Evidence of meeting #67 for Health in the 41st Parliament, 2nd Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was testing.
A recording is available from Parliament.
4:30 p.m.
Conservative
The Chair Conservative Ben Lobb
Okay. We'll have you folks go first by video conference.
After that, we have some guests here who will present. Then we'll open it up to questions and answers.
Go ahead in Vancouver.
4:30 p.m.
Chair, Lung Tumour Group, BC Cancer Agency, As an Individual
Good afternoon, Mr. Chairperson and members of the health committee.
I'm Dr. Stephen Lam from the BC Cancer Agency. Thank you for the opportunity to present to you the current status of lung cancer screening in Canada.
As Dr. Natasha Leighl pointed out earlier, lung cancer screening using low-dose CT scans can reduce lung cancer mortality, reducing the proportion of people dying of lung cancer, by 20%. These are heavy former or current smokers between the ages of 55 and 74. It should be noted that more than 50% of the lung cancer patients we see now are former smokers. These are the people who have listened to our advice, have stopped smoking already for a number of years, and yet have come down with lung cancer. Lung cancer screening will offer the opportunity to reduce the mortality. As Dr. Leighl also pointed out, even in the United States lung cancer screening is cost-effective. On average, the cost is $81,000 per quality-adjusted life years gained in the U.S. In Canada it can be cheaper.
The next thing is that not only can we reduce lung cancer mortality by screening, but screening also shifts the proportion of people from advanced cancer to early cancer, what we call stage I and stage II lung cancer, which can be amenable to treatment with surgery with curative intent. Without lung cancer screening, three-quarters of the patients with lung cancer present with advanced disease and are mainly suited for palliative treatment. But with lung cancer screening, with low-dose CT, we can shift the proportion to the opposite direction so that three-quarters of people have the early stages of the disease, stages I and II, amenable to curative surgery.
A study we conducted in Canada, a screening study from coast to coast, from Vancouver to St. John's, Newfoundland, was supported by the Terry Fox Research Institute, the Canadian Partnership Against Cancer, and Lung Cancer Canada. In this study, we found that if we treat people who have screen-detected stage I and stage II lung cancer, we can actually save $14,000 over two years versus treatment of advanced cancer, stage III and stage IV, by chemotherapy, radiotherapy, or both.
Now, not only can we reduce lung cancer mortality, but we can also save money by reducing the symptom burden. A study in Ontario showed that people who presented with clinical lung cancer have moderate to severe symptoms of loss of appetite, shortness of breath, lack of well-being, and fatigue in over half of the patients. Another third have significant pain, anxiety, or drowsiness, and one-quarter will have depression. If we can find the cancer early, we can reduce the symptom burden.
Another thing is that patients with clinically diagnosed lung cancer utilize hospital resources at a very high rate. Within three months prior to diagnosis, about 40% of them show up at the hospital emergency department. Within three months before their death, three-quarters actually showed up at hospital emergency because of symptoms. Again, we can reduce the proportion of people who utilize hospital resources.
There are four Canadian innovations that would put us onto the world leadership map in terms of lung cancer screening. We have a very innovative electronic web-based lung cancer prediction tool that allows us to identify who would benefit from lung cancer screening. For the ones who come to the screening program, we have a calculator that allows us to determine which spots or nodules on the CT scan need attention, through repeat imaging or biopsies, and to determine how often we should do follow-up CT scans. We have developed a very innovative surgical tool that allows the surgeon to remove small parts of the lung quickly and precisely to treat early cancer. The fourth innovation is a genomic signature that allows us to tell which cancer is aggressive and may benefit from additional chemotherapy after surgery.
Another innovation is computer technology that allows us to automatically highlight abnormal spots and help radiologists make recommendations regarding the management of spots detected on CT scans.
In summary, lung cancer screening allows us to shift from palliative treatment to curative treatment. We can reduce the symptom burden associated with advanced lung cancer diagnosed without screening. We can also transform lung cancer care.
The federal government can help us to improve lung cancer care and improve the outcome of lung cancer patients by funding low-dose CT screening programs—for example, for federal employees like veterans and the RCMP. For those who live in more remote areas, such as our first nations people who live in sparsely populated areas, we can use mobile CT, or combine smoking cessation with lung cancer screening, depending on the age group of the population.
Finally, the federal government can help us by facilitating implementation of screening at the provincial level—for example, through the Canadian Partnership Against Cancer. We now have a Canadian lung cancer screening network that is supported by CPAC and funded by the federal government.
I think I will stop there to answer any questions you may have.
4:35 p.m.
Conservative
4:35 p.m.
Oncological Pathologist, Department of Pathology, BC Cancer Agency, As an Individual
No. I submitted a brief for you, which in a way is a supplement to what I will talk about.
4:35 p.m.
Oncological Pathologist, Department of Pathology, BC Cancer Agency, As an Individual
Yes.
4:35 p.m.
Oncological Pathologist, Department of Pathology, BC Cancer Agency, As an Individual
Mr. Chairman and members of the health committee, I would like to thank you for the opportunity to talk to you today about the role of pathology and laboratory testing in the diagnosis and treatment of lung cancer, a subject about which I am very passionate.
Although not always obvious to the patients and the public, pathologists are on the front line of cancer prevention and screening. My colleague Dr. Lam just presented to you some data about lung cancer screening. When a nodule is identified radiologically in the lung and there is a clinical and radiological suspicion that it may be cancerous, the nodule is sampled through biopsies and sent to pathology for microscopic examination.
Pathologic examination has been the gold standard for diagnosis of cancer for over a century. A screening program for lung cancer without a pathology diagnosis is like a detective story without a final answer.
Since I started working as a consultant pathologist and as a lung pathologist at the BC Cancer Agency in Vancouver approximately nine years ago, my role in lung cancer has changed dramatically. This change occurred around 2007, and it was due to the discoveries of drugs effective for only certain molecularly defined tumour types, for treatment that we now call “targeted therapy”. Medical oncologists require increasingly specific information about each individual lung tumour for treatment decision-making. In fact, drugs are developed with molecular tumour characteristics in mind. “One treatment fits all” is no longer the standard of care, and we are personalizing treatment for each lung cancer patient.
One of the most exciting parts of my daily work is testing tumours to identify the best treatment for the right patient at the right time. These tests, which predict tumours' response to a drug, are known as companion diagnostic tests. We are looking to identify characteristics of the tumour, or biomarkers, at a molecular level, and therefore these tests are also known as biomarker tests. Companion diagnostic tests help tailor treatment and provide better patient stratification, response prediction, and treatment monitoring. Companion diagnostic testing is a relatively new concept, but it is not specific to lung cancer. Usage of such tests is only going to increase in the era of personalized medicine, and they are already available for patients with other types of cancers.
One of the pioneer biomarkers in oncology, which we have been testing for in pathology since the early 1990s, is a tumour's receptor for estrogen. We are testing for this particular biomarker in all breast cancers with significant clinical impact. One of the most moving statements I have ever heard was from a young mother, a non-smoker diagnosed with lung cancer. She said she wished she had breast cancer, because at least then society would care.
There is so much we can learn from all the great work that breast cancer research has done over time in biomarker testing, but we need your help to ensure that we have the infrastructure and continuous support for other types of cancer research being done in our country.
In Canada the landscape of biomarker testing in lung cancer has been developed since 2009 by multidisciplinary national groups of medical oncologists and pathologists who have worked together to develop and implement a testing strategy for Canadian lung cancer patients. We took into consideration not only scientific results but also the economical reality of our health care system, and we have been very successful. This national approach to testing is simple and elegant, and it makes us, as Canadian lung physicians, proud to be able to collaborate with each other and with health care authorities in this way, and to see our work being cited by academic and private testing centres around the world.
For lung cancer in Canada, we currently clinically test for two biomarkers called EGFR and ALK to identify patients who will respond to several targeted therapies. I respectfully submitted data about my biomarker testing in lung cancer in Canada in a brief sent to your attention and for your review.
Additional drugs with companion diagnostic tests will soon be available for lung cancer patients, and that includes immunotherapy drugs. It is of very high importance that we have a testing system in place in the laboratories to be able to identify these patients efficiently and accurately. This shows once again the increasing importance of pathology in the lung cancer care team.
Given the fast advances in personalized medicine in lung cancer and its clinical impact on the survival and quality of life of our patients, we need to look at drugs and companion diagnostic tests as one entity and support these programs together scientifically, financially, and politically.
I would like to thank you for the opportunity to talk to you today.
4:40 p.m.
Conservative
The Chair Conservative Ben Lobb
Thank you very much.
We're going to move along here to our guests here: Dr. Jason Pantarotto and Dr. Jacques Ricard.
Would you like to go first, sir?
June 16th, 2015 / 4:45 p.m.
Dr. Jason R. Pantarotto Radiation Oncologist, Chief of Radiation Oncology, The Ottawa Hospital, As an Individual
Thank you for having me here.
My name is Jason Pantarotto. I'm the head of radiation oncology at the University of Ottawa and the Ottawa Hospital. I'm here as an expert in the treatment of lung cancer with radiation. Also, I've been involved in the provincial Cancer Care Ontario system, and I can speak to that in a my role as regional lead for radiotherapy for eastern Ontario in the Champlain LHIN, the local health integrated network of 1.3 million people. Further to that, I'm involved in a significant effort at the Ottawa Hospital to address lung cancer wait times. I'll speak to some of the challenges there.
I thought I would reserve my comments for this afternoon to the four components of the resolution passed by the committee.
In terms of the main causes of lung cancer beyond smoking, I think the speakers today have addressed many of those, but I want to make further comments and address as well some of the questions brought up in the last hour.
There are several agents, both man-made and natural, that can cause lung cancer. Many of the industrial agents used in the last 100 years can be inhaled, but frankly, it's difficult to assess the risk of each individual agent. There is clear evidence gathered over the last several decades that agents such as asbestos, diesel fuel, silica dust, and arsenic, whether breathed in or ingested, can cause lung cancer specifically, but there is a latent period of many years between exposure and the actual development of lung cancer.
The findings often show that the insults from these agents work synergistically with the effects of cigarette smoking. Therefore, you see higher rates of lung cancer in smokers rather than non-smokers, given the same exposure. For many industrial exposures, with the effect of cigarette smoking and the fact that it was really so prevalent over the last 60 or 70 years—so many people smoked—it's really quite difficult to tease out the actual impact of many industrial toxins that are out there.
Specific to radon, which of course is not an industrial agent but, as we've heard today, a naturally occurring substance in the earth's crust caused by the natural breakdown of uranium, personally I believe that Health Canada has very good documentation that can be found on their website, but with my patients, and even with my colleagues and my friends and neighbours, radon testing is really not a priority for the general population.
In fact, you can ask yourselves this: how many of you have had your own homes tested for radon? If not, why not? I suspect we have a number of good answers. I think costs are one of the barriers, and if it's a struggle to get people to put four dollars' worth of batteries into a smoke detector, then how do we get people to perform a test, whether it's $99 or $30 or what have you, plus all the things that potentially might need to be done to your home? If there is a synergistic effect between radon and cigarette smoking, then in fact for those populations who smoke more, which typically are those with reduced socio-economic status or less education, their barriers to access or to perform radon testing and then do something about it are arguably even higher.
Moving on to fundraising challenges, there is a general lack of awareness of how prevalent and serious lung cancer is, even amongst health care professionals. With few survivors and hence few advocates to promote research programs, we really haven't been able to get significant fundraising programs to the levels observed for other cancer types. Then again, smoking rates are higher in those segments of the population that I just mentioned, those with a reduced socio-economic status, and historically those groups have not been able to do a good job advocating for themselves, for obvious reasons.
With respect to research related to the causes of lung cancer for men and women, I think there are a number of established causes, cigarette smoking being by far and away number one on that list. I see a lot of research being done on the treatment of lung cancer, which we've heard a little bit about today, and also in terms of prevention and effective screening.
I think screening is key, but it has to be an effective screening program. In Ontario and various other jurisdictions across Canada we have established screens for cancers such as breast cancer, cervical cancer, and colorectal cancer, but if we look at the latest data for Ontario, of eligible women from 2011 to 2013, 62% underwent screening for cervical cancer. For the same period, 59% of eligible women underwent screening, and for colorectal cancer it was much lower, in the range of 30%, despite the fact that colorectal cancer is the number two cancer killer, if you will, in Canada. It's number two of course, with lung cancer being number one. All of that data comes from the Cancer System Quality Index, published by the Cancer Quality Council of Ontario.
To finish off, the emerging best practices for screening was the last item in the resolution. I think we've heard a lot of good information today about how there is some firm evidence behind performing low-dose CT scanning in high-risk populations. I think when you have a screening program, there's a lot of depth there that needs to be addressed. There's accreditation of each facility and the staff that works within them, database management, a recall system for suspicious nodules because you're going to find all sorts of things once you start looking, surveillance clinics, and then of course access to timely lung biopsy. Integration is key.
In Ottawa and the Ottawa area, which has a fairly affluent and well-educated population, according to 2011 data, the time from having an abnormal CT scan to getting treatment for your lung cancer was 117 days for the 90th percentile. That's in Ottawa and that's the story all across the country for various reasons. When you get into some of these other populations, they have a tougher time getting screened once a screening system is set up and a tougher time getting biopsies. That time is even longer.
I just want to finish off in terms of the segments of the population that fall under the jurisdiction of the federal government: aboriginals, the military, incarcerated individuals, and the RCMP. There is evidence in some subgroups of the aboriginal population that smoking rates are high. For the population in Nunavut, and specifically this comes from studies from Professor Kue Young at the University of Alberta, indigenous populations that live around the Arctic Circle in various countries have higher lung cancer rates than do pretty much everyone else in the world. The aboriginal population in Canada specifically seemed to have even higher rates.
Similarly in notable journals like Cancer there is published evidence—though I didn't find any Canadian evidence—that there are higher rates of lung cancer amongst veterans in the American military and Australian military, and that if they get lung cancer, there is a higher likelihood they will die from the disease. I would not be surprised if we saw similar results if studies were performed on the Canadian veteran population, or if they have been performed and I just don't know about them. I would not be surprised if we saw exactly the same thing.
I'll leave it at that, because I believe I'm out of time.
4:50 p.m.
Dr. Jacques Ricard As an Individual
Thank you, Mr. Chairman.
Ladies and gentlemen, thank you for listening to me. I'm not sure what I can bring to this except maybe put a human face to the statistics you've heard. If I hear one more time about the survivability rate, I think it will be a single malt scotch evening for me, because my chances are not very good, are they? But they are still there—those chances.
I'm Colonel Jacques Ricard. I'm a medical officer, as we call it in the forces. I'm a physician, a general practitioner, and I have 33 years of service.
About a year and a half ago, as I was doing my physical fitness test, I felt a lot of pain in my back. The next day I couldn't get up. I thought it could have been a herniated disk or something. We started the process to get it tested, with the usual MRI to see if it was herniated disk. I got the MRI in July. The doctor came to see me, and he said it was not a herniated a disk, but cancer. He went to the next step, to try to find out where it came from. The CT scan showed it was from the lung. It was quite a surprise for me, because I am one of those non-smokers.
Initially you have to deal with the emergency stuff, radiotherapy for the spine and everything. I met Dr. Wheatley-Price for the medical oncology to see if there was a treatment for it.
When you're told that there is no cure, you start asking yourself, well, why isn't there a cure? When you're at stage IV, and you actually present so late that no surgery can be contemplated, you need to go through palliative care, if you like.
I did the radiotherapy. I was asking myself, what did I miss that would have made a difference in catching this at the early stage? I didn't miss anything. You know, you have a cough or something in the morning, and you think it's probably from the medication you're taking for hypertension, because one of the side effects is coughing. You have a little bit of rib pain, and you think it's costochondritis. You have a reason, an explanation, for just about every little symptom you have. When you do show up for that back pain, it's too late.
It's funny, because we have to go through all our annual physical medical examinations. I had a colonoscopy at the age of 50. I had a colonoscopy at the age of 55. I had the PSA for prostate, the blood test. My wife had a mammogram. My daughter had a pap smear. But nothing gets done for the lung part of it. There is so much reliance on the patient to themself to identify in their own body that there's something wrong and to show up and be tested for it, and then it's too late if you're trying to catch it in the patient.
I do believe there needs to be a way to identify people before they have symptoms, because when they have symptoms it's much too late. We have all those screening processes like that... I didn't have any symptoms at all to warrant the colonoscopy. I didn't have any symptoms at all to warrant the prostate. They were offered to me.
This brings me to the treatment. I'm one of the lucky ones, because I did have a biopsy. Being a non-smoker, I was told that there was a higher chance that I would have one of those mutations they were looking for, the ALK or the EGFR. You have to wait about a month before you get the results.
When the results came in, I was told I had a 50% chance of being positive. I was positive for EGFR, so I was one of those lucky ones—lucky unlucky ones—who could actually get the targeted therapy with medication that you take once a day and that gives you a very good quality of life. It's not chemotherapy and it's not radiotherapy. But this only puts a handbrake on the disease. For the last 10 months, I've been taking this medication and I haven't changed. My disease is stable, and I'm working part time, and everything looks the same. But the disease is still there. The CT scan shows the same things in my lungs and in my spine and in my pelvic area.
Now we have to rely on somebody to find a cure for something that I was told, a year ago, there is no cure for. But maybe in two years, or three years, maybe I will be told that we have a cure now for exactly what I have. The funding for the screening program would help somebody like my kids, and the funding for the research program would help somebody like me.
I'm really hoping that we can make a lot of progress if we invest a lot of money in this very lethal disease, with its very specific characteristic, if you like, of very often being identified too late to have a surgical cure.
Thank you.
4:55 p.m.
Conservative
The Chair Conservative Ben Lobb
Thank you very much.
To get through our rounds before the votes, I think we'll have to do five-minute question-and-answer sessions.
Mr. Rankin, go ahead, sir.
4:55 p.m.
NDP
Murray Rankin NDP Victoria, BC
Thank you.
Thanks to all of the witnesses for their really stimulating testimony.
I have a short amount of time left for questions. I think I'd like to start with you, Doctors Lam and Ionescu, if I could, because I was really taken by your testimony about the effect of low-dose CT scanning in high-risk populations.
Dr. Lam, I was particularly struck by what you referred to as I think the four “innovations”. I was having a little trouble understanding it as I put that together with your first idea of an electronic lung cancer predictive tool. You said it was very advanced, and then you talked about the genomic signature.
Dr. Ionescu, you talked about the two biomarkers that are particularly appropriate for lung cancer.
Were you talking about similar things? Or was the biomarker analysis different from the electric predictive tool or the genomic signature that you, Dr. Lam, were talking about? Maybe you could explain that to me.
4:55 p.m.
Chair, Lung Tumour Group, BC Cancer Agency, As an Individual
Maybe I'll go first.
The lung cancer risk predictor is to identify which of the current or former smokers would develop lung cancer or harbour an early lung cancer that could be detected by low-dose CT. It is based not only on smoking history, but on things like age, educational level, body mass index, family history of lung cancer, and a number of other barometers. It's something we can use on an iPad or an electronic medical record. The patient can answer a few questions within about 5 to 10 minutes and then we can determine the lung cancer risk.
This is just to see who would benefit from low-dose CT screening. The biomarker that Dr. Ionescu talked about is for people who already have lung cancer, in order to find out which of the targeted therapies they would benefit from.
5 p.m.
Oncological Pathologist, Department of Pathology, BC Cancer Agency, As an Individual
If you would still like me to answer my part of the question—
5 p.m.
Oncological Pathologist, Department of Pathology, BC Cancer Agency, As an Individual
—it would be that what Dr. Lam was referring to as the genomic signature of lung cancer, anything that has to do with genomics, with DNA testing or molecular testing, is done in pathology.
The first step is the diagnosis of lung cancer, which doesn't really require any of this genomic testing. However, we are now asked in pathology to subclassify lung cancers based on their genomic signature, on what type of biomarkers each tumour has that can either prognosticate the cancer's behaviour or predict the response to treatment. Those are predictive markers.
We currently do not test for any prognostic markers. We do test for the two, EGFR and ALK, which are predictive in regard to treatment response.
5 p.m.
NDP
Murray Rankin NDP Victoria, BC
Dr. Lam and then Dr. Pantarotto, you both made reference to aboriginal communities and the high rate of smoking, particularly to Nunavut as the lung cancer hot spot of the planet, if I'm understanding properly. Dr. Lam then suggested that one of the things that could be done was mobile CT scans, with a smoking cessation program, both of which of course could be done by the federal government.
I wonder if you could talk a little more about that, because you did start your testimony, Dr. Lam, by talking about the cost of these screening devices. I'd like to get a sense of whether either of you have given any thought to this issue of just how much it would cost to do such a thing as you recommend.
5 p.m.
Chair, Lung Tumour Group, BC Cancer Agency, As an Individual
We know from the pan-Canadian lung cancer screening study that the cost of screening one person per year is about $225. When we go to more remote communities such as those of the first nation people, because they're very sparsely populated it's very difficult for them to go to a large city to get a CT scan done.
One solution is to do what the Japanese have been doing for over a decade. It's to do a mobile CT scan. In the same scanner, we can screen for lung cancer and use the same CT scan to diagnose other diseases without the patient travelling to a major medical centre. In the same mobile units, we can have counsellors to help people to stop smoking.
I want to mention that we can now have technology to feed the CT scan into software to display what the lung looks like if you have COPD or emphysema, as well as to show whether the patient has calcification of the coronary artery. These are very potent visual images to show people what their health status is and, if people are still smoking, would facilitate smoking cessation.
5 p.m.
Conservative
David Wilks Conservative Kootenay—Columbia, BC
Thank you very much.
Dr. Ionescu, I wonder if you could talk a little more about the two biomarkers you test for. You referred to them as EGFR and ALK. What are they exactly and what do they do?
5 p.m.
Oncological Pathologist, Department of Pathology, BC Cancer Agency, As an Individual
Historically we used to classify lung cancer into two large groups called small cell carcinoma and non-small cell carcinoma. We did that for over 50 years, I think, because we had only two groups of treatments for these two particular types of lung cancers.
Now we are learning that approximately 54% or 55% of lung cancers, especially the subtype called adenocarcinoma, have some mutations, some genomic changes, that are called driving mutations, the ones that drive the behaviour of the cancer. One of the most common ones is EGFR. This is a receptor on the surface of the tumour that changes the behaviour of the tumour cells to make them divide uncontrollably and therefore be more able to grow and to metastasize.
We test for this particular EGFR biomarker because several groups of drugs called EGFR tyrosine kinase inhibitors have been developed and are available on the market, including on the Canadian market, for lung cancer patients, but only for those who present this particular mutation.
Testing for EGFR and ALK is completely different. The testing is done at different levels. For example, EGFR mutation testing is a molecular test. It's a test that looks at the DNA signature of the tumour, at the EGFR gene, to identify this particular mutation that makes the tumour more susceptible to certain drugs.
ALK or ALKi, which is a rearrangement in the tumour's genomic signature, is identified in the laboratory through completely different types of tests that we call immunohistochemistry and fluorescence in situ hybridization.
One aspect I would like to bring up, which I think will be of interest to this committee, is the fact that the drug that helps the patients with ALK rearrangement, called crizotinib, was first approved in the United States by the FDA for patients who have the ALK rearrangement only according to this particular fluorescence in situ hybridization test. Now, this is a highly specialized test. It is expensive. It is time-consuming, and it requires technical and professional expertise. Knowing that you cannot really screen a large number of lung cancer patients to identify a relatively small number of them—we're talking about 5% of lung cancer patients—who have this ALK rearrangement, in Canada we worked together at the national level to design a type of testing that used immunohistochemistry as a screen, followed by confirmation through this more specialized fluorescence in situ hybridization or FISH test. This particular exercise allowed us to screen using a much faster and less expensive test like immunohistochemistry to identify the 95% negative patients, and to confirm only the 5% positive ones using the more expensive test. This is a type of testing that later on was also implemented in other countries like Japan and France and many other European countries that really took into consideration the balance between the scientific reality and the reality of their health care system.
5:05 p.m.
Oncological Pathologist, Department of Pathology, BC Cancer Agency, As an Individual
Did I answer your question?