Health Committee on June 13th, 2024

[Dr. Martin Yaffe]

Absolutely. Randomized trials can prove and have proven the principle, but the technology used is no longer representative of current practice. Observational trials allow us to be more quantitative and to use modern data to show what the possibility of mortality reduction is. Modelling will allow us to go beyond that and extrapolate from what we've learned in the randomized and observational studies.

[Brendan Hanley, Liberal, Yukon, YT]

That's a good segue. Based on the premise that all models are wrong but some are more useful than others, could you defend your modelling practice? I think you alluded to its compatibility with other modelling exercises, particularly in the United States.

[Dr. Martin Yaffe]

It's not my model. It was developed by Statistics Canada in partnership with the Canadian Partnership Against Cancer. It's a wonderful model, and it is available for multiple cancers. It's been validated against empirical data, against actual measurements in the public. We compare it to the U.S. models, of which there are five. Actually, one of the models is from the Netherlands. We always cross-compare models, and they tend to agree with each other, which is great. That gives us more confidence in their validity.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you very much.

Dr. Kulkarni, I have so many questions for you, but I'm going to limit myself to one. I believe the European recommendations are for age 45 onward.

[Dr. Supriya Kulkarni]

That's correct.

[Brendan Hanley, Liberal, Yukon, YT]

Can you comment on that versus the U.S.? Is there a difference in the methodology or the basis for conclusions in Europe?

[Dr. Supriya Kulkarni]

Different organizations tend to have a bit of variation as to whether to start at 40 or 45. Even some organizations in the U.S., such as the ACS, recommend age 45. We have some provinces in Canada that recommend 45 and above too, so there's a bit of variation. However, overall, if you look at all the evidence that is currently available, it is a best practice to start screening at 40, and that's what we are pushing for.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you.

I'm going to hand it over to Dr. Powlowski.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

Dr. Yaffe, were you a subject matter expert adviser to the task force?

[Dr. Martin Yaffe]

No, I wasn't. I was invited by the Ottawa evidence review and synthesis centre to advise them. However, as Dr. Seely and I mentioned, we both worked with them. There was interference by the task force on what that group was allowed to do.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

Am I right that anyone who dealt with the task force had to sign a confidentiality agreement as part of working with it?

[Dr. Martin Yaffe]

That's correct, and that's one of the reasons I wasn't willing to work with them directly. I wanted to be able to speak freely.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

To your knowledge of the people who worked with them directly, did the task force follow the advice of their own experts? We've already had Dr. Seely say they didn't, but I know she can't speak for the other experts and neither can you. To your knowledge, did they follow the advice of their own experts?

[Dr. Martin Yaffe]

I really don't know. I did speak with one of them, who informed me that he felt his interaction with them was minimal. He didn't understand much of the decision-making process and didn't feel that he had much influence on the process.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

Is it troubling to you that for a matter so important, advisers were forced to sign a confidentiality agreement and therefore can't really make public what they told the task force?

[Dr. Martin Yaffe]

Sometimes confidentiality agreements are limited in time, and there are sometimes reasons for that. However, I did feel that the restriction, especially when I found the whole process very difficult to understand and agree with, was very problematic. Why should we be looking at studies that were done 60 years ago that are completely unrepresentative? That makes no sense at all.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

Lastly, the reason given for putting non-subject matter experts on the task force making the decision is that they didn't have any personal financial interest in the outcome. I know that some taking the other side are going to say that of course radiologists want to do more mammograms, because they make a fair bit of money on mammograms.

Do you want to formally reply to that, Dr. Yaffe or Dr. Kulkarni?

[The Chair, Liberal, Sean Casey]

Give a brief response, please.

[Dr. Martin Yaffe]

I'll just say that I am a Ph.D. and I get a salary for doing research, so the amount of screening that takes place doesn't affect my personal life.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Yaffe.

Mr. Thériault, you have six minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you very much, Mr. Chair.

I have a question for Mr. Yaffe.

Jacques Simard, vice-dean of research and higher education at the faculty of medicine at Laval University, suggested that instead of changing the screening age for everyone, women should obtain personalized care according to their level of risk, which would be assessed taking into account family history, breast density and age. He suggests that those who represent a so‑called normal risk continue to have a mammogram every two years between 50 and 69, while those who represent an intermediate risk begin having an annual mammogram in addition to an MRI.

What do you do think about this recommendation?

[Dr. Martin Yaffe]

It's a very interesting recommendation, and I respect Dr. Simard's work very much, but I don't think at this point we have validation that it would work. In other words, to screen people less frequently, we have to know that the risk of developing cancer is so low that they're not going to have cancers missed because of that policy. That has not at this point been validated.

Most individuals don't express risk factors for breast cancer other than being female and getting older. It is a great idea, and I think in the future it may be something we do, but we're not ready for it at the present time.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you.

At a press conference, the chair of the working group said this about the updated recommendations: “Just because we are seeing more cancer does not mean we need more screening. We need to be asking why there is more cancer.”

What do you think?

[Dr. Martin Yaffe]

Was that for me or for Dr. Kulkarni?

[Luc Thériault, Bloc, Montcalm, QC]

The question is for you.