them to Health Canada to follow the process for how you find the right mitigator and who in your region can do it. There are still a lot of capacity gaps in the area of professional mitigators. Our B.C. office has been involved in co-sponsoring training programs to increase the number of people who are licensed mitigators.

As we promote awareness and have more people getting tested, we're going to find more people with high levels, and there's going to be more of a demand for mitigators. I do think that's another area where there's a potential opportunity for federal oversight of the training and for ensuring that more people are licensed and trained to be able to know what's wrong with the house and what needs to be done to resolve it.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

You talked earlier about an awareness program that we've undertaken. Maybe you could describe that a little better.

[Dr. Robert Nuttall]

There's a Take Action on Radon network that has a lot of support from Health Canada, the Canadian Lung Association, and the Canadian Cancer Society. There's also a group, the Summerhill group, but I can't remember what they do. Again, they're a community awareness and environmental initiatives group. We come together to talk about those strategies we're doing and learn from each other.

Health Canada runs programs. They run testing programs. Some groups run community education programs. We can share resources, and it's a good way to not have four different groups that are involved in it doing four different things. We can work together. If B.C. is where we're heavily involved but not so much in Saskatchewan, in Saskatchewan the Canadian Lung Association is doing a lot. It helps us prioritize our own work and where we need to put our efforts and where we don't. I think that kind of an approach really wouldn't have happened without Health Canada convening that group and bringing the stakeholders together.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

To our panel guests, thank you for taking the time today to appear before our committee. You're welcome to stay or go, or do whatever you have to do, while we set up our next panel.

Thanks again.

[The Chair, Conservative, Ben Lobb]

We're back. We have more guests this hour.

Can the individuals appearing by video conference hear us okay?

[Dr. Diana Ionescu, Oncological Pathologist, Department of Pathology, BC Cancer Agency, As an Individual]

Yes.

[Dr. Stephen Lam, Chair, Lung Tumour Group, BC Cancer Agency, As an Individual]

Yes, we can hear you very well.