Health Committee on Feb. 12th, 2024

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Thank you very much for that.

One of the other questions is around the salpingectomy, for instance, with a vaginal hysterectomy.

I apologize, because I've forgotten who the expert is in robotic surgery.

[Dr. Shannon Salvador]

That would be me.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Okay. That's you. Good. I'm sorry to pick on you again.

I practise in Nova Scotia, and we have a very robust gynecological oncology program. It's very centralized. The difficulty, of course, is travel. Certainly in smaller rural hospitals, we're not seeing robotic surgery other than for cholecystectomies. That's basically where we are. There might be appendectomies, depending on who's working.

However, the difficulty is talking about salpingectomies, for instance, with vaginal hysterectomies. Does that create a bigger issue for local gynecologists to be able to do them?

[Dr. Shannon Salvador]

Actually, no. The nice thing about a salpingectomy—Dr. McAlpine can definitely speak to this, as well, as they did large educational programs on it—is it's actually a fairly easy thing to add to a surgery that's being done anywhere near the pelvis. That's why they're branching out in their colorectal and general surgery teams, because if you're there to take out an appendix, it's a pretty easy thing to also pop out a couple of Fallopian tubes while you're down there. Even at the time of doing a vaginal hysterectomy, it's fairly easy to move the Fallopian tubes into the vagina to be able remove them safely and allow the ovaries to stay behind.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Thank you for that.

For any of you who have seen it, it's not really that easy. I was not a gynecological surgeon. Anyway, that's a whole other story.

One of the other issues across this great country—whoever feels like answering this, feel free—is Pap test screening. First of all, you have the issues with access. For instance, if you are a female, do you want to see a male physician like me? Those things present some difficulties and require creative answers.

However, it's the recall process that worries me the most. First of all, we don't know who's actually getting a Pap test with respect to who should be getting one, and then once you have a Pap test, you never get the answer back. You have to rely on the physician to say this is good, bad or indifferent and say that you need a recall, etc.

Even if we create a process with HPV testing at home, the recall process is something we will have to really look into. Has anybody put any thought into that? I have some ideas, but if you have a better idea, I'd love to hear it.

[Dr. Jessica McAlpine]

I can comment a bit, as we've rolled this out in British Columbia with self-screening.

We also have a crisis, which has been mentioned by many of the members already, of a shortage of family physicians. There are clauses in there for how to deal with a result if you don't have a family physician and how to deal with the result if you do, and how to engage them. It actually piggybacks onto the same system of vaccine notification and availability that we used for COVID in the provincial program, so it comes to their phone and it comes to an app to be able to inform them. It is also sent to their physician if they have one.

I'm encouraged, because with the system before, from a couple of months ago, it became increasingly challenging if we didn't have a primary care physician. I think we have the tools now to do this and to do this well.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. McAlpine and Dr. Ellis.

Next we're going to go to Dr. Hanley—the one from Yukon—for five minutes.

[Brendan Hanley, Liberal, Yukon, YT]

Finally, I get to speak.

I'll start with Dr. Hanley.

Rather than engage on what common relatives we might have, I just want to ask about salpingectomy. You mentioned how effective it is. You referred to a study. You don't give a lot of detail, for good reasons.

I'm just wondering if you could give us an overview of what we have learned about the actual effectiveness and what the numbers are. How many do you have to do to have a positive outcome? Where are we going with the literature to really support the expansion of this technique?

[Dr. Gillian Hanley]

There should be a really easy answer to this question. Unfortunately, there's not, and that's partly because we're still in fairly early stages of the research.

As you may be aware, the average age of diagnosis for ovarian cancer is 61. We actually do these opportunistic salpingectomies on people who on average are in their early forties. We haven't had all the follow-up time that we need to really answer that question.

Our 2022 article in JAMA Network Open was the first prospective study of opportunistic salpingectomy done for the purpose of ovarian cancer prevention. It is important, because it means the surgeon is removing the entire fimbriated end of that Fallopian tube to really reduce the risk.

In that study, we saw zero high-grade serous cancers in the approximately 26,000 people who had an opportunistic salpingectomy. This was statistically significantly lower than the number that we would have expected to see if the cancers had been arising at the same rate as they were in the control groups, which were people who had hysterectomy or tubal ligation alone.

We haven't had enough follow-up time to give the specific number needed to treat, but we have a lot of preliminary evidence that suggests that opportunistic salpingectomy is going to be very effective at reducing the risk of high-grade serous ovarian cancers.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you.

I guess there's a common theme around implementation. How do we move forward and make things more uniform in areas where we see successes?

I'm equally...I don't know if it's “shocked”, but certainly it's quite alarming to see the recent rise in cervical cancer incidence when this is probably the most preventable cancer there is. There seems to be a bit of a disconnect here.

Dr. Salvador, I think you were talking about this as almost like an older demographic, one that would not have been in the vaccine cohort. I'd like to dig a bit more into that. Are we seeing this in peer countries?

I heard Dr. Gina Ogilvie, I think it was, talking on the radio just the other day about how amazing the Australian vaccine cohort results are. They are on track for elimination. At the same time, we're seeing this kind of separate phenomenon in the presumably older demographic.

Can you unpack that a little more for us?

[Dr. Shannon Salvador]

I think the thing that also disturbed me the most when that data came out is that the data collection ends at 2019, and we all know what happened in 2020 and the years thereafter.

If we thought there was a problem with screening going up to 2019—because I think the majority of the issue was probably that women were not getting screened or were being screened late—we're going to have a major uptick, I think, once we get the 2020 to 2024 data, because the screening dropped off drastically. It hasn't gone back up to the levels it reached before because of lack of access. People were not being screened during the COVID years, and then even when screening was restarted, people were not having access to locations to get screened.

I think we're actually on track to get another big shock with the next collection of data when it comes through, unfortunately.

[Brendan Hanley, Liberal, Yukon, YT]

I'll have to cut you off because I'm almost finished my time.

I think this may segue into what Dr. Ellis was asking about, which was self-testing.

Is there an opportunity here that we can kind of leapfrog into expanding and widely implementing HPV self-testing as a way to get this back on track?

[Dr. Shannon Salvador]

I absolutely think so. That's actually one of my desired mandates when I take over as president of GOC. I want to get all the partners at the table to talk about how to bring HPV self-testing to this entire country.

As you mentioned, it really requires a strong provincial program of database collection, and again British Columbia has among the strongest programs in the country. They know who has been tested, who hasn't been tested and when they were last tested. They send recall letters to remind people that it's time for testing. The provinces that are looking to create a program, if they don't have one, should really use B.C.'s program as a model to move forward.

I agree completely that adding HPV self-testing and going in that direction is a strong recommendation.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Salvador.

Next we have Dr. Kitchen for five minutes.

Go ahead, please.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you, Chair.

Thank you all for being here. It's a great pleasure to have you here, and the tremendous amount of information you have provided for our report and for Canadians who are watching is greatly appreciated.

I come from Saskatchewan, very rural Saskatchewan. My riding is 43,000 square kilometres, and yet it's not the biggest riding. I had many patients who travelled quite long distances to see me. The unfortunate part for us in the southeast corner of Saskatchewan is that we don't have a lot of family practitioners who have skills and knowledge in the gynecological area, so I think a lot of things get missed.

Your comment, Dr. Salvador, about the self-screening is tremendous, because when we talk about HPV self-screening, I would say to you that I would bet that maybe only 5% of the population knows it even exists.

To further emphasize that, though, what sort of costs is that going to involve?

[Dr. Shannon Salvador]

That's one of the things we've debated in discussing how to a create a program and whether you create an opt-in program or an opt-out program.

As you can imagine, an opt-out program would be incredibly expensive. That would involve mailing a self-testing kit to every person who was available and then seeing who mailed it back. I don't know, from a cost analysis standpoint, whether that would actually work out.

I think if you were going for something like an HPV self-testing program, you'd have to go for letters of introduction, followed by an opt-in, and then send a test to someone who requested it. You would then be more likely to actually get that test back and be able to do that screening.

Definitely health costs are a huge consideration for those types of programs.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Given those huge challenges, would you see this more as a national program or a provincial program?

[Dr. Shannon Salvador]

That is obviously a very huge challenge.

Currently it obviously falls under each province's responsibility to create its own program. The big issue, again, with it being just provincial is that people move. When someone crosses a provincial border, it's a little bit like starting all over again in terms of their medical health. You may not have access to records of things that were previously done. Records can't move across a provincial border unless the patient physically brings them.

The best screening program would be a national one in which access to patient information about previous screens would be available for all people across the country.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you.

As you are probably well aware—although the general public isn't well aware of this—the reality is that HPV goes back to Neanderthal times. We first found out about HPV, I believe, in 1949. Strauss et al. discovered it, and the reality was that it was done using an electron microscope.

When I started practice, the electron microscope was the testing device of the day, but the reality is that we've seen it out there. The vaccine was basically found in 2008, and again that's public knowledge that we need to get out to Canadians to truly understand the value.

The challenge we have is the cost of that HPV vaccine, because there is a perception out there that it is free, but it isn't. In some cases they're talking about $300, $400 or $500 for people who just can't afford it.

Do you have any thoughts on that?

[Dr. Shannon Salvador]

That's definitely a challenge.

We are currently vaccinating the majority of children across the province with something called Gardasil 9, which protects against nine types of HPV. They get two vaccinations six months apart. When someone is outside of that young children's program, then yes, the cost falls upon the individual.

Once someone is past the age of 18—which has been set as a bit of an arbitrary marker—they no longer mount the same immune response, so it requires three vaccinations. That's the point at which this starts approaching $600, and for a person who has not had the opportunity to be vaccinated as a child, that's a shame.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you.

I'll touch briefly.... I don't have much time, but one of my concerns is when we look at the rural practitioners. How do we educate them? What suggestions would you have that we can put out there for our future primary care practitioners so that they're educated enough to understand the steps that need to occur? They see it in school, but oftentimes, if it doesn't become part of their practice, it gets missed. Could you comment on that?

[Dr. Shannon Salvador]

Some of the groups that we are bringing to the table are the family medicine practitioner national societies so that they can help distribute the information to their bodies as well. Obviously, these physicians have to go through continuous medical education. We all do. It's a requirement as part of our practice. Whenever we get new information or have new things to inform family physicians about and to help with their education, we reach out to their conferences—we all do this—and we send experts to their conferences to speak and allow the dissemination of information in each of the provinces.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Salvador.

[Dr. Jessica McAlpine]

I would add very quickly that for each initiative, we have tool kits and education, things that we're trying to build for family practitioners and general gynecologists, not just the cancer specialists in the room. Those are things that probably could use better funding and support, but those are priorities. I agree that they are incredibly important, and that's what we're working towards.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. McAlpine.

Next we have Dr. Powlowski, please, for five minutes.