Health Committee on Feb. 15th, 2024

[The Chair, Liberal, Sean Casey]

I call this meeting to order.

Welcome to meeting 103 of the House of Commons Standing Committee on Health. Today's meeting is taking place in a hybrid format, pursuant to the Standing Orders.

We have a couple of witnesses on Zoom today, so I just want to let them know that they have interpretation available to them on Zoom. There is the choice, at the bottom of the screen, of floor, English or French. Please don't take any screenshots or photographs of your screen.

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 the 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. As individuals, we have Dr. Ghadeer Anan, medical oncologist, who is joining us by video conference; Dr. Ambreen Sayani, scientist; and Dr. Andrea Simpson, obstetrician gynecologist, St. Michael's Hospital, Toronto, who is joining us by video conference. Representing the Canadian Cancer Society, we have Helena Sonea, director, advocacy; and Ciana Van Dusen, advocacy manager, prevention.

We thank all of our witnesses for being here today. You will have up to five minutes for your opening statements, and we will begin with Dr. Anan.

Dr. Anan, welcome to the committee. You have the floor.

[Dr. Ghadeer Anan, Medical Oncologist, As an Individual]

Thank you, Mr. Chairman. Good morning.

Good morning, members of the committee.

Thank you for giving me the opportunity to be here today.

I should mention that, when I received the invitation, I was only asked to speak about women and cancer and was not given any further details about what specific area was of interest. I have prepared my notes on my own experience in my own practice, but I'm more than happy to answer any questions.

I’m a medical oncologist, practising in Fredericton, New Brunswick. I have been in practice for more than 13 years. Patients with breast cancer represent most of my practice.

Fredericton is a city with a population of more than 60,000 people. However, the catchment area that we look after has a population of more than 170,000, so the majority of the population in my catchment area live in a rural setting. The annual population growth rate in my area is 6.2%, per Statistics Canada. However, our local data shows that the increase in cancer patients is 8.2%. New Brunswick has seen an unprecedented increase in population since the COVID pandemic.

I would like to share with you today the differences in the journey of women who get diagnosed with breast cancer, depending on where they live. As you are aware, breast cancer is common and can affect one in eight Canadian women. When a woman is diagnosed with breast cancer, she usually undergoes surgery, with or without radiation, with or without chemotherapy, and it may or may not be followed by endocrine therapy in the form of pills. The problem is not having access to surgery, chemotherapy or radiation. The problem is having access to extra supports, which are just as important. Luckily, the cure rate is high, but it comes with a price. That’s where your place or residence can make a difference. That’s when it matters whether you live in an urban or a rural setting.

After such a diagnosis, a woman may require physiotherapy following her surgery. If she doesn’t, she might end up with long-term limitations to arm and shoulder movements, which would obviously affect her quality of life. Some women might develop lymphedema, which can be a complication following surgery and radiation that may cause pain, swelling and even disfiguration of the chest and arm on the affected side. Having access to a physiotherapist with special training in the treatment of lymphedema is crucial to help mitigate that. A physiotherapist with such training can provide treatment, fit the affected woman with the proper compression sleeve or glove, or even make it to order. Women living in rural New Brunswick have limited access to such services.

A breast cancer diagnosis and all the treatments that come with it, including the endocrine treatments that a woman can be on for five to 10 years, can have a significant toll on mental health. Having access to mental health services can make a huge difference. Again, women living in rural New Brunswick have limited access to such services.

Unlike surgery, which is required once or twice, radiation, which is usually prescribed anywhere from three to six weeks, or even chemotherapy, which is prescribed for anywhere from three to six months, physiotherapy or mental health support is usually required for a much longer duration and has a maintenance component to it.

What makes this even more challenging is that not only are we seeing an increase in the numbers of women being diagnosed with cancer in general, but we are also noticing that they are being diagnosed younger. The average age for a woman to be diagnosed with breast cancer is 60 to 65, but we are seeing more women being diagnosed in their forties and even in their thirties, when they have jobs and young families to look after and have to live with the complications of the treatments longer.

I am seeing an increasing number of women who are unable to go back to their jobs and normal lives after the completion of their treatments, and even having to go on disability due to treatment long-term effects that are not managed properly due to the lack of resources in rural areas.

In summary, I believe that women living in rural New Brunswick have good access to treatment once diagnosed with breast cancer, equal to women living in urban centres. They should have equal access to supportive services during and after completion of treatment.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Anan.

Next, we're going to hear from Dr. Sayani, please, for five minutes.

Welcome to the committee. You have the floor.

[Dr. Ambreen Sayani, Scientist, As an Individual]

Thank you.

Good morning, Mr. Chairman, committee members and fellow witnesses. I am Dr. Ambreen Sayani. I am a scientist at Women's College Hospital and an assistant professor at the University of Toronto.

I lead a person-centred research program focused on promoting cancer prevention, early detection and access to high-quality care for all. I supervise our next generation of learners, including graduate and medical students. In my role as health equity expert adviser to the Canadian Partnership Against Cancer, I guide the partnership's efforts to achieve equitable access to quality cancer care for all people in Canada. In 2020, I co-founded a group called EMPaCT, which engages directly with members of the community from underserved populations to give them direct influence on health care decisions. I am also an international medical graduate. I practised surgical oncology before moving to Canada.

From my community-engaged work, I want to give you some insight into the lived experiences of three women with cancer in Canada.

The first is a 65-year-old woman with colon cancer. Let's call her Audrey for the purposes of today. She said, “You have no idea how time consuming it is to be poor. You spend so much time proving you are poor, by getting photocopies of things. Plus, I am dealing with the fact that I am dying. It is so terrible”.

The second is a young adult bone and lung cancer survivor. We will call her Fatima for today. She said, “As newcomers to Canada, my parents did not know anyone or the system. Our primary care doctor didn't take my symptoms seriously and we did not know how to advocate for ourselves”.

The third, Maria, is a 71-year-old woman who has since died of cervical cancer. She said, “I went into the hospital, and I got treated so badly. I don't want to go back. I don't want to go through that ever again.”

Mr. Chairman and committee members, in Canada we are supposed to have universal access to cancer care, yet cancer care is not universally accessible to all. One out of every five women diagnosed with cancer will die from the disease. Last year 40,200 women died of cancer in Canada. That is on average 110 women a day, but not all women have the same risk of dying from cancer. Such factors as racism, sexism, ableism, classism and ageism can be the difference between life and death from cancer.

For women, biological sex influences susceptibility to certain types of cancer, while socially and culturally constructed gender roles impact women's cancer outcomes by influencing their health literacy, their health care-seeking behaviours and access to health care. Issues related to financial hurdles, geographic challenges, lack of transportation and limited availability of culturally and linguistically appropriate services directly contribute to delays in cancer diagnosis, inadequate treatment and poor quality of care.

For indigenous peoples, racialized communities, people living with low income and gender-diverse individuals, issues of systemic racism and discrimination lead to poor care experiences, avoidance of care and missed diagnosis. This can occur in part because of a lack of competencies to deliver equity-oriented health care in the workforce and services that are not designed to respond to their needs.

As a country, we've made strides in cancer prevention, detection and survivorship. These efforts include the implementation and coordination of preventative measures, organized cancer screening and design of innovative models of care. However, as I have shared with you today, care gaps are evident. They will require concerted and multipronged efforts across all sectors to address the root causes of social inequalities so that we can improve health outcomes for all women by elevating their living and working conditions.

In conclusion, I want to recommend three areas for action based on the lived experiences that I have shared with you today.

For women like Audrey, who are experiencing financial toxicity, we need to reduce the administrative burden of accessing the resources required to support cancer care. More broadly, this implies that we must invest resources to understand and respond to the real-life experiences of patients, with a focus on engaging those who are marginalized and underserved.

Second, for women like Fatima, who experience multiple barriers to care, we need culturally and linguistically accessible care pathways. To achieve this more broadly, we must strengthen community-based care and focus on diversifying the health care workforce so that it is representative of the populations it serves.

Last, for women like Maria who experience discrimination, we need to train and raise awareness across the health and social sector on the historical and systemic factors that shape health. Responsive care can lead to better health outcomes.

Thank you for inviting me to share my perspective.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Sayani.

Next, we're going to hear from Dr. Simpson.

For the next five minutes, the floor is yours. Welcome.

[Dr. Andrea Simpson, Obstetrician Gynaecologist, St. Michael's Hospital, Toronto, As an Individual]

Thank you very much.

I'd like to thank the members of the House of Commons Standing Committee on Health for the opportunity to speak today about women and cancer for the women's health study.

I'm here to advocate for the prevention of endometrial cancer, which is the most common type of cancer of the uterus, to suggest simple strategies that can be instituted by the government for early diagnosis, and to ensure equitable access to treatment for all Canadian women with endometrial cancer.

My name is Dr. Andrea Simpson. I'm an OB/GYN and minimally invasive gynecological surgeon at St. Michael's Hospital in Toronto. I am an assistant professor at the University of Toronto. I am also a researcher with a focus on equitable health care access.

One of my areas of clinical and research expertise is the surgical care of women with endometrial cancer, including those with obesity, who experience barriers in accessing health care and surgery. I am one of four gynecological surgeons at St. Michael's Hospital who run a specialized clinic for women with early endometrial cancer, enabling streamlined care and providing laparoscopic and robotic surgery for treatment—rather than a large abdominal incision—which affords them the best possible outcomes.

Our mission is to ensure that women with obesity or a high body mass index receive the same excellent care as women with a body mass index in the normal range. We endeavour to remove geographic barriers to care. We receive referrals from all over Ontario.

Endometrial cancer is the fourth-most common cancer in women. About 8,500 Canadian women will be diagnosed each year. The incidence of endometrial cancer has been on the rise for over 10 years. Endometrial cancer can be prevented through education of the public about risk factors such as obesity, polycystic ovarian syndrome and genetics, and the availability of funded hormonal therapies, such as those that are available in British Columbia.

Early signs of endometrial cancer are often not well known by the public. They include abnormal uterine bleeding, such as heavy or irregular menstrual periods, or any vaginal bleeding after menopause. The diagnosis can be made by performing an endometrial biopsy, which is a small procedure that can be performed in an outpatient office.

Our national guidelines recommend biopsy for any woman over the age of 40 with abnormal bleeding and in younger women who have risk factors for endometrial cancer. In recent years, we've seen younger and younger women diagnosed with endometrial cancer. A major contributing factor to this rise in incidence is the rise in obesity, which is a major risk factor.

Unfortunately, our research has shown that women with obesity experience discrimination in health care settings, which can often lead to avoidance of health care. This can result in a delay in diagnosis. When they're diagnosed with endometrial cancer, due to the complexity of the surgery, they also experience delays in access to surgical care. Not every hospital or surgeon is comfortable managing patients with obesity. These systemic delays render Canadian women with obesity a marginalized group that cannot access equitable health care.

The surgical treatment for endometrial cancer is removal of the uterus, cervix, ovaries and fallopian tubes. Minimally invasive surgery or keyhole surgery is the standard of care. It results in the best possible patient outcomes, but it is more challenging in people with obesity. Robotic-assisted technology can help overcome many of the surgical challenges for women with obesity who are undergoing endometrial cancer surgery.

I would like to acknowledge and applaud Ontario Health for recently providing funding for robotic surgery for women with endometrial cancer and obesity, which was a huge step forward in providing equitable access to surgery for women with obesity. Ensuring that surgeons and hospitals are incentivized to provide the surgery would be the next step.

I would suggest that the following actions be taken to ensure timely and equitable access to cancer care for women with endometrial cancer.

First, create initiatives to increase public awareness about the risk factors for and early signs of endometrial cancer. Public awareness initiatives include routine screening for menstrual abnormalities and post-menopausal bleeding through primary care and public messaging to seek medical attention if these abnormalities are experienced.

As part of this women's health study, several witnesses have suggested national education programs, including a standardized high school curriculum on menstrual disorders. An inclusion of abnormal bleeding in this curriculum may also help increase public awareness.

Second, encourage all provinces to fund hormonal therapy that prevents endometrial cancer, as is available in British Columbia.

Third, improve availability of endometrial biopsies for women with abnormal uterine bleeding. In addition to incentivizing primary care physicians to offer this in their practices, the creation of rapid access clinics for abnormal uterine bleeding would also increase timely diagnosis.

Fourth, improve access to robotic surgery in Canada. Robotic surgery overcomes many of the surgical challenges we experience when we operate on women with obesity. Expansion of training, facilities with this technology, funding across Canada for the provision of this technology and increased remuneration to hospitals and surgeons who perform these complex surgeries would improve equitable access for patients.

Enacting these strategies should result in the prevention of endometrial cancer, earlier diagnosis of cancer, shorter wait times and better outcomes for patients. If diagnosed early, endometrial cancer can be cured with surgery alone in many cases. Based on our research, improved access to robotic surgery in patients with obesity would result in a higher proportion of patients who undergo minimally invasive cancer surgery rather than a large abdominal incision, which would shorten their hospital stay, recovery time and return to work.

It is only fair that all Canadian women, no matter what province they live in and what body type they have, should have the same access to preventative measures for endometrial cancer, early diagnosis and treatment.

I would like to again thank the committee for allowing me to highlight these very important and actionable issues.

[The Chair, Liberal, Sean Casey]

Thank you very much, Dr. Simpson.

Next is the Canadian Cancer Society.

I understand you have a joint statement, Ms. Sonea and Ms. Van Dusen. We'll go over to you.

You have the floor for the next five minutes.

[Helena Sonea, Director, Advocacy, Canadian Cancer Society]

Thank you very much.

Hello. My name is Helena Sonea, director of advocacy at the Canadian Cancer Society. With me today is Ciana Van Dusen, manager of prevention, and our colleague Rob Cunningham, senior advocacy adviser.

Cancer is the leading cause of death in Canada and is responsible for 26% of all deaths. In 2023, researchers estimated that there would be over 200,000 new cancer cases and nearly 87,000 cancer deaths in Canada, about half of which are expected to occur in women.

Lung cancer is the leading cause of death in women. About 72% of lung cancer cases in Canada and 30% of all cancer deaths are due to smoking tobacco. A comprehensive strategy is needed to reduce tobacco use among women and girls to achieve Canada's objective of under 5% tobacco use by 2035.

We recommend that tobacco taxes be increased by six dollars per carton; that Bill C-59's legislative measures for a cost-recovery fee be adopted with strengthening amendments and subsequent regulations to cover the full cost of the initiatives in Canada's tobacco strategy from tobacco and vaping companies; that tobacco legislation be strengthened by banning all remaining tobacco promotion and banning flavours in all tobacco products; that measures be adopted to reduce youth vaping, including banning flavours in e-cigarettes; that cessation and other programs be enhanced; and, finally, that action be taken on nicotine pouches, which can be sold to children of any age and are advertised in places where youth are exposed to them.

Cancer does not solely touch the person who lives with it. It takes a community and a society to care for them, and no one understands that better than caregivers. Caregivers provide vital, unpaid, practical, physical and emotional support to loved ones with complex health conditions, including cancer. Half of the people in Canada will be caregivers in their lifetimes.

In 2018, caregivers provided 5.7 billion hours of care work, the value of which is estimated to be between $97 billion and $112 billion annually. Women disproportionately bear the challenges of this work.

The Government of Canada has tried to recognize the tremendous role of caregivers; however, substantial unmet needs remain. We recommend the federal government improve support for current and future caregivers by implementing or enhancing accessible, refundable federal tax credits to compensate these families.

I will now turn it over to Ciana to speak to cervical cancer.

[Ciana Van Dusen, Advocacy Manager, Prevention, Canadian Cancer Society]

After a 30-year decline, cervical cancer is now the fastest increasing cancer in females, with most cases occurring in women under 50. This rise is explained by lower uptake in screening and vaccination against the human papilloma virus, or HPV.

Because virtually all cervical cancers are caused by HPV infection, we can reverse this trend and achieve the Canadian Partnership Against Cancer's goal of eliminating cervical cancer by 2040 through prevention and early detection.

For example, replacing the Pap test with HPV testing as the primary method of screening for cervical cancer, with the option to self-test, can better detect cervical cancer and reduce barriers related to socio-economic factors or lack of access to health care providers.

While many provinces and territories are preparing for this change, the swabs used for HPV tests currently have an indication that they must be conducted by a health care professional. Health Canada has an opportunity to update this indication and remove this barrier in providing at-home tests. We recommend that Health Canada proceed with this update promptly.

Lastly, when talking about cancer prevention and women's health we must acknowledge that alcohol is a cancer-causing substance and is estimated to be one of the top three causes of cancer deaths worldwide. However, over 40% of people in Canada are not aware that alcohol consumption, even at low levels, increases cancer risk.

In 2019, almost 20% of women between the ages of 15 and 54 reported consuming over six standard drinks of alcohol per week. Because of biological factors, this high-risk level of alcohol consumption has long-term health impacts, including breast cancer.

We recommend the federal government implement mandatory labels on all alcoholic products sold in Canada to ensure more people can make informed decisions for their health. Additionally, honouring the scheduled 4.7% federal alcohol excise duty increase slated for April 2024 would maintain the alcohol industry's contribution to our economy, which, as is, only partially offsets the social costs and harms directly caused by their products.

We thank you all for your attention today and look forward to your questions.

[The Chair, Liberal, Sean Casey]

Thank you to all of our presenters today. We're now going to begin with rounds of questions, starting with the Conservatives.

Mrs. Vecchio, you have six minutes.

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

Thank you very much.

I'd really like to thank all of the panellists for being here today as we talk about this really important topic.

When you're talking about the HPV self-testing, I'm thinking of my own schedule and the schedules of so many women. Trying to get into a doctor's office can be very complicated. I'm thinking of the COVID test and the fact that I hated putting that thing up my nose.

What are some of the concerns that people would have with self-testing and why at this time is it only in doctors' facilities? What is the concern of expanding it to home care?

[Ciana Van Dusen]

It's really the process that's going to be the biggest change. As far as doing it ourselves is concerned, it's less invasive than the Pap test and it's fairly easy. It's actually a huge opportunity for women who, like you said, may not have access to a health care provider or may not feel comfortable due to all sorts of barriers, whether it's language or past experience with trauma. We're really excited by the opportunity to give the option. This is not to say that it would be mandatory. Women who prefer to go to their health care providers to receive this test could still have the ability to do so.

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

I'm thinking of the FIT test that you actually just pop in the mail. Could this not be a similar way of processing this?

[Ciana Van Dusen]

It would be.

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

Dr. Andrea Simpson, thank you very much for your testimony. I think it's really important when we're talking about the diversity of women. One thing you talked about was obesity. I'm not a physician. I've never done surgery. I've been in people's mouths doing dental surgery, but never in the body.

When you're talking about the issues, is it just because of the additional layers that they don't feel comfortable doing that or other concerns...or with the robotics? Can you share a little more on why, when dealing with obesity, there is concern?

I wouldn't know, so can you share that with me?

[Dr. Andrea Simpson]

When we are doing these surgeries we actually have to tilt patients' heads down in order to access their pelvis. The anesthesiologist is trying to ventilate the patients lungs, we're trying to expand their belly with gas so that we can see into their pelvis. When someone has obesity this can add a whole lot of extra weight or pressure on what the anesthesiologist is trying to do.

With robotic surgery, the robot has the ability to actually lift up the abdominal wall so that we can lower our gas pressure inside the abdomen to take a lot of pressure off the lungs. Compared to conventional laparoscopy, robotics is 3-D rather than 2-D, so we have much better visualization at the time of surgery. The robot also has articulating arms, so instead of only being able to move your instrument in two directions, you actually have a full 360° of rotation. This can be especially helpful when working deep in the pelvis.

These are some of the things that make robotic surgery better for patients with obesity. We did a study looking at the literature and found that conversion to the big up-and-down incision was lower for obesity-related reasons when the robot was used compared to conventional laparoscopy.

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

Thank you very much. I really appreciate that.

I want to go on to Dr. Ghadeer.

You were talking about New Brunswick and looking at mental health. I think any time we're looking at anyone postsurgery specifically and the isolation, the fact that—I'm thinking of someone I know personally—when you're trying to get better faster and you just don't seem to be getting better faster, mental health supports are really an important part of that. There's that absolute rural-urban divide.

I'm very fortunate because I'm 20 minutes away from the London Health Sciences Centre, where we have great things.

What happens if you're in a community where there might not be a psychologist or social worker, and sometimes not even a nurse?

What types of things are available in New Brunswick to people who are living in rural areas to be able to get those mental health supports?

[Dr. Ghadeer Anan]

Thank you for that question. Unfortunately, it really ends up depending on what type of insurance plan you have. The majority of New Brunswickers unfortunately have access to the provincial drug plan, which is good when it comes to drug coverage. It doesn't cover private practice when it comes to access to mental health, so you have to access—

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

I want to interrupt you there, as you're continuing with that, because with the mental health services, we have that insurance, but could you talk about trying to find those providers in those rural settings?

[Dr. Ghadeer Anan]

There are a good number of private providers, but the problem is the patients not having the financial ability to go and seek help from them. If you have private insurance, your private insurance will pay for your mental health services. If you are under the provincial drug plan, that is not a possibility. You always have to go to the hospital-based mental health care providers, which adds to the pressure on the system.

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

Thank you.

[Dr. Ghadeer Anan]

I don't know if that answers your question.

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

That's fantastic. Thank you so much.

I'm going to go on to Helena.

Helena and Ciana, thank you very much for being here.

We're talking about cervical cancer. What can we do to ensure that women and young girls get the HPV vaccine?

[Ciana Van Dusen]

I think a lot of it is coming out of this awareness piece. Especially after COVID, we saw a decrease in vaccination, so we remind people that this remains one of the two best ways to prevent cervical cancer along with our screening. Whether it's awareness campaigns or conversations with our doctors, we encourage that for both boys and girls of the appropriate age, based on the provinces.

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

Thank you so much.