Status of Women Committee on June 11th, 2024

[The Chair, Conservative, Shelby Kramp-Neuman]

I call the meeting to order. Welcome to meeting 115 of the House of Commons Standing Committee on the Status of Women.

Before we begin, I ask all members and all in-person participants to consult the cards on the table for guidelines on how 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. Please use only the approved, black earpieces. The former grey earpieces must no longer be used. We need to be mindful to keep the earpieces away from the microphones at all times. When you're not using your earpiece, please face it down on the sticker placed on the table for this purpose. We thank you in advance for your co-operation on this.

To all members, please wait until I recognize you by name prior to speaking. For members in the room, please raise your hand if you wish to speak. For members on Zoom, please use the “raise hand” function. The clerk and I will be managing the speaking time, and I remind you that all comments need to be addressed through the chair.

For the benefit of the witnesses, before speaking, please wait until I recognize you by name. For those participating by video conference, click on the microphone icon to activate your mic and please mute yourself when you are not speaking. For those of you in the room, your mic will be controlled by the proceedings and verifications officer. You may speak in the official language of your choice. Interpretation services are available. You have the choice of floor, English or French for your earpiece. If the interpretation is lost, please inform me right away.

We have a number of wonderful witnesses present and online, and because of the volume of witnesses I am going to be relatively precise on time, just to respect everybody's time here today. Pursuant to Standing Order 108(2) and the motion adopted by the committee on Tuesday, June 4, 2023, the committee will commence its study in response to the call for public comment on the breast cancer draft recommendations from the Canadian Task Force on Preventive Health Care.

Today's meeting will take place in the form of a two-hour panel with our witnesses so that we can maximize the time on this very important topic.

I now welcome and introduce our witnesses. As individuals, we have Shira Farber, by video conference; Dr. Ify McKerlie; Dr. Jean Seely, professor of radiology, University of Ottawa, by video conference; and Dr. Moira Rushton, medical oncologist. From the Canadian Cancer Society, we have Helena Sonea, director of advocacy; David Raynaud, senior manager, by video conference; and Ciana Van Dusen, advocacy manager, prevention and early detection. We also have, from CancerCare Manitoba, Dr. Pamela Hebbard, head, surgical oncology, joining us by video conference; and Dr. Donna Turner, chief, population oncology, joining us by video conference as well. Lastly, from the Coalition for Responsible Healthcare Guidelines, we have Dr. Shiela Appavoo, chair.

If you're appearing as an individual, you have five minutes for an opening statement. If you are appearing on behalf of an organization, you have five minutes shared with your colleagues.

At this point, I give the floor to Ms. Farber to start. You have the floor for five minutes.

[Shira Farber, As an Individual]

Thank you.

My name is Shira Farber. I'm here today to share my own story, but I represent a sisterhood of breast cancer patients across Canada who give of their own limited time and energy to improve breast screening guidelines for all Canadians.

Today is an important anniversary for me. Three years ago to this exact date, I was at Princess Margaret Cancer Centre in Toronto, undergoing a biopsy confirming my cancer diagnosis. I can recall the visceral sensation of hearing the words “breast cancer” and believing in my heart of hearts that everything would be okay, because I thought I had caught it early. However, diagnostic testing revealed three large tumours in my right breast and stage 3 breast cancer—what my surgical oncologist described as a cancer found not too late, but one she wished she had found earlier.

What I have learned and what the task force has not paid enough attention to in these guidelines is that stage does matter when it comes to quality of life and reducing some of the side effects associated with more aggressive treatments.

The chemotherapy I received was a dose-dense treatment, which made me so ill I could not work, and I spent most of my days in bed. I could not care for myself, let alone my children or mother. My mouth was full of sores. I lost all of my hair, and my joints were severely impacted. I developed iron-deficiency anemia and tachycardia, and I became extremely ill and was hospitalized with acute constrictive pericarditis. I almost required emergency open-heart surgery.

I couldn't walk short distances without being winded, and I was forced to use a wheelchair. Forty of my lymph nodes were removed, resulting in permanent lymphedema. The mobility in my arm is severely restricted. I get run down and tired easily. I do what I can with physiotherapy, but I'm living with chronic pain. The treatment protocol for a more advanced stage of cancer also limited my options for reconstruction and required multiple surgeries. My body image was shattered, and my mental health was severely impacted. I live with PTSD and fear of recurrence.

The task force guidelines refer frequently to shared decision-making between patients and doctors. When I turned 40, I recall asking my former family doctor, who was a wonderful family doctor, if I needed to have a mammogram. I was advised that women with average risk didn't need them according to the new Canadian breast screening guidelines. I recall asking again closer to the age of 45 and receiving a similar response.

I did not understand that risk factors like breast density, which can only be discovered with your initial mammogram, placed me at higher risk. I was not aware that most women with breast cancer do not have a family history. I didn't push back or self-advocate because I trusted my doctor implicitly and was fearful of the pain I had associated with mammograms erroneously. I had faith that these guidelines, if they were Canada's recommendations and those of my medical practitioner, were the gold standard and would keep me safe.

Women's voices are simply not reflected sufficiently in the Canadian Task Force on Preventive Health Care guidelines. There is a major disconnect between what they are recommending and what actually occurs in family doctors' offices. They fail to take into account the power imbalance between doctors and patients. I speak to women with later-stage diagnoses all the time. Some describe having to advocate for themselves to get a screening referral and being denied because their doctors believe they know best or are not up to date on the latest research and evidence. Some are fearful of pushing back too hard and being labelled a difficult patient and potentially losing the privilege of having a family doctor.

The task force also infers one of the harms associated with screening as anxiety associated with callbacks. I would give anything in the world to experience the transient anxiety of a callback over the physical pain I have experienced and the fear I have of leaving my children without a mother or my husband without a partner.

Women are resilient. We can handle anxiety with the right tools. Over the past year, I watched as the task force, while in the process of conducting an evidence review, made numerous public statements to the press on social media and lectured about what they refer to as the “harms of screening”. I have no faith in a process where members who claim to be objective have publicly declared and maintained their bias.

When I was diagnosed with cancer, I did the same thing I did for family and friends in similar situations. I researched my doctors. I found a cancer care hospital I trusted, and I spoke to others with similar experiences. Isn't that what every Canadian woman deserves? Why are family doctors and Canadians taking directives from non-specialists in the field of detection? Why aren't we listening to the screening experts and surgical oncologists who are at the front lines of this disease? Why aren't we learning from patients' lived experiences? Where are our voices?

Canada has the ability to make this change now. We have an opportunity to give women modern, evidence-based guidelines that could protect some from later-stage cancers. We can't undo the past harms, but we can prevent future unnecessary suffering and deaths.

Thank you.

[The Chair, Conservative, Shelby Kramp-Neuman]

Thank you very much for that.

Next we will pass the floor to Dr. Ify McKerlie.

I will kindly remind everyone speaking and all our witnesses, especially those online, to speak a little bit slower so our translators can accurately do their work.

Dr. Ify McKerlie, you have the floor for five minutes.

[Dr. Ify McKerlie, As an Individual]

Good morning. Thank you.

I'd like to thank the members of the Standing Committee on the Status of Women for this incredible opportunity to speak about the current Canadian breast screening guidelines.

My name is Dr. Ify McKerlie. I've been a general radiologist with a focus on breast imaging for over 20 years. I co-chair the patient engagement group of the Canadian Society of Breast Imaging. In my practice over the years, it has become increasingly obvious that patients who are affected by breast cancer are getting younger and younger. In addition, the increased incidence of breast cancer has also been shown in recent Canadian research.

My daily practice includes diagnosing and performing biopsies on these patients and, as such, I'm often the first point of contact and the deliverer of bad news. Breast cancer in younger women tends to grow faster and is more aggressive.

The task force has recently released its recommendations for breast cancer screening. It is important to acknowledge that the task force members do not specialize in the field of medicine—breast cancer screening—for which they have set the guidelines. They have mistakenly placed higher emphasis on the potential harm that early screening may cause rather than the life-saving benefits.

Breast cancer is a disease that has a far-reaching impact. The brutal harm of a late-stage diagnosis is significantly more severe than the potential harm of undergoing additional imaging. The outdated study from the 1980s, which the task force continues to use to make its guidelines, comprises a population that is 98% white women.

Forty years later, however, Canada is a much more racially diverse country. Over 9.5 million Canadians were identified as a member of a visible minority group in the 2021 Canadian census, making up 26.5% of the total population.

In the U.S., it was noted that in Black, Hispanic and Asian women, breast cancer peaks at an earlier age of 40 when compared to white women. Recent Canadian analysis shows that Caucasian women are the only group whose peak incidence is greater than 50. The task force was aware of this recent yet-to-be-published paper from Statistics Canada, but did not lower the screening age.

In the recently released guidelines, the task force notes that the lifetime risk of breast cancer in these populations is lower than the risk in white populations. They go on further to note that non-white populations in the 40 to 49 age group are diagnosed more with breast cancer, have a higher proportion of aggressive subtypes of cancer, are less likely to have hormonally sensitive cancers and are less likely to have stage 1.

Black women have an even more sobering outlook, with a 42% higher mortality than white women, more aggressive cancers and worse outcomes stage for stage. For the 40 to 49 age group, the task force notes:

There are data showing variability in incidence, mortality, subtype and stage at diagnosis (e.g., higher mortality in Black women....

Despite listing all the disadvantages facing racialized women, it put a strong emphasis on informed patient choice, which would require an educated discussion with a family physician. The task force promotes a one-size-fits-all approach, which counters the observed variability in values and preferences. If a woman chooses to be screened, it still recommends screening every two to three years.

When the U.S. guidelines were announced, the U.S. task force stated that “New and more inclusive science” had led it to call for screening at 40. In Canada, where is the use of new and inclusive science? With knowledge comes responsibility, so knowing the above—acknowledging higher mortality in Black women in the 40 to 49 age group—and not acting on it is simply unethical and discriminatory.

The task force also discriminated against women with dense breasts by not recommending supplemental screening. Breast density is highest in Asian, Black and Hispanic women.

It's 2024. We must include the 40 to 49 age group in the screening population, particularly given the incidence in racialized women and higher mortality in Black women, as well as the high risk to women with dense breasts. Lives depend on it.

In the absence of proper governance and an accountability structure for the task force and indeed for any organization, there is chaos. Women in their forties are not acceptable losses.

Thank you.

[The Chair, Conservative, Shelby Kramp-Neuman]

Thank you, Dr. McKerlie.

Next, we have Dr. Jean Seely.

You have the floor for five minutes.

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

Members of the Standing Committee on the Status of Women, thank you for the opportunity to comment on the draft task force breast cancer screening guidelines. As a breast imaging specialist, I diagnose women along their entire cancer journey. I detect breast cancer from screening, or I diagnose it after a woman presents with a palpable lump. I perform breast 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.

Screen-detected cancers found before symptoms occur have a very different diagnosis than one found because of symptoms at stages 2 or 3, or already metastatic at stage 4. The task force falsely states that an additional imaging test is a harm comparable to a delayed diagnosis of a late-stage breast cancer. My patients attest that the severity of the harm of a delayed diagnosis vastly exceeds any stress associated with an additional imaging test.

The recent draft guidelines released by the task force for breast cancer screening have sparked significant concern within the medical community, and as an expert included on the evidence review panel, I found their recommendations profoundly disappointing. These guidelines ignore robust recent evidence that supports the initiation of screening at age 40, a standard now adopted by the U.S. task force and by numerous other countries worldwide.

The task force recommendations are anchored in studies that date back 40 to 60 years using obsolete technologies such as screen-film mammography. This reliance on outdated data overlooks monumental advances in breast cancer treatment, including hormone receptor-positive treatments, less invasive surgical options like lumpectomy, sentinel lymph node biopsy and all the modern immunologic and chemotherapeutic agents that have completely revolutionized breast cancer management.

The task force approach diminishes the importance of recent observational trials that involve millions of women comparing screening to no screening using updated diagnosis and treatment. This includes a large Canadian study of over 2.7 million women screened over 20 years showing a 44% reduction in breast cancer mortality in women who began screening in their forties. Similar studies in Sweden show an even greater benefit, with reduction in mortality of 50% to 60%.

Breast cancer is a devastating diagnosis, but the harms are mostly preventable when it is detected early. The survival rates are starkly different across the stages. It's nearly 100% five-year survival for stage 1 detected by screening compared to only 22% five-year survival for stage 4 when the disease has spread and become incurable. Further, the treatments are much less intensive and less costly when treated early. Stage 1 costs an average of $36,000 Canadian to treat as compared to stage 4, which can exceed half a million dollars per patient diagnosed. These statistics underscore the critical importance of early detection, which the task force draft guidelines fail to adequately prioritize.

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

The task force also acknowledged that women with dense breasts were twice as likely to develop breast cancer than women with non-dense breasts, but it failed to recognize the reduced sensitivity of mammography in these women, which drops from as high as 90% in women with non-dense breasts to a low of 60% in those with the densest breasts. The task force ignored very high-quality randomized trials that showed that adding screening with MRI reduced interval cancers, those that are found by symptoms after a normal mammogram, by 80% with MRI and by 50% in those screened with supplemental breast ultrasound. These interval cancers have been shown in evidence-based medicine to be acceptable surrogates for breast cancer mortality, which may take 10 to 20 years or more to demonstrate. They failed to acknowledge the importance of supplemental screening in these women and, again, are not following international standards.

We must demand that our health policies be reflective of the latest scientific evidence and best practices in medicine. As a medical community, we owe it to every woman in Canada to advocate for guidelines that are not only scientifically sound, but also reflective of modern medical technology and treatment advances.

Let us stand together to call for an immediate review and revision of the task force guidelines to truly reflect what is best for women's health today.

Thank you very much.

[The Chair, Conservative, Shelby Kramp-Neuman]

Thank you, Dr. Seely.

Dr. Rushton, you have the floor for five minutes.

[Dr. Moira Rushton, Medical Oncologist, As an Individual]

Thank you.

Honourable members, thank you for your invitation to testify today on breast cancer screening.

As a medical oncologist as well as a 41-year-old woman, concerned for both the well-being of my patients and the health of my generation, I was deeply disappointed with the draft report from the Canadian Task Force for Preventive Health Care last month.

The report significantly overstates the harms of screening while ignoring the benefits of early detection. What has been missing from the ongoing public discourse are the benefits of early detection of breast cancer from a treatment perspective. We hear frequently about the harms of screening, but there's been little discussion about the differences in treating a cancer that is clinically evident versus screen detected.

Treatment of breast cancer is complicated, and it is expensive. Beyond surgery and radiation, I offer patients medical treatments to reduce their risk of recurrence or dying of cancer. While the task force mentioned chemotherapy and no chemotherapy, our treatments today go far beyond that, including things like immunotherapy, targeted therapies, antibody-drug conjugates, cell cycle blockers and up to 10 years of hormone-blocking therapy for patients with stage 3 hormone-sensitive breast cancer.

Catching a breast cancer at an early age when it becomes clinically detectable reduces the need for extensive medical treatment and lowers the risk for distant recurrence and death. A larger tumour with lymph node involvement, which has become clinically evident to a patient, means higher risk disease and, therefore, more treatments to achieve similar outcomes, leading to higher costs for both individuals and our society.

Individual costs include time out of work, hair loss, cognitive dysfunction, chronic fatigue, sexual dysfunction, infertility, premature menopause, nerve damage, cardiac complications and mental health issues, not to mention the constant fear of recurrence.

The financial toxicity of breast cancer treatment is real and is carried by all of us in our publicly funded health care system. As was just mentioned, we know that the costs significantly increase by stage, with screen-detected stage 0 cancer costing only about $14,000, whereas stage 3 cancer management in Ontario today, based on the treatments we use and publicly funded, costs nearly $400,000.

This year we took those numbers and put them into cost-effective analysis using the same OncoSim modelling that CPAC has endorsed. We found that not only is this cost-effective; it's cost saving because the treatment of breast cancer at stage 4 is so very expensive.

Screening typically diagnoses breast cancers at an early stage. Only 35.7% of women age 40 to 49 in Ontario are diagnosed with stage 1 disease in the absence of an organized screening program, whereas, for those who participate in the Ontario breast screening program between ages 50 and 74, nearly 87% will be diagnosed with stage 1 or stage 0 cancer.

The communication tool provided by the task force meant to inform discussions between patients and their primary care providers about the risks and benefits of screening at an earlier age makes no mention of the downstaging that's achieved by early detection with a screening program.

The updated guidelines raise many questions. There are major discrepancies between the Canadian and U.S. task forces in terms of the benefits estimated for population-based screening. The U.S. task force predicts more deaths averted and lives saved than the Canadian task force by reducing the age of screening to 40, but even with the conservative Canadian estimate, lowering the age of screening to 40 from 50 would prevent an additional 2,600 deaths over the 10 years of screening in the demographic of women aged 40 to 49.

The task force has opined that this benefit does not justify the harms of additional testing and a few overdiagnosed cases. On this point, I disagree as does the literature, from which we know that women will accept up to six overdiagnosed cases to save one life.

The task force has also ignored the long-term benefits of early detection by focusing only on a 10-year time frame in terms of both the report and the discussion tools to evaluate the benefits of screening. The reality is that, for the most common type of breast cancer, which is hormone sensitive, even if you have a stage 2 or stage 3 breast cancer that may come back some way, probably, even if it does recur within that 10-year time frame, in 10 years you're still going to be alive. You'll just have stage 4 disease and be living through chronic treatments.

As my patients will tell you, living with cancer is not the same thing as surviving it, but the tools being provided to our family physicians make no differentiation of the two points.

Until we figure out a way to prevent breast cancers from developing, the only way to reduce morbidity and mortality as well as the cost to our health care system is with early detection. The task force has significantly minimized the benefits of early detection and has not provided transparent modelling data about the downstaging that can be achieved with an organized screening program. Without this crucial part of the conversation, we are only informing women about half of the story.

I hope my testimony today will start a broader conversation about the harms of breast cancer treatment and the risks of delayed diagnosis.

Thank you.

[The Chair, Conservative, Shelby Kramp-Neuman]

Thank you so much, Dr. Rushton.

At this point, I would like to give the floor to the Canadian Cancer Society.

Your organization now has the floor for five minutes.

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

Hello. My name is Ciana Van Dusen and I am the manager, prevention and early detection. With me today, virtually, is David Raynaud, who is the senior manager for Quebec. We are part of the advocacy team at the Canadian Cancer Society, the CCS.

The CCS is the voice of Canadians who care about cancer. As part of our commitment to improving and saving lives, we are happy to make recommendations about breast cancer screening.

Cancer is the leading cause of death in Canada. Two in five people are expected to receive a cancer diagnosis over their lifetime, and approximately one in four people will die of the disease.

In Canada, it is estimated that one woman in eight will receive a breast cancer diagnosis in her lifetime. Breast cancer is the type of cancer most often diagnosed in women in Canada, and even though there are fewer cases among women under age 50, it is still the leading cause of deaths from cancer among women aged 30 to 49 years. While the data show that the incidence of breast cancer among women in their forties has risen over the last 35 years, the overall incidence of breast cancer and the mortality rates in Canada are dropping, with improving early detection, treatment and care being significant contributors.

However, international data indicate that more Black, Asian and Hispanic women who have breast cancer receive a diagnosis before the age of 50. In addition, they often receive a diagnosis when the disease is at an advanced stage compared to other women. That means that starting breast cancer screening at age 50 is a missed opportunity to do early screening among the women in those communities.

The data have shown the benefits of starting regular, systematic breast cancer screening starting at age 40. Timely screening is essential in order to detect breast cancer early, when treatments have more chance of being effective.

We will keep hearing about people who have breast cancer whom the current guidelines do not take into account, because those guidelines do not reflect their lived experience.

As well, a national survey has shown that most respondents said they support expanding access to systematic breast cancer screening by setting the age to start screening at 40.

Our organization supports systematic breast cancer screening for women at average risk aged 40 to 49. We also have to make sure there are clear guidelines for people at high or very high risk of developing breast cancer, such as people who have certain genetic mutations, family histories, or dense breasts.

I will now give the floor to Mr. Raynaud.

[David Raynaud, Senior Advocacy Manager, Canadian Cancer Society]

Thank you, Ms. Van Dusen.

Thanks also to the members of the committee.

A growing number of Canadian provinces have begun expanding access to breast cancer screening services to people starting at age 40, or have said they would expand access. While the provinces and territories are examining the new national guidelines on this subject, the CCS is calling on governments that have not yet done so to include women aged 40 to 49 who are at average risk of breast cancer in their organized cancer screening programs. This change also reflects the new evidence that has been published between the last update of the guidelines in 2018 and the guidelines that were presented a few weeks ago.

The data about participation in the breast cancer screening program in Canada will be updated shortly by the Canadian Partnership Against Cancer. Our most recent figures date from before the pandemic, and at that time, breast cancer screening programs were not hitting the national target of a 70% participation rate. It is therefore important to expand the capacity to meet the needs of Canadians while at the same time adapting our services to address the needs of underserved populations.

As well, the CCS recommends that the federal government invest more in research, to expand our knowledge about screening and the risks associated with cancer. It is also important to close the gaps in the data so we have a better understanding of the impact of breast cancer in Canada. The pan-Canadian Cancer Data Strategy and the pan-Canadian Health Data Strategy offer good opportunities for improving the data in Canada.

In addition, governments must invest in prevention, early detection and treatment, and reducing the effects of the labour shortage. Those investments include new investments in human resources, integrating new technologies, digital infrastructure, and modernizing care paths to meet the present and future needs of Canadians.

As a final note, I would like to thank you for taking the time to listen to our recommendations. We are eager to continue working together to offer better support to people affected by cancer, because to take on cancer, it takes a society.

[The Chair, Conservative, Shelby Kramp-Neuman]

Excellent. Thank you, Mr. Raynaud.

At this point, I would like to give the floor to CancerCare Manitoba.

Your organization has five minutes.

[Dr. Donna Turner, Chief, Population Oncology, CancerCare Manitoba]

Thank you very much, Madam Chair.

Thank you also to the committee for the opportunity to speak about the draft guidelines prepared by the Canadian Task Force on Preventive Health Care, also known as the task force on breast cancer screening.

This is an important topic, and all of us here today want to reduce the impact of breast cancer on Canadian women. It's important to remember that we are united in this goal, even if opinions and perspectives differ.

I am Dr. Donna Turner, an epidemiologist and the chief of population oncology at CancerCare Manitoba. Joining me today is Dr. Pamela Hebbard, who is a cancer surgeon and the head of surgical oncology for CancerCare Manitoba.

Breast cancer is a complex subject, and considering breast cancer screening, we find there's often confusion about what is screening and what is not. Screening is a test offered to all women who do not have symptoms and who have an average risk of breast cancer. Women who find a lump in their breast or who are experiencing symptoms that are not normal for them need a diagnostic workup. Women who are at higher than average risk, due to family history or genetic predisposition, are often best served by tailored or individualized screening.

Regardless, our message to all women is that, if you experience something that is not right for you, please see your health care provider right away.

In our province, CancerCare Manitoba works to deliver evidence-based programs, while supporting Manitobans throughout their cancer journey. For example, as a result of the evidence coming forward related to screening, we are promoting screening where the evidence is strongest, including for women aged 50 to 74. I note that, like other Canadian jurisdictions, we have not achieved the 70% target rate among women who are most likely to benefit from screening, which are those in these age groups.

Second, we work with communities and Manitobans who are at risk of being underserved by our health care system, including those who are racialized, gender diverse and/or residents of geographically remote communities, to reduce inequities in breast cancer screening access and ensure improved health outcomes.

Third, we are acting with our health care partners to provide avenues to best support all women to make informed decisions about their health. Based on recent evidence, this includes women aged 40 to 49 who may want to explore their options for mammography by further understanding the benefits as well as the harms.

At this time, I'll turn it over to my colleague, Dr. Hebbard.

[Dr. Pamela Hebbard, Head, Surgical Oncology, CancerCare Manitoba]

Thank you, Chair, for the opportunity to be here today.

As Dr. Turner mentioned, I am the head of surgical oncology, and my clinical practice is dedicated to the treatment of breast cancer and gastrointestinal cancers.

Particularly with breast cancer, the number of scientific studies is immense and varied. It is important that we don't make health policy decisions based on personal bias or even on a well-meaning desire to make a difference. You need experts who are impartial. They need to not have skin in the game. The statistics that go into these recommendations are complex, and you need experts to interpret the data correctly.

There is a misconception that mammography will prevent cancer or significantly de-escalate the treatment required. This is actually the exception rather than the rule. Breast cancer is not a single disease. We tailor breast cancer treatments based on protein profiles, which is the largest determinant of their treatment. Based on cancer subtype, there are some five-millimetre cancers that will get chemo, and some five-centimetre cancers that will not.

In the modern era of breast screening, this largely impacts how many women are diagnosed with stage 1 versus stage 2 cancers, with stage 3 and 4 cancers largely unaffected by screening programs. The treatment of stage 1 and 2 breast cancer is largely the same.

I believe the harms of screening are real. We know younger women are more likely to have an abnormal screen, which results in multiple follow-up tests and biopsies. Women commonly report this process as highly distressing. In some women, it is so distressing that they never go for screening again and miss out on future benefits.

However, on a health care system level, an increase in mammograms is a large financial and human resources problem, but the outflow of follow-up testing and biopsies is the greater problem and risks creating new and very significant delays in the diagnosis and treatment of those who actually have cancer.

What would be the most impactful to the breast cancer landscape in Canada? We need to increase screening in our current age groups, include women who are remote and those who have social disadvantages and belong to minority groups. In my practice, I see women who die of colorectal cancer at a young age, and people with cervical cancer and many other diseases. I personally see the lack of access to primary care driving more deaths in young women and young men due to this health care crisis.

We also have too few studies on breast cancer prevention, and there really needs to be a renewed focus on this.

In conclusion, I thank the committee and all the people here today who have a passion to improve the future of this disease, even if we see a different way forward.

My final comment is that I'm a 47-year-old mother, breast cancer surgeon and health care leader, and I have not personally had a mammogram, because I do actually believe in the work of the Canadian task force.

Thank you very much.

[The Chair, Conservative, Shelby Kramp-Neuman]

Thank you, Dr. Hebbard.

Lastly, we have Dr. Shiela Appavoo.

You now have the floor for five minutes.

[Dr. Shiela Appavoo, Chair, Coalition for Responsible Healthcare Guidelines]

Thank you very much.

Honourable members of the Standing Committee on the Status of Women, thank you for convening this important study with such urgency. I spoke yesterday at HESA, so any resemblance between today's statement and my statement from yesterday is purely coincidental.

I'm Dr. Shiela Appavoo. I'm a general radiologist with an interest in breast imaging. I founded and co-chair, along with Dr. McKerlie, the Canadian Society of Breast Imaging patient engagement working group. I also founded and chair the Coalition for Responsible Healthcare Guidelines.

I speak today about my serious concerns about the recent draft guideline issued by the Canadian Task Force on Preventive Health Care regarding breast cancer screening that is recommending against screening women 40 to 49. This guideline stands in stark contrast to those provided by the U.S. task force, the Canadian Cancer Society and the majority of Canadian provinces, all of which have recognized the need to lower the screening age to 40. The Nurse Practitioner Association of Canada has also recently withdrawn their endorsement of the similar 2018 task force guideline.

The decision to not screen women 40 to 49 is biased. The May 30 news that the task force had again refused to recommend screening for women 40 to 49 was not a surprise to those of us following along with the guideline development process. This result was predetermined. The task force leadership indicated in the media in early May 2023, immediately following the release of the U.S. task force guideline draft, that there was no need to change the Canadian guidelines. This was before the evidence review began. Lo and behold, this prophecy was fulfilled almost exactly a year later.

How does the task force come to such different conclusions from the rest of the modern world? Without the context provided by the fulsome guidance of experienced content experts, they amplify harms, such as overdiagnosis, benign biopsies and callbacks for additional imaging, and they minimize the benefits of early detection. In their calculations they do not include important morbidity benefits of screening, such as decreased rates of mastectomy, chemotherapy or lymphedema, a permanent, disabling and disfiguring form of arm swelling caused by aggressive lymph node surgery needed for later-stage cancers.

The task force’s focus on the harms of screening, particularly the anxiety of recall, is paternalistic. The paternalism of making decisions for women because of their concern about the possible reaction of anxiety to a recall is disturbing. It’s tantamount to saying, “Don’t worry your pretty little head about breast cancer.”

If instituted, the consequences of these new task force guidelines will be dire. Many young women will potentially pay with their lives. Most provinces and territories have recognized this and have allowed self-referral for women aged 40 to 49. However, the recommendation of a primary care provider is still the strongest predictor of whether a woman will actually go for screening. As long as doctors are being given the task force message that women in their forties don’t need screening, many of those women won’t get access.

By continuing to make the same breast cancer screening recommendation that the task force has made since 2011, Canada’s national guideline is falling farther and farther behind the provinces, other countries and expert recommendations. Unfortunately, these guideline problems are not isolated to breast screening and are a pattern seen in multiple other guidelines, including those that directly affect women’s health.

Please bear with me as I veer slightly off the topic of breast cancer, as this is important for context. The task force’s pregnancy and postpartum depression, lung cancer and cervical cancer screening guidelines are similarly dismal. All of these affect women.

The cervical cancer guideline has not yet been updated since 2013, despite multiple landmark studies that should have prompted a revision. It does not recommend HPV screening, although this was recommended nationally and instituted in such countries as the U.K., Australia, Norway and the Netherlands dating back to 2017. While Australia is on its way to being the first country to eliminate cervical cancer through vaccination and HPV screening, women in Canada have been getting invasive cervical cancer—avoidably—for the greater part of a decade because of this weak task force leadership.

We must not allow these guidelines to stand as they are. We must have a breast screening guideline that is informed by the latest evidence and not by paternalism, one that truly serves the best interests of Canadians. With respect, looking at its record, we must dismantle and rebuild the Canadian Task Force on Preventive Health Care to safeguard Canadians in the future.

Thank you for your attention to this critical issue.

[The Chair, Conservative, Shelby Kramp-Neuman]

Thank you all very much for your opening remarks.

At this point, we will move on to our rounds of questioning from members.

I'd like to begin with Anna from the Conservative Party, for six minutes.

[Anna Roberts, Conservative, King—Vaughan, ON]

Thank you, Madam Chair.

Thank you to all the witnesses for being here. This is an important topic, especially for women.

I have a question for Dr. Shiela Appavoo.

I'm wondering if you can explain this to me. If someone has been adopted and they have no family history, what is the best test in ensuring the prevention of breast cancer?

[Dr. Shiela Appavoo]

Screening is considered secondary prevention. As opposed to preventing the cancer, it prevents late-stage cancer diagnosis. In general, for people who have no available family history, so whether they're adopted or estranged from their family, we treat them as average risk. Again, our recommendation is to start at 40 and screen annually until they are within 10 years of life expectancy.

[Anna Roberts, Conservative, King—Vaughan, ON]

My other question is this...and this has happened to someone I know. If there's a family history of breast cancer and breast cancer is detected in one of the breasts, in Ontario they'll remove that breast but not the other one because that would be considered cosmetic. However, with this particular individual, two years after the breast was removed, she received a diagnosis of stage 3 breast cancer in the second breast. Why wouldn't they have removed both?

[Dr. Shiela Appavoo]

I can't speak to Ontario, and I'm not a breast surgeon or involved in treatment. I'm more involved with diagnosis. However, perhaps I could defer to one of my colleagues who is more of an expert in that field.

Dr. Rushton...?

[Dr. Moira Rushton]

Sure. I'm not a surgeon, but I do see a lot of patients with early-stage breast cancer.

The current guidelines for surveillance after a breast cancer diagnosis is annual breast imaging of both breasts. Having a singular breast cancer diagnosis does increase your risk of having contralateral breast cancer, so for our breast cancer survivors, our recommendation is to have annual mammography screening for, essentially, the rest of their lives.

Typically, patients who have undergone treatment would have their first mammography screening.... At least here in Ottawa, our standard would be to do it six months after the completion of radiotherapy, as their baseline.

I agree with Dr. Appavoo that it's very difficult to comment on an individual case, and I think some of our guidelines have evolved over the years. Now we're doing a lot more MRIs for patients at time of diagnosis, especially if they have risk factors like dense breasts, to ensure that there are no small contralateral lesions that are being missed.

However, it is currently not the standard of care to automatically do a prophylactic contralateral mastectomy because it has not been demonstrated to improve survival. The focus, rather, is annual screening in all breast cancer survivors, which is also a problem in our breast screening programs because in most provinces breast cancer survivors are excluded from screening, meaning they have to go back to their primary care providers year after year to get those screening mammograms.

[Anna Roberts, Conservative, King—Vaughan, ON]

In this particular situation, the mother had breast cancer, and two of the three siblings had breast cancers. The doctors of the siblings have recommended that the female grandchildren—because it is a pattern because the great-grandmother also had breast cancer.... They were refused by their family physician to have the screening because they were under the age of 40.

However, because they have a history of multiple diagnoses going back, you know, 100 years, why would we not go ahead and do the mammograms?

[Dr. Moira Rushton]

Family doctors in Canada go through four years of medical school and two years of residency training for their specialty. They have extremely limited exposure to any sort of education around oncology, and breast cancer is no exception. At the University of Ottawa, they get about one week of oncology lectures in their time during medical school, and there is no mandatory training in oncology.

The real biggest issue with the task force is that the task force guidelines are about as much as the family doctor has time to understand and process. If a big national organization recommends against routine screening, then they are not going to do routine screening because they do not have the time, and nobody has taken the time to educate them or include this in their medical education over the years.

That family that you speak of should have been referred—or if they have not, should be referred—to medical genetics for genetic screening. Those members of that family should be in a high-risk screening program.

[Anna Roberts, Conservative, King—Vaughan, ON]

Would you agree that we have to put the patient care back onto the patient? I agree with you. I mean, let's face it. There's a shortage of family doctors, a shortage of experience. However, do you agree that lives are more important than skipping a step?