Health Committee on June 13th, 2024

[The Chair, Liberal, Sean Casey]

I call this meeting to order.

Welcome to meeting number 123 of the House of Commons Standing Committee on Health.

Before we begin, I'd like to ask all members and other in-person participants to consult the cards on the table for guidelines to prevent audio feedback incidents.

Please take note of the following preventative measures in place to protect the health and safety of all participants, including the interpreters. Use only the approved black earpiece. The former grey earpieces must no longer be used. Please keep your earpiece away from all microphones at all times.

[Luc Thériault, Bloc, Montcalm, QC]

On a point of order, Chair.

[The Chair, Liberal, Sean Casey]

Go ahead.

[Luc Thériault, Bloc, Montcalm, QC]

I cannot hear a single thing.

First, I would like you to call for decorum. Next, through you, Mr. Chair, I would like to say to the interpreters that if we want everything to go smoothly today, then they will have to get as close to their microphones as possible. I know that they have a tough job to do, but I can barely hear anything and the volume on my headset is almost at 10, which is dangerous to me.

[The Chair, Liberal, Sean Casey]

Is it the same technical problem as the other times, which is unrelated to the noise in the room?

[Luc Thériault, Bloc, Montcalm, QC]

Last week I chose to follow the meeting nonetheless, but the situation is not resolved.

[The Chair, Liberal, Sean Casey]

Okay. We will suspend the meeting to try to resolve the technical problem.

Meeting suspended.

[The Chair, Liberal, Sean Casey]

I call the meeting back to order.

Mr. Thériault, does it appear to be resolved for the moment?

[Luc Thériault, Bloc, Montcalm, QC]

The volume is now set to 8 out of 10 and I can hear properly. I will need to pay attention when a new interpreter enters the booth because at this volume, the sound can be damaging. I will keep going like this because I can hear now. The sound in the room will also have to be adjusted according to the witnesses appearing via video conference.

[The Chair, Liberal, Sean Casey]

Okay, thank you.

I will carry on.

When you're not using the earpiece, place it face down on the sticker placed on the table for this purpose. Thank you for your co-operation.

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 April 11, 2024, the committee is continuing its study of breast cancer screening guidelines.

I would like to welcome our panel of witnesses.

Colleagues, you will notice from the notice of meeting that we've arranged the witnesses in two two-person panels. This was done to accommodate the schedule of the witnesses and to ensure the maximum amount of time to question each one.

From 11 to 12 today, we have, appearing by video conference, Dr. Jean Seely, professor of radiology, faculty of medicine, University of Ottawa. With us in the room, from the Canadian Cancer Society, are Kelly Wilson Cull, director of advocacy, and Ciana Van Dusen, advocacy manager of prevention and early detection.

We'll begin with Dr. Seely online for her opening statement of up to five minutes.

Welcome to the committee, Dr. Seely. You have the floor.

[Dr. Jean Seely, Professor of Radiology, Faculty of Medicine, University of Ottawa, As an Individual]

Thank you very much, Mr. Casey and members of the committee, for the opportunity to comment on the draft Canadian task force breast cancer screening guidelines.

As a breast imaging specialist, I diagnose women along their entire cancer journey. I detect breast cancers through screening or diagnose them after a woman presents with a symptom of a palpable lump. I perform biopsies and I localize breast cancers for the surgeons. I interpret the imaging of women diagnosed with late-stage or recurrent breast cancer. I speak to women at all stages of breast cancer. A screen-detected cancer found before symptoms occur is a very different diagnosis from one found because of symptoms at stages 2 or 3, or when it's incurable, at stage 4.

The task force falsely equates an additional imaging test as a harm comparable to a delayed diagnosis of late-stage breast cancer. My patients attest that the severity of the harm of a delayed diagnosis vastly exceeds any stress associated with any additional imaging test. Equating these harms is a false equivalency.

The recent draft guidelines released by the task force for breast cancer screening have sparked significant concern within the medical community. As an expert included on the evidence review panel, I find their recommendations profoundly disappointing. These guidelines ignore robust and recent evidence supporting the initiation of screening at age 40, a standard now adopted in the United States and numerous other countries.

The task force recommendations are anchored in studies dating back 40 to 60 years, utilizing obsolete technologies like film-screen mammography. As experts, we recommended against including these outdated data, which overlook monumental advances in breast cancer treatment, including hormone receptor-positive treatments like tamoxifen, less invasive surgical options like lumpectomy and sentinel lymph node biopsy, and modern immunological and chemotherapeutic agents that have revolutionized breast cancer management. The task force working group interfered with our expert recommendations and insisted on using these studies.

The task force approach diminished the importance of recent observational studies, involving millions of women, comparing screening to no screening with updated diagnosis and treatment. These studies include one Canadian study of over 2.7 million women screened over 20 years, which demonstrated a 44% reduction in breast cancer mortality in women who began screening in their forties. Similar studies in Sweden show even greater benefits, with reductions in mortality of 50% to 60% in women aged 40 years and older.

Furthermore, the task force used the old trials to evaluate cancer stage at detection and therefore missed the benefits of early-stage detection with up-to-date screening technology. The improvements in screening technology in the past 15 years have improved breast cancer detection by 20% to 40%.

Breast cancer is a devastating diagnosis, but the harms are mostly preventable when it is detected early. The survival rates are starkly different across stages—a nearly 100% five-year survival rate for stage 1 detected through screening as compared with only a 22% five-year survival rate at stage 4, when the disease has become incurable. Furthermore, the treatment is much less intensive and costly when treated early. Stage 1 cancer costs an average of $30,000 Canadian to treat, as compared with up to $500,000 for stage 4. Systematic screening programs in Canada find that 87% of breast cancers are stage 1 at diagnosis.

The task force disregarded data that showed women of a race or ethnicity other than white are more likely to be diagnosed with breast cancer in their forties. A one-size-fits-all approach to recommending screening only starting at 50 discriminates against these women and contributes to their twice-higher rates of advanced breast cancer due to delays in screening, access to screening and delays in diagnosis.

The task force acknowledged that women with dense breasts were twice as likely to develop breast cancer as women with non-dense breasts. However, it failed to recognize the reduced sensitivity of mammography in these women, which drops from 90% in women with non-dense breasts to 60% in those with the densest breasts. The task force ignored high-quality randomized studies that showed adding screening with MRI reduced interval cancers—cancers diagnosed by symptoms after a normal mammogram—by 80% and by 50% in women screened with supplemental breast ultrasound. These have been shown to be evidence-based acceptable surrogates for breast cancer mortality, but the task force did not consider them despite an expert recommendation.

We must demand that our health policies be reflective of the latest scientific evidence and best practices in medicine.

Thank you very much for your attention.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Seely.

Next we have the Canadian Cancer Society, with Ms. Wilson Cull or Ms. Van Dusen, or a combination of the two.

You have five minutes. Welcome to the committee. You have the floor.

[Kelly Wilson Cull, Director, Advocacy, Canadian Cancer Society]

Good morning.

My name is Kelly Wilson Cull, and I'm the director of advocacy. With me today is Ciana Van Dusen, who's the advocacy manager of prevention and early detection.

The Canadian Cancer Society is the voice for people who care about cancer in Canada. As a part of our commitment to improving and saving lives, we are pleased to provide recommendations on breast cancer screening.

Cancer is the leading cause of death in Canada. It is predicted that two out of five people will be diagnosed with cancer in their lifetime, and approximately one in four will die of the disease. In Canada, an estimated one in eight women is expected to be diagnosed with breast cancer during their lifetime. Breast cancer is the most common cancer among women in Canada, and despite fewer women being diagnosed with breast cancer under the age of 50, it remains the leading cause of cancer death for people in Canada aged 30 to 49.

While data from a new study shows that breast cancer incidence rates for women in Canada in their forties have increased over the last 55 years, overall, breast cancer incidence and death rates in Canada are trending downwards as early detection, treatment and care continue to improve. However, we must acknowledge that international data indicates that more Black, Asian and Hispanic women with breast cancer are diagnosed before the age of 50 and are more often diagnosed with a later-stage disease compared with other women. This means that waiting to start screening at age 50 could result in missed opportunities for early detection among women in these communities.

Evidence from trials, modelling studies and real-world data has shown benefits from regular breast cancer screening starting at age 40. Timely access to breast cancer screening is critical to finding breast cancer early, when treatment is most likely to be successful. We continue to hear from people living with breast cancer that they do not feel represented by the current guidelines because they do not reflect their lived experiences. Furthermore, according to a national survey, most respondents support expanding systematic access to breast cancer screening to include women aged 40 to 49.

CCS supports expanding access to breast cancer screening for women and trans, non-binary and gender-diverse people aged 40 to 49 at average risk of developing breast cancer. We also need to ensure that there is clear guidance for people who have an elevated or high risk of developing breast cancer, such as people with certain genetic mutations, a family history or dense breasts.

I will turn the remarks over to Ciana.

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

Thank you, Ms. Wilson Cull.

A growing number of provinces in Canada have started offering cancer screening services starting at the age of 40 or have made announcements about expanding access to these services. While the provinces and territories are looking at the new national guidelines, the Canadian Cancer Society, or the CCS, is asking remaining administrations to include women 40 to 49 at an average risk for breast cancer in their breast cancer screening program. This change also reflects the new evidence that was released between the last update of the Canadian guidelines in 2018, and those that were presented a few weeks ago.

The data on participation in breast cancer screening programs in Canada will soon be updated by Canadian Partnership Against Cancer. For now, our data goes back to before the pandemic and the breast cancer screening programs do not meet the national objective of 70% participation. It is important to increase capacity to meet people's needs in Canada, while taking into account the needs of underserved populations, specifically individuals who are part of racialized or indigenous communities, as well as low-income individuals or those living in a rural or remote region, and adapting the services accordingly.

What is more, the CCS recommends that the federal government invest more in research in order to expand knowledge on screening and the risks associated with cancer. It is also important to fill the gaps in data in order to have a better understanding of the incidence of cancer in Canada. The Pan-Canadian Cancer Data Strategy and the Pan-Canadian Health Data Charter describe interesting possibilities for improving the data in the country.

Governments need to invest in breast cancer prevention, early detection and treatment and in reducing the effects of the labour shortage. These investments include many investments in human resources, in integrating new technologies, in digital infrastructure and in modernizing care trajectories to meet Canadians' current and future needs.

Thank you for taking the time to listen to our recommendations. We look forward to continuing to work together to better support people affected by cancer because it takes society as a whole to tackle cancer.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you.

We will begin the round of questions with the Conservatives.

Mr. Ellis, you have the floor.

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

Thank you very much, Chair.

Thank you to our witnesses for being here for this very important topic.

What we've heard very clearly is that in spite of what the task force has said, the science is perhaps changing very rapidly. It's a dynamic environment. Some science is not being taken into account, which is very discouraging.

Dr. Seely, I know you don't have a crystal ball—or if you do, I'd be happy to borrow it now and again—but the task force has put out its draft guidelines. Do you think there's a way, with the voice of this particular committee and your voices added, that the draft guidelines from the task force can be changed to be more reflective of current science?

[Dr. Jean Seely]

The problem with the task force recommendations is that they dictated what evidence could be used. They insisted on including the randomized controlled trials that were 40 to 60 years old. Because of that, the evidence generated for these recommendations does not reflect the most up-to-date evidence. My concern is that these draft recommendations will not change despite the feedback.

Our recommendations are to not adhere to any of these recommendations and to start again with the evidence that experts recommend should be used.

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

Going down that line, there's a concern that I think we should all share. It's certainly one of my concerns. We don't want women in Canada getting mixed messages. That creates a difficulty. If we believe—and I believe what you're saying is true—that the draft guidelines will become guidelines, how can we amplify the voice saying, on behalf of women, that they should be able to access screening for breast cancer at age 40?

I live in Nova Scotia. That is a reality there. Women can access screening, as you well know, at age 40. Would it behoove this committee to write to every provincial minister of health after the final report of this committee to ensure they hear that message loud and clear? Is that another path we could possibly go down to ensure the message is heard clearly?

[Dr. Jean Seely]

That certainly would help. What we know is that all the provinces and territories have now updated their screening guidelines. The only two that remain are Quebec, which is looking at the evidence, and Manitoba. The problem is that these task force guidelines are adhered to by many family physicians in the country. We know that when the task force changed its recommendations in 2011, British Columbia—which, like Nova Scotia, allowed women to be screened in their forties—saw a marked decrease in the participation of women in their forties. It dropped from 50% participation to 25%.

We must have even better messaging to not adopt these guidelines, as they are adhered to by many family physicians who don't have time to follow the most up-to-date evidence.

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

Do you think there's an opportunity, then, to target The College of Family Physicians of Canada so that family physicians can hear this message very clearly? Obviously, the science exists, but most of this is a communications exercise, as you mentioned very clearly, to family physicians and to women in Canada. I realize you're not a marketing expert, but what I'm asking is how we get that message out there so that it's loud and clear without, sadly, the task force changing its guidelines.

[Dr. Jean Seely]

For sure a message from the government and this committee would be very helpful. It would probably be very useful to target it to the family physicians, who have a more limited knowledge about this, and to amplify it at the level of the screening programs.

I would encourage Quebec and Manitoba to have a systematic approach. The programs that have been delivering screening are excellent, and we would recommend that all of that screening be done within a screening program and by self-referrals starting at age 40 and older.

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

Thank you very much.

Ms. Cull, is that approach something the Canadian Cancer Society believes would help amplify the message as well? I realize I'm putting you on the spot, but that's what we're here to do, so thank you for that.

[Kelly Wilson Cull]

Certainly, yes. The Canadian Cancer Society is very actively engaged with all provincial governments across Canada on this issue. We recognize that many provincial programs—

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

On a point of order, I'm showing English, but I'm getting French interpretation right now.

[The Chair, Liberal, Sean Casey]

We'll get you to repeat your answer once we check what the technical problem is.

I believe the problem is resolved. When this happened, Mr. Ellis still had about a minute left on the clock, but you were in the middle of your answer, so please go ahead and complete your answer.