Health Committee on June 13th, 2024

[Kelly Wilson Cull]

As I said, we see the importance of distinguishing between what population-based screening programs do and a differentiated pathway for people who have an elevated and high risk. We hear from patients, and we've done a lot of work surveying patient groups. People are showing up at their family doctors with signs and symptoms and are being refused screening access within this group. If you have, for example, a family history, your risk pathway needs to look different from that of someone who is asymptomatic or not presenting signs and symptoms.

To go back to the mixed messaging point, we see different provinces and territories with different approaches to high-risk guidelines. Again, that creates an inequity of access from province to province. We need leadership in this country to ensure that all Canadians, whether of average risk, high risk or elevated risk, are getting a consistent approach to screening, regardless of where they live in Canada.

[The Chair, Liberal, Sean Casey]

Thank you very much.

That concludes the time we have available for this panel.

I want to thank you so much for being with us. I don't think there can be any greater statement on the importance of your work than the level of emotion and personal attachment to these issues that you've seen demonstrated by parliamentarians posing questions today. Thank you for what you do and for being with us.

We'll suspend for about three minutes to allow our witnesses to take their leave and get the others set up and tested.

Thanks, everyone.

[The Chair, Liberal, Sean Casey]

I call the meeting back to order.

I would like to welcome our witnesses for the second hour of today's meeting and thank them for being with us. Appearing as an individual, we have Dr. Martin J. Yaffe, a senior scientist at Sunnybrook Research Institute, University of Toronto. Appearing by video conference on behalf of the Canadian Society of Breast Imaging, we have Dr. Supriya Kulkarni, president.

Welcome to both of you. We will start with your opening statements of up to five minutes each.

Dr. Yaffe, you have the floor.

[Dr. Martin Yaffe, Senior Scientist, Sunnybrook Research Institute, University of Toronto, As an Individual]

Thank you very much, Mr. Chairman.

I'd like to thank the committee for this opportunity to discuss this very important issue.

The decision to participate in breast cancer screening or not should be up to individuals, but to inform that decision, they need accurate, unbiased and accessible information regarding the benefits, limitations and potential harms associated with screening. The Canadian Task Force on Preventive Health Care provides advice to primary care physicians and the public, but disturbingly, the information it provides has been distorted to discourage participation in breast cancer screening. This may be responsible in part for the low participation rates mentioned earlier by Ms. Van Dusen.

I am a senior breast cancer research scientist who leads a group of 20 researchers at the Sunnybrook Research Institute in Toronto. I also co-lead the imaging research program at the Ontario Institute for Cancer Research. Much of my work over the past 44 years has focused on breast cancer screening, and my group has helped develop and validate the technique of digital mammography that is now used worldwide. We established breast density as a risk factor for breast cancer. Also, in 2015, I helped write the World Health Organization's IARC handbook on breast cancer screening.

I've been at odds scientifically with the task force since 2011.

Dr. Seely already mentioned the randomized trials conducted in the 1990s that proved earlier detection of breast cancer by mammography screening can help reduce breast cancer deaths. With the modern developments in both screening and breast cancer therapy, more recent large studies, including the one done in Canada that was mentioned earlier, show a 44% reduction in breast cancer deaths in women from the age of 40 onward participating in mammography screening. They have shown definitively that breast cancer screening of younger women saves lives. Certainly, this is a much larger benefit than was seen in earlier randomized trials conducted 40 to 60 years ago. In addition, screening detection of breast cancers in younger women can, in some cases, give them back 20 additional years of life to be with their families, in the workplace and interacting with society.

A decision on screening involves weighing the benefits of averting premature death against the limitations and possible harms. The task force has not done this. Instead, it's made blanket statements about harms, suggesting without evidence that they may approach or outweigh the benefits for younger women.

The task force commissioned a project to model screening outcomes. A table in its guidelines suggested very low benefits from screening younger women. However, we have not had the opportunity to see the details of how it did that work.

I published modelling results in 2015 and 2022, some using the same model as the Canadian task force, and the U.S. preventive services task force commissioned modelling to inform its 2024 guidelines update. Results coming from five NCI-funded models in the U.S. agree well with those from my lab. They show continuously increasing absolute and relative benefits of breast cancer mortality reduction when the starting age for screening is reduced to 40, the stopping age is increased to 79—in other words above 74, as we've been discussing—and screening is performed annually rather than every two years. The worst results are obtained when screening is done at three years, which is a strategy suggested by the Canadian task force with no evidence at all to support it.

Modelling allows us to weigh the benefits versus the possible harms of breast cancer screening, and it has shown that the net improvement in quality-adjusted years of life—I can talk about that later if you want—gained by screening increases when screening starts earlier, ends later and is annual. The benefits consistently dwarf the harms.

As an expert invited to the Ottawa evidence review and synthesis centre, I had the same experience as Dr. Seely of interference by the task force. Against the advice of invited experts, they focused on the older, now obsolete randomized controlled trial data, set arbitrary thresholds to assess the data and used too short an observation time to allow the full impact of the benefits to be measured.

The task force takes a “less is more” position toward screening, and this comes at the cost of thousands of lost lives, accompanied by increased morbidity due to later treatment of disease. Of course, the task force also insists on specifying outcomes only in absolute quantities, which minimizes the perceived level of benefit, especially for lay people. Two lives saved per thousand seems like a small benefit, but that represents a 40% mortality reduction and 470 or more deaths avoided each year in Canada.

It's apparent that the task force has a strong bias against screening or preventive medicine of any kind. Of course, nobody should be coerced into being screened. It's a personal decision, but impediments to access must be removed to provide equity in saving lives. No woman should ever be put in a position of having to debate with her doctor, who has been misinformed by the task force, that she should be able to access screening.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Yaffe.

Next, from the Canadian Society of Breast Imaging, we have Dr. Kulkarni.

Welcome to the committee. You have the floor.

[Dr. Supriya Kulkarni, President, Canadian Society of Breast Imaging]

Thank you.

Honourable health committee members, I am grateful to have this opportunity today to talk to you all about breast cancer screening, a topic that is very close to my heart.

I am an academic breast imaging radiologist working at the Princess Margaret Cancer Centre in Toronto and am currently serving as the president of the Canadian Society of Breast Imaging. I am greatly invested in improving patient care and experience through the health care system.

The recently issued Canadian task force recommendations, which excluded screening of eligible women between 40 and 49 years of age, came as a huge disappointment. The recommendations conflict with those of other reputable organizations, leading to confusion among health care providers and patients.

Canada's evolving ethno-racial landscape has been systematically excluded by task force recommendations, which are still predominantly based on older studies involving white women. The data is not fully representative of our population, leading to recommendations that might not be applicable, beneficial or safe for everyone. For example, Black women experience poor breast cancer survival rates, are more likely to be diagnosed with advanced-stage breast cancer and have biologically aggressive tumours, all of which occur at an earlier age than in white women.

Canadian data shows significantly higher proportions of stages 2, 3 and 4 breast cancers occurring in women in Canadian jurisdictions that do not include women in their forties in screening programs as opposed to those that do. Lower stage means less aggressive treatment, fewer side effects and increased disease-free survival. Stage matters. Modelling has shown that by not screening women in the 40 to 49 age group, we would see an additional 470-plus avoidable deaths every year. This is equivalent to allowing a passenger jet full of young Canadian women to crash every year because we refuse to screen them at the right time. This is the chilling reality of the situation.

Mammography is a compression technique. Tissues overlap, and up to 16% of women who come for their first mammogram are likely to be recalled for additional pictures or an ultrasound and sometimes end up with a biopsy with benign diagnosis. This percentage drops over subsequent years. Recalls are not harms. These are like sending your bag through airport screening. Most of the time, it goes through. However, sometimes it gets pulled out, opened, checked and given back, and occasionally a forgotten nail clipper gets thrown out. Most women are grateful that they went through the one extra step for safety.

The task force recommends shared decision-making to allow women to discuss with their primary care providers the age at which they should have a mammogram. In a country that is grappling with a severe shortage of family doctors, this is a distant dream. The power differential between the physicians following the task force guidelines and the patient is a barrier to shared decision-making.

The current tools provided by the task force are biased towards not having a mammogram. Among other recommendations, the task force recommended against supplemental screening for women with dense breasts. We know that dense breast tissue precludes finding breast cancers at an earlier stage, akin to finding a snowball in a snowstorm. This often leads to delayed diagnosis, greater stage and spread of cancer and more extensive and expensive drugs, which may lack funding. These drugs can have a devastating side effect that significantly diminishes quality of life and function.

The task force has stated that there was insufficient evidence to support supplementary screening, and they selectively chose to follow the U.S. task force on their dense breast recommendations. Meanwhile, there are decades of data that demonstrate the benefit of supplementary screening. More recently, Ontario conducted a health technology assessment and drafted a recommendation to publicly fund supplemental screening.

To conclude, we want guidelines based on new and inclusive science that are aligned with other international guidelines and that consider the changing landscape of diversity and ethnicity in Canada. Early detection with normal, personalized therapies is the best we can give women in their cancer journey.

No woman should be denied a mammogram. Self-referral should be allowed, and for those women who prefer not to have a mammogram, they should be free to opt out.

Thank you so much.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Kulkarni.

We'll begin now with our rounds of questions, starting with Mrs. Vecchio for six minutes.

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

Thank you very much. It is absolutely wonderful to have both of you here today.

I want to start off with Dr. Martin Yaffe. Thank you very much for the information you provided.

I want to go back to the task force and the task force members: who, what, where and why? Can you start by telling me how these members are appointed to the task force? How are they chosen to represent Canadians on the task force?

[Dr. Martin Yaffe]

That's a very good question. I am not exactly sure how they're all appointed, but some of them are appointed through The College of Family Physicians. There were other bodies as well, I think, that recommended individuals.

What I've noticed, though, is that there tends to be over time—how can I put it?—a concentration of people who are like-minded. The like-mindedness tends to be an attitude that less is more and that somehow, when a woman finds a cancer, treatment alone is adequate, even if the cancer is found at a relatively advanced point.

There's a mindset that has accumulated and has been concentrated within the membership of the task force that tends to be like-minded on the subject and demonstrates a fairly clear bias against screening.

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

I'll go back to you. We're talking about screening, and we have heard, like many of you who have come to this committee to share with us, that it should be lowered to age 40. Those 40 to 49 should be included, up to 74, and we may see that expanded as well.

You're not part of the task force, but did you have a role to play in reviewing the information and providing your own recommendations? What type of information did you get as feedback?

[Dr. Martin Yaffe]

As I mentioned, I've been at odds scientifically with the various task forces since 2011. I've found that they've been very resistant to receiving information from experts like me, Dr. Kulkarni, Dr. Seely and others who are aware of and very familiar with the scientific literature in the area. Instead, they've focused narrowly on the old studies because they're randomized trials. That's a great way of doing a study, but they're so old that they're not relevant.

I may have drifted a bit from your question. If you don't mind, just repeat the last part of it. I want to make sure I answer you.

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

Actually, you answered it. That's where I wanted to go. I just wanted to know whether or not you had the opportunity to review some of these things. As you said, you have not been in agreement since 2011.

If we could just put it on the record, would you like to see all the recommendations that have come from the task force reversed?

[Dr. Martin Yaffe]

Absolutely. I agree with the other witnesses. They have recommended strongly, based on science, that women should have unfettered access to screening as of age 40. There should be a strong consideration for continuing screening beyond age 74 as long as women are otherwise in good health.

That's all backed by the modelling that I mentioned. There is at least the capability or the possibility of saving a thousand additional lives in Canada every year if we do these things—screening women in their forties, extending screening beyond age 74 and doing supplemental screening for women with dense breasts, for whom mammography does not work all that well.

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

I want to switch over, because I have a quick question for Dr. Kulkarni.

Thank you so much for talking about this. I really liked your analogy that compared this to airline screening. I always wonder if I've left a water bottle. You get anxiety, but the anxiety sure is a lot better than what else could happen.

That's what we have to see for women. When they're talking about the harm being anxiety, we can deal with it when we have solutions. Having early detection for women is really important.

We are talking about the ages 40 to 74. I want to get your opinion on those 75 and older and what that should look like. My mother-in-law is in phenomenally great shape. I expect to have her around until she is about 120. What do we do for women over the age of 74 who are in exceptional health?

[Dr. Supriya Kulkarni]

We see that all the time. There are people who come for screening and a very common comment is “These people are healthier than me”. As long as a woman is healthy and active and has at least a seven-plus-year life expectancy, they should continue to screen.

That's what we are all recommending as part of our organizations. That is the recommendation—they should continue screening. The program should allow these women into the screening program.

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

Do I still have time?

[The Chair, Liberal, Sean Casey]

You have 45 seconds.

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

Great.

I'm going to go back to you, then. We've talked about recognizing dense breasts and recognizing that makeup and ethnicity may have an impact on the composition of one's breasts. I heard someone talk about ages 25 to 40. What should we be doing for women who are 25 to 40 prior to having a physical screening?

[Dr. Supriya Kulkarni]

At the current time, there is a lot of discussion about risk assessment. It's been generally recommended, even by the NCCN guidelines, that women between 25 and 30 years of age can get a basic risk assessment profile. They are not yet at the age where systematic screening is offered, but they should at least get a risk assessment performed so that, in case there's a flag that they're high risk, appropriate steps can be taken. High-risk women generally get screened much earlier than average-risk women. That's what we want to offer to all these young women.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Kulkarni.

[Dr. Martin Yaffe]

May I add something to that?

[The Chair, Liberal, Sean Casey]

Please be very brief.

[Dr. Martin Yaffe]

We have a program in at least one province—Ontario—for women who have been identified as high risk. Those women are eligible as of age 30 to receive an MRI and ultrasound, which are more accurate for women at high risk.

[The Chair, Liberal, Sean Casey]

Thank you both.

Next we have Dr. Hanley, please, for six minutes.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you very much to all the panellists.

I want to acknowledge the courage of my fellow panellists for speaking up. I don't think we hear enough in general from people with lived experience, and hearing testimony from panel members themselves is extremely powerful.

Dr. Yaffe, I'll go to you, but I'd appreciate brief answers, with full respect. I'd love to spend hours on this, but I only have three minutes. I'm going to share some time with my colleague Dr. Powlowski.

Regarding randomized trials versus observational trials, what I'm taking away is that we can no longer do the randomized trials that were done in the fifties and sixties because it would be unfeasible to do a control and test group, let alone with the evolving technology. In other words, we can't really replicate previous gold-standard trials.

Do you favour the U.S. approach, which is to understand the basic concepts and then move on and use only modern trials from 2016 onward, even though most of them are observational? Could you quickly comment on the merit of that approach?