Health Committee on Dec. 6th, 2023

[Mark Holland, Liberal, Ajax, ON]

If you take the comments made by the Conservatives today at their face value, they wouldn't have entered into advance purchase agreements. They wouldn't have had vaccines for the country. You have to wonder, then, with all their talk of the cuts they would make, whether or not they would be investing in domestic manufacturing.

When they talk about cuts and cuts, but don't tell us where they are going to be.... We have to look back to their past. The decisions they made were to cut in places like public health, to devastating effect.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you.

In terms of the seven APAs, would you call that, in general, risk mitigation—having seven different APAs with different vaccine technologies in play?

[Mark Holland, Liberal, Ajax, ON]

One hundred per cent. I think we had to take a bet on all viable options. Of course, it wasn't us making that decision. There was an external group convened of experts in virology and immunology, and industry leaders. They were brought together to advise the government on what the viable options were, and then to go and get advance purchase agreements.

Again, it's easy now. Mrs. Atwin was talking about the environment we're in now, where we're largely feeling safe. Go back to the beginning of the pandemic. None of us was feeling safe. We were terrified about what was going to happen to the people we loved.

If the government made the decision to follow the advice the Conservatives were talking about—not entering into advance purchase agreements and just letting the wind blow to see what happens—I can't imagine the thousands of lives that would have been lost.

[Brendan Hanley, Liberal, Yukon, YT]

Thanks.

I have a couple more questions.

In your opinion.... I know you were not involved as a minister. Clearly this was, as you say, recommended by a panel of experts. However, do you see Medicago as one of the candidates chosen on its own merits, or was there also an element of building domestic manufacturing capacity that weighed into that decision? Are these two separate influences in considerations?

[Mark Holland, Liberal, Ajax, ON]

No. It was very much on its technical merit. This was an innovative, plant-based technology. Most vaccines are developed off of eggs. Of course, we now have mRNA, but having additional options.... We can't imagine what that will mean for us. While we don't need Medicago right now, this innovative technology could very well save countless lives in the future. We do not know the direction of this pandemic, future pandemics or other viral threats, so having more options at our disposal is excellent.

However, the technical, scientific merit of Medicago was present, as evidenced by the fact that they manifested a viable vaccine.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Hanley.

Thank you, Minister.

That concludes our rounds of questions.

We genuinely appreciate your making yourself available. I would have to say I share in the kind words that you have passed along to your team for their work throughout. Thanks to you all. You're welcome to stay, but you're free to leave.

Colleagues, we're going to suspend, because we need to do some sound tests for the next panel.

The meeting stands suspended for about five minutes.

[The Chair, Liberal, Sean Casey]

I call the meeting back to order.

Pursuant to Standing Order 108(2) and the motion adopted on May 16, 2022, the committee is now going to resume its study of women's health.

As we have some remote participants, I'd offer the following comments for their benefit.

You have at the bottom of your screen interpretation available to you. There are three channels: floor, English and French. Please don't take screenshots or photos of your screen.

I would like to welcome our panel of witnesses. Appearing today as an individual, we have Dr. Steven Narod, senior scientist.

We also have Jacques Simard, who is a full professor in the department of molecular medicine at Université Laval.

We also have with us Dr. Anna Wilkinson, doctor of medicine. Representing Dense Breasts Canada, we have Jennie Dale, co-founder and executive director, and Dr. Paula Gordon, both appearing by video conference.

Thanks to all of you for being here with us today. You each have five minutes for your opening statements.

We're going to begin with Dr. Narod.

You have the floor. Welcome.

[Dr. Steven Narod, Senior Scientist, As an Individual]

Thank you very much.

I'm a professor at the Dalla Lana school of public health at the University of Toronto, and I'm grateful to the federal government. I hold the Canada research chair in breast cancer, which I've held for the past 21 years. I've been a professor at Women's College Hospital and, for 25 years, have focused almost entirely on breast cancer.

One of my topics of interest is early detection and screening. In 2014, I published what was considered kind of a landmark paper. I was the senior author responsible for the statistical analysis and the write-up of the Canadian national breast cancer screening study, which was a study of mammography.

In that study, which started in 1983, we took 90,000 women across Canada and randomized half of them—by chance, randomly—to a mammography every five years. The other 50% received a physical examination. We followed them for 25 years, and I published in 2014 with my mentor, Dr. Tony Miller. After the 25 years of follow-up, we saw almost exactly the same number of deaths from breast cancer in those women who received five mammograms—500—as in those who received no mammogram—505.

That led me to the conclusion that mammography was capable of early detection. The mammographically detected cancers were smaller. They were less likely to be node-positive cancers. Also, the survival of the women with the mammogram-detected cancer was much better, but unfortunately it didn't result in any reduction in the number of deaths.

In fact, there were 177 women who had their nonpalpable breast cancer detected by the mammogram—they found the breast cancer by the mammogram—who were alive at the 30-year mark. I believe that 177 of those women thought the mammogram had saved their lives and would testify to it and do a testimonial saying, “We really believe in mammograms. I had a mammogram and it caught my breast cancer before it was palpable, before you could feel it as a mass.” However, the number of deaths was the same.

The study has been criticized. To a large extent, people criticize that which they don't like. I've written hundreds and hundreds of papers—730 papers on breast cancer—and that was probably the one that had the most response to it, I think largely because we showed that we didn't believe mammography was capable of reducing mortality from breast cancer. A lot of allegations were made against the paper, generally in the lay press.

Anyway, I took the allegations seriously, went back to the data, reviewed all the data as to whether the allegations were consistent with the findings and came to the conclusion that they were not. I hold the paper to be the standard of scientific research. I think it remains the best breast cancer screening study done, and I think the results are valid.

I could go on, but is that my five minutes?

[The Chair, Liberal, Sean Casey]

You have another minute, if you want it.

[Dr. Steven Narod]

I have another minute? Okay.

I've been studying breast cancer in all its formats for 25 years. Much of what I study is early detection. We have to think of the concept that mammography works. Mammography finds cancers when they're small and node-negative. There's no doubt that a mammogram will pick up a cancer when it's small and node-negative. Those have good prognoses.

The last five years I've devoted myself to trying to interpret why it doesn't save lives. I've come to a different conclusion from most of the other physicians on the planet. That is, if breast cancer is going to spread, it will spread very early on. There's a kind of breast cancer that becomes metastatic early on and one that doesn't become metastatic over the course of its clinical time.

In the past year, I have written a 300-page book about it. It will be finished tomorrow on the train ride home. I got the first half proofread today. The other half I'll do tomorrow coming home.

Anyway, I thank the committee for inviting me to express my opinions.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Narod.

[Dr. Steven Narod]

They are opinions. I mean, there are no facts here. There are scientific interpretations. There are facts and then the interpretation of them. We all have our own way of interpreting data.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Narod. I'm sure you'll get a chance to expand on that during the rounds of questions.

Welcome to the committee, Mr. Simard. You have the floor for five minutes.

[Jacques Simard, Full Professor, Department of Molecular Medicine, Université Laval, As an Individual]

Thank you.

I would like to thank the committee for this opportunity to expose some of our work.

For 21 years I have been the holder of a Canada research chair in cancer genetics. I'm also a fellow of the Royal Society of Canada.

A screening program will be sustainable if it delivers more benefit than harm, demonstrates value for money, is feasible to implement, is accepted by both the users and the providers and ensures equitable accessibility.

Currently, breast screening programs determine eligibility based on age, primarily targeting women aged 50 to 74 years of age with mammograms every two years. However, the risk of developing breast cancer varies a lot among women. There are no national guidelines for screening individuals deemed high risk. Screening protocols vary across jurisdictions, and the definition of high risk of developing breast cancer also varies across Canada.

Typically, women are identified as high risk based on a family history of breast cancer followed by testing for BRCA1 and BRCA2 gene mutations. This identification process is often initiated ad hoc by the affected individual and their care provider rather than through systemic population-based identification strategies. This approach overlooks women without a known family history but with a significant genetic predisposition and women at high risk due to the combination of other risk factors like polygenic risk, lifestyle and hormonal factors and mammographic breast density.

Polygenic risk scores represent the combined effect of multiple genetic variants on cancer risk identified through genome-wide association studies—called the genomic approach—and provide a powerful risk prediction approach with the potential to identify many more individuals at high or low cancer risk than is possible by screening based on age alone. In this regard, comprehensive risk prediction tools, including both genetic and non-genetic risk factors, have shown promise in providing personalized risk prediction and informing cancer-screening strategies.

A risk-stratified program involves assessing the risk of breast cancer for each woman in the population, stratifying the population into several risk groups, assigning individuals to their respective risk groups and tailoring the screening strategy to each risk group. This approach may result in some women starting mammographic screening at a younger age, having different screening intervals or having supplemental screening with another imaging modality such as MRI. Additionally, women deemed to be at the highest risk of breast cancer could be offered prophylactic preventative treatment.

Evidence from simulation studies so far shows that risk-stratified screening allows for better trade-offs between benefits and harms. By focusing more intensive screening efforts on high-risk individuals, it is possible to detect cancers earlier in this group while reducing unnecessary screening of low-risk populations. This targeted approach would potentially lead to earlier detection and improved outcomes and reduce overdiagnosis and overtreatment. Also, these studies have shown that risk-stratified screening programs are more cost-effective than the current age-based screening, allowing more efficient use of resources within health care systems.

For 25 years I've been the principal investigator of an international interdisciplinary team. Our last large-scale project was called “Personalized Risk Assessment for Prevention and Early Detection of Breast Cancer: Integration and Implementation”, which is the first study that will provide real-world evidence on the optimal implementation of approaches within the Canadian health care system. The Perspective I and I study leverages resources available through the existing screening program, including infrastructure, data collection, methods and analytical tools. This will enable seamless integration into the existing health care infrastructure and facilitate adoption into clinical practice.

Our project will inform collection of saliva sample and questionnaire-based risk information at the population level, risk communication preferences, psychological and emotional outcomes following communication of breast cancer risk information, adherence to the risk-based recommendations of screening, outcomes of screening—cancer detection rates, false positive rates, stage of diagnosis—using multifactorial risk levels and also the relative contribution of self-reported risk factors, mammographic density and the polygenic risk score to breast cancer risk level estimates by the comprehensive CanRisk prediction tool.

This assessment is to strike a balance between the accuracy of risk assessment and the practicality of collecting this information at the population level.

Identifying screening protocols will optimize the cost-effectiveness and a benefit-harm balance of a risk-stratified screening program. We're also looking for a strategy to increase the health care organizational readiness to implement a risk-based breast screening program.

So far, we have learned that it's feasible to collect samples and data for risk estimation. More than 4,000 women participated in Ontario and Quebec in this real-world implementation study. Risk-based screening is acceptable to the woman and to the health care provider. Using multifactorial risk levels compared to age, family history or breast density alone may provide more appropriate recommendations by reducing over-screening in those at average risk and increasing screening for those at higher risk.

Thank you for your time.

[The Chair, Liberal, Sean Casey]

Thank you, Professor Simard.

Next is Dr. Wilkinson, please.

Welcome to the committee. You have the floor.

[Dr. Anna Wilkinson, Doctor of Medicine, As an Individual]

Thank you, Mr. Chair.

Thank you to this committee for your important work, especially today, on the National Day of Remembrance and Action on Violence Against Women.

Very few people see the impact of breast cancer screening guidelines the way I do. I am a family doctor. I train future family doctors, and I am a GP oncologist, working on the cancer wards caring for patients who are too sick to be at home. I am also a researcher. I work with Statistics Canada to understand the impacts of Canadian guidelines on breast cancer outcomes. I became a researcher almost accidentally. I could not understand why, as a family doctor, I was told not to screen women in their forties, but as a GP oncologist I was seeing so many women in their forties and early fifties dying of cancer.

If you walk a day my shoes, you will see what it's like to have to tell a woman in her forties that she has incurable cancer. I talk with these women and their families. I sit with them. I walk them through the transition to palliative care. It's not something I forget. These women stay with me, as do their children and spouses who have journeyed alongside them.

The Canadian Task Force on Preventive Health Care determines the recommendations for screening in Canada. In 2011 the task force recommended against screening women in their forties. However, some provinces continued organizing screening programs and some did not, creating a natural experiment in our country. Together with Statistics Canada, Dr. Seely and I used these differences in provincial screening practices to perform an audit of the impact of the task force guidelines.

We reviewed more than 55,000 breast cancer cases over seven years. We found that the proportion of incurable or metastatic breast cancer increased by 10% in women in both their forties and fifties after the guidelines changed in 2011. When we compared jurisdictions that screened with those that did not, we found that women in their forties had significantly more advanced cancers and significantly lower survival than if there was no screening. We also saw a knock-on effect where women in their fifties had significantly more advanced cancers if they weren't screened in their forties. We saw an overall significant increase in the total number of breast cancer cases being diagnosed in women in their fifties if they weren't screened in their forties.

I've also investigated the cost of breast cancer treatment. The cost of treating just one case of metastatic breast cancer is half a million dollars. Compare that with $68 for a mammogram.

Working with Statistics Canada, we found that non-white women—Black, indigenous, Chinese, South Asian and Filipina—have a peak age of breast cancer diagnosis in their forties, while white women have a peak age in their sixties. This means that the majority of breast cancer cases in non-white women are diagnosed before screening even starts. Finally, we found that the incidence of breast cancer has increased rapidly in younger women over the last few years.

Currently, I am an expert for the evidence review team in the guideline update process. Our team creates the evidence base from which the task force makes their guidelines. We experts have recommended against using 40-year-old to 60-year-old trials, which were performed in primarily white populations with primitive and now obsolete technologies. This aligns with what the U.S. task force did for their new guidelines.

However, the Canadian task force dictated the inclusion of these outdated trials, thereby ensuring that the guidelines would not change. We wrote to Minister Holland to demand that the evidence base be established independently. I remain skeptical that the new guidelines will change, as I feel that this is a flawed process, with co-chairs who publicly state their bias against screening, place an overemphasis on harms and have limited openness to adjusting methodologies to embrace modern data.

The U.S. and many of our provinces have recommended that women 40 to 49 be screened. However, family doctors deeply respect the task force guidelines and follow their edicts, even if they are contrary to what the patient in front of them wants. Until the task force recommends screening women in their forties, most family doctors in Canada will not advise their patients to be screened, even if there is a provincial screening program.

My asks of the committee are as follows.

Ensure that the task force process is transparent and uses inclusive, modern evidence. We cannot be basing our 2023 recommendations on trials from 1963.

Ensure that experts can vote and that there is oversight so that individual biases cannot drive the outcome of the process.

As well, in the longer term, develop a guideline process that is responsive to new evidence, with scheduled frequent reviews and a mechanism to evaluate the effectiveness of guidelines once they are in place.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Wilkinson.

Next, we're going to hear from Dense Breasts Canada, with Ms. Dale and Dr. Gordon.

I understand you have a joint statement, so you have five minutes to use as you will.

Welcome.

[Dr. Paula Gordon, Doctor, Dense Breasts Canada]

Thank you.

I am Dr. Paula Gordon, and I'll start.

Thank you for the opportunity to be here today.

I am a breast radiologist. I've been in practice for over 40 years, reading mammograms and ultrasounds, and doing needle biopsies and other breast procedures. I've volunteered with Jennie Dale and Dense Breasts Canada for seven years as their medical adviser, advocating for optimal breast cancer screening.

Breast cancer is common. One in eight Canadian women will be diagnosed with breast cancer during her lifetime. Mammograms are low-dose X-rays of the breasts that allow us to detect cancers earlier, before there are symptoms. Breast cancer treatments are less intensive and outcomes are better, when cancers are diagnosed at an early stage. The five-year survival rate for stage 1 breast cancer is 99%, but it's only 22% for stage 4.

Some breasts have more normal glandular tissue than fat, and we call these “dense breasts”. These people have a higher risk of getting cancer, and mammograms are less effective at finding their cancers. They benefit from supplemental imaging, typically with ultrasound or MRI, based on the patient's risk.

The current task force guidelines recommend against screening women younger than 50 and older than 74, against additional screening for people with dense breasts, and against doing breast self-exams. Experts disagree with these guidelines, which were created using a flawed process. The same process has impaired other guidelines on women's health. The Canadian task force is an arm's-length body with no accountability and no requirement to monitor the impact of their guidelines.

In the past, the task force has intentionally excluded subject matter experts from their guideline panels. Without expert input, the task force based recommendations on decades-old trials that included, almost exclusively, white women, so they discriminate against racialized women. The guidelines discriminate against women with dense breasts and against women older than 74, who have the highest mortality from breast cancer. The guidelines have led to inequity of access among provinces. A Canadian woman's access to early detection of breast cancer should not depend on where she lives.

The panel for the 2024 update includes family doctors, a nurse practitioner, a gastroenterologist and a kidney specialist. For the first time, four experts are included; however, the task force methods manual states, “Clinical and content experts do not provide input or vote on the direction or strength of recommendations”.

To ensure Canadian women have access to equitable and optimal breast screening, we ask that the guideline process be reformed to ensure appropriate oversight, use of current research and meaningful input from experts.

Jennie.

[Jennie Dale, Co-founder and Executive Director, Dense Breasts Canada]

I am Jennie Dale. I am a breast cancer patient. In 2016, I co-founded Dense Breasts Canada, a non-profit that raises awareness and advocates for optimal breast cancer screening. I've spoken with hundreds of breast cancer patients across Canada, and it's an honour to be here tonight to represent them.

I could spend hours telling you about the damage the current breast screening guidelines are doing. I could tell you about Jennifer and Carolyn, who are in the committee room tonight. Both were diagnosed with later-stage breast cancer after not being given access to screening in their forties because of the current guidelines. Instead of lumpectomy and radiation, they were subjected to aggressive treatment—mastectomy, chemotherapy and lymph node dissection. I could tell you how they both missed critical years of work, how their families worried they would lose them and how they worry now about metastases. I could tell you they live with lingering pain and debilitating side effects, and I could tell you that the task force members who created these guidelines believe all of these are acceptable costs for Jennifer and Carolyn to pay in the name of not screening.

I could also tell you that, if Jennifer and Carolyn lived in B.C., Nova Scotia, P.E.I. or the Yukon, they could have self-referred for mammograms in their forties and been spared much of what they've gone through. I could tell you that, even though current research shows clear benefits to early detection, members of the task force don't believe that earlier screening results in better outcomes for enough women. Instead, they cling to the flawed findings of 40- to 60-year-old studies—like the CNBSS—that have now been discredited.

I could tell you more, but the one message I want to leave with you is that the current guidelines are harming Canadians and causing avoidable deaths. The very guidelines that everyone would expect to protect Canadians are doing the opposite. The task force is denying us the opportunity to access preventive health care that results in better outcomes. Their overstatement of harms and understatement of benefits are not based on modern science. Their paternalistic concern about anxiety caused by screening is not borne out by patients' lived experiences. Their insistence on shared decision-making perpetuates power imbalances between doctor and patient. Finally, their dismissal of the impact of the guidelines on patients' quality of life is reductive at best and callous at worst.

Please bring Canada into the modern era by using relevant, current and inclusive evidence. Don't allow a group of biased non-subject matter experts to continue to destroy Canadians' lives by denying us health care.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Ms. Dale and Dr. Gordon.

We're now going to begin rounds of questions, starting with the Conservatives and Mrs. Vecchio, please, for six minutes.

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

Thank you very much, Chair.

Ms. Dale, I want to begin with you, because one of the first things I see here is a note in which you opined that the Trudeau government had broken its promise to update the screening guidelines for breast cancer. I just want to hear a bit from you on that.

Can you tell me why you believe it broke that promise?

[Jennie Dale]

A commitment was made during an election campaign that the government would address better guidelines, and after the election, it did not address the guidelines. It was not until this past June that the commitment was fulfilled—and it was fulfilled.

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

I usually do not try to get political on women's health issues because I think this is really important, but this government has said it's going to be doing a gender-based analysis on everything it's supposed to be doing. I'm extremely concerned. We're hearing about the discrepancies.

I would like to speak to you, Ms. Wilkinson, about this because you talked about the fact that we see gender gaps. For people who are non-white, we are looking at their forties. For people who are white, we're looking up into their sixties. We're also talking about the regional disparities as well.

Can you please share a bit more on that, because I hear you loud and clear. We obviously need to do something, because women are dying and we know that there are disparities. What would you like to see this government do, and how can we assure that more women survive?

Thank you.

[Dr. Anna Wilkinson]

What you're referring to are the inequities that we are seeing. These inequities are driven by these guidelines. The inequities that are created by the task force guidelines happen on so many levels.

They happen on a provincial level because they create differences in provinces. Some provinces have the resources to create their own programs and some don't. They create inequities in patient levels, because when the task force says, “Don't screen”, family doctors really listen. The College of Family Physicians really pushes that mandate. Patients really have to know to advocate for themselves.

Having these national guidelines really drives inequity among individuals, particularly individuals who are marginalized; who are Black, who have worse outcomes with breast cancer; and who have lower socio-economic status—which we see with lung cancer, because these guidelines also refer to many different areas of preventative care, including lung cancer screening.

What would I like to see? Although health care is a provincial matter, these national guidelines really drive what the provinces do. Until we have a clear and transparent mechanism for creating guidelines that include modern, relevant evidence, we're going to continue, as a country, to be behind the eight ball, dragged back to really old data and not moving forward in an innovative fashion.

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

I want to continue with you, because you talked about the screening being done under the age of 50, because of that 40 age. I'm a happy 52-year-old woman, but you look at that.... What would you say is the best way of screening? Does it start off with a mammogram? Do we do biopsies? What is the procedure if a woman is concerned, or if she is that 40-something and we're looking at screening?

What should that protocol be to ensure that we're doing health right?