Status of Women Committee on Nov. 18th, 2024

[The Chair, Conservative, Shelby Kramp-Neuman]

I call the meeting to order.

Welcome to meeting number 131 of the House of Commons Standing Committee on the Status of Women.

Before we begin, I'd like to ask all in-person participants to read the guidelines written on the updated cards on the table. These measures are in place to help prevent audio and feedback incidents and to protect the health and safety of all participants, including the interpreters. You will also notice a QR code on the card that links to a short awareness video.

To all members, again, please wait until I recognize you by name prior to speaking. I will remind you that all comments should be addressed through the chair.

Thank you all for your co-operation.

Pursuant to Standing Order 108(2) and the motions adopted by the committee on Tuesday, June 4, 2024, and Wednesday, September 25, 2024, the committee will resume its study of breast cancer screening for women aged 40.

I would like to welcome our witnesses. They are all appearing by video conference this morning.

As an individual, we have Dr. Nadine Caron, professor. From Ontario Health, we have Alethea Kewayosh, director, indigenous cancer care unit and indigenous health equity and coordination; and Dr. Amanda Sheppard, senior scientist. From The Olive Branch of Hope Cancer Support Services, we have Juliet Daniel, professor.

At this point, we will begin with opening remarks. Each of you has up to five minutes.

Dr. Caron, you have the floor for the first five minutes.

Thank you.

[Dr. Nadine Caron, Professor, As an Individual]

Thank you. Meegwetch. Merci.

I'm joining you today from the traditional and ancestral territory of the Lheidli T'enneh peoples, Prince George, British Columbia.

I am a cancer surgeon and professor at UBC. I join you today as an indigenous woman, daughter, mother, sister, auntie, cousin and member of the Sagamok Anishnawbek First Nation.

In the field of breast cancer, I work with many hats. I strongly recommend that we move or return breast cancer screening guidelines to commence at the age of 40, as opposed to the current age of 50.

The current guidelines in B.C. state that screening mammography is available to women in their 40s and recommend that women at “average risk” start screening mammograms at the age of 50.

There is a distinct difference between a service being available and a service being recommended. These guidelines, current and previous, have never—

[The Chair, Conservative, Shelby Kramp-Neuman]

I'm sorry to interrupt you. We have a question from the floor. It's from one of our members.

[Leah Gazan, NDP, Winnipeg Centre, MB]

I'm so sorry.

Can you turn up the volume? I can't use my earphones. There's an echo on the floor.

[The Chair, Conservative, Shelby Kramp-Neuman]

Certainly.

[Leah Gazan, NDP, Winnipeg Centre, MB]

Thanks.

[The Chair, Conservative, Shelby Kramp-Neuman]

We'll attempt to turn up the volume.

With the consent of all of you, I'll turn these television screens off to help people hear a little bit better. Is that fine?

[Some hon. members]

Agreed.

[The Chair, Conservative, Shelby Kramp-Neuman]

Okay. We'll start that process.

In the meantime, I apologize for having to interrupt you.

[Dr. Nadine Caron]

That's okay.

[The Chair, Conservative, Shelby Kramp-Neuman]

You can start where you left off. I'll be mindful of the time.

[Dr. Nadine Caron]

Okay. That's great.

Just to recap a bit, there's a difference between a service being available and a service being recommended, and these guidelines—current and previous—have never, to my knowledge, taken indigenous data or perspectives into consideration.

In recent research with the First Nations Health Authority and the BC Cancer Agency, we have found that when comparing first nations women in British Columbia to all other women in British Columbia, first nations women were diagnosed at a later stage of breast cancer.

First nations women had a lower breast cancer survival rate. Screening mammography rates were lower for first nations women, and this was very evident in the 40- to 49-year-old age group. Also, attachment to a primary care provider is lower for first nations women, which may explain the lower mammogram rates in this age group, as “discuss with your health care provider” is suggested when women consider it in this 40- to 49-year-old age group. The guidelines do indeed state to start at the age of 40 if individuals are considered at a higher risk. Currently, the age recommendation changes based on risk factors.

This is vital. These definitions of risk have limitations from an indigenous context and therefore do not seem to take indigenous realities and challenges into consideration. For example, high-risk women include those who are carriers of a pathogenic gene variant that significantly increases the risk of breast cancer. These are fancy words for DNA or genetic bases such as BRCA1 and BRCA2 and a list of others.

There are concerns regarding inequitable access to hereditary cancer testing and research, and while it has not been proven, I suspect it is similar to other documented disparities in access to genetic and genomic testing and care for indigenous people. These inequities in this health care field may limit access to screening mammography when access is based on the current guidelines. If you or your family don't get referred or tested for these genetic variants, how do you know that these recommendations to start at the age of 40 even apply to you?

The other risk factor that current guidelines use to recommend starting at the age of 40 rather than 50 is family history. Women with a family history of breast cancer are considered at higher risk, based on specifics: number of relatives with cancer, whether they're first-degree relatives and the age at which they were diagnosed.

These guidelines as they stand already recommend mammography at the age of 40 for those with a family history that matches the criteria. This is something that I just don't think we look at. What if you don't know your family history? What about factors that potentially changed your family history? What if that in itself is a barrier? What if your family history or potential family history increases your risk of developing breast cancer, but not knowing it decreases your access to the screening that can save your life?

Consider indigenous people in Canada. The legacy of the Indian residential school system includes women like my mom. These women were disconnected from their family, their culture and their community, which may have led them to not returning to or staying in their community and to losing their knowledge of their family history. Those children who never lived to leave residential school.... Caveat: I grew up in Kamloops, B.C., and the number 215 is ingrained in my soul. These children didn't grow up to be a sister with breast cancer or an aunt or a daughter with breast cancer.

The sixties scoop left individuals completely cut from their family, with many never knowing that they had a family history that would match the criteria to get a screening mammogram when they were 40. Forced relocation of indigenous communities separated families, including from the stories that could tell them their family history. The egregious differences in life expectancies and statistics between indigenous peoples in Canada and the rest of Canada include increased deaths in childhood and young adulthood, from infant mortality rates to teenage suicide, trauma and otherwise. Our family members may never have grown up to be a sister with breast cancer or an aunt with breast cancer.

So many of my patients have been robbed of their family history, of not knowing it, or of having our loved ones never grow up to be adults, yet that determines access to services to detect a common cancer that is treatable if detected early. Indigenous women should be recommended to start screening mammograms at the age of 40, given that criteria to obtain it at the age of 40 are based on a risk assessment that is a barrier in itself.

Screening mammograms change lives. I think we should remove limitations to accessing them.

Chi-miigwech.

[The Chair, Conservative, Shelby Kramp-Neuman]

Thank you very much for your testimony.

At this point, I would like to welcome Ms. Kewayosh with Dr. Sheppard.

You have the floor for five minutes.

[Alethea Kewayosh, Director, Indigenous Cancer Care Unit and Indigenous Health Equity and Coordination, Ontario Health]

Thank you.

Good morning. My name is Alethea Kewayosh, and I am the director of the indigenous cancer care unit and indigenous health equity and coordination unit for Ontario Health. Joining me today is Amanda Sheppard, senior scientist, indigenous cancer care unit. Thank you for the opportunity to appear before the committee.

Ontario Health is an agency of the Government of Ontario with a mandate to integrate and transform Ontario's health care system. Ontario Health connects and coordinates the health system to make transitions into care easier for Ontarians, with a focus on driving value and ensuring equitable access to high-quality care when and where it is needed.

Indigenous people are the original inhabitants of Canada. Indigenous peoples are not a cultural group to Canada, but are distinct, constitutionally recognized peoples with aboriginal treaty rights. There are over 400,000 indigenous people in Ontario. This estimate undercounts the true number of first nations, Inuit and Métis people in Ontario.

Retrospective cohorts of females for first nations and other Ontarians were examined to assess breast cancer incidence, mortality and survival. First nations females had significantly lower incidence and mortality. However, once diagnosed with breast cancer, first nations females were significantly more likely to die, compared to other Ontarians.

In a matched cohort design comparing first nations to non-first nations women diagnosed with breast cancer in Ontario, survival was more than three times poorer for first nations women diagnosed at stage 1 than for non-first nations women. Furthermore, the risk of death after a stage 1 breast cancer diagnosis was about five times higher among first nations women with a comorbidity other than diabetes and was more than five times greater for women with diabetes than for those without a comorbidity. Therefore, having a pre-existing comorbidity was the most important factor in explaining the observed survival disparity among first nations women.

Improving care at breast cancer screening could increase their survival after early-stage breast cancer diagnosis.

There are very few cities that have examined breast screening uptake in Inuit and Métis.

The Ontario breast cancer screening program is a province-wide screening program that aims to reduce breast cancer deaths through regular screening. The program offers screening to two different groups of people who qualify for breast cancer screening. One is people aged 50 to 74 who are at average risk. OBSP recently expanded the program to people aged 40 to 49. The other group is people aged 30 to 69 at high risk.

Indigenous adults are often under-screened or never screened when it comes to cancer screening. There are many reasons for this, including intergenerational trauma and social determinants of health, and, specific to health and cancer care, stereotypes and prejudice, communication barriers and lack of translation, lack of trust for the medical system, having no family physician and poor coordination of care and jurisdictional issues.

There is no terminology for cancer in most first nations languages. In some first nations communities, cancer is a taboo subject that is surrounded in secrecy and fear, because historically, cancer was rare among first nations people.

The historical and cultural contexts have contributed to unique views and a generally pessimistic attitude toward cancer. When asked what they thought of cancer, the response was usually, “It's a death sentence.”

These views may impact the receptiveness to cancer education, prevention and delivery of care. Traditional spirituality, which is important to many indigenous people, may contribute to beliefs about cancer.

Ontario Health aims to improve cancer care for first nations, Inuit, Métis and urban indigenous people in Ontario. The indigenous cancer care unit strives to reduce inequities in care and access to cancer services to ultimately improve cancer outcomes. We do this by collaborating with regional, provincial and national indigenous and non-indigenous partners and organizations to develop and implement indigenous cancer strategies. Working together with the regional cancer programs and indigenous partners, the ICCU ensures that proposed programs and strategies are relevant and have the potential to be highly effective at the individual, family and community levels through the development of regional indigenous cancer plans.

One of the strategic priorities within the indigenous cancer strategy is cancer screening. The main objectives are to improve access and participation in cancer screening, improve coordination and integration of cancer screening services and support specific initiatives to improve organized cancer screening programs.

I would like to say I also share and appreciate the comments of the speaker prior to me.

Thank you for your time. I look forward to any questions that may come forward.

Meegwetch.

[The Chair, Conservative, Shelby Kramp-Neuman]

Thank you very much.

To conclude, we have Professor Daniel. You have the floor for up to five minutes.

[Professor Juliet Daniel, Professor, The Olive Branch of Hope Cancer Support Services]

Good morning.

First I'd like to thank the Standing Committee on the Status of Women for inviting me to appear as a witness for its study of breast cancer screening for women aged 40 to 49.

I am a professor and cancer biologist at McMaster University. I'm a 15-year breast cancer survivor myself and a member of the research subcommittee of The Olive Branch of Hope Cancer Support Services, or TOBOH.

I have been partnering with TOBOH for the past decade to organize and host “Think Beyond 'Love Pink' Breast Cancer Awareness” education workshops and symposia specifically for Black and other racialized women who consider a breast cancer diagnosis to be a curse or stigma. TOBOH's mission is to tackle this stigma head-on, since knowledge is power and we know that an early diagnosis of breast cancer correlates with good survival outcomes.

Due to advancements in early detection, screening programs and treatment options, breast cancer mortality rates have actually declined almost 50% in the past four decades, from 42 deaths to 22 deaths per 100,000 people. However, epidemiological data continues to describe cancer disparities among racialized Canadian females, which contribute to overt inequities in lived experience during the cancer care continuum and in survival outcomes.

I just celebrated my 25th anniversary as a professor at McMaster. For the first decade of my career, my team was focused on characterizing a novel transcription factor that I discovered and named “Kaiso”.

As it turns out, Kaiso is implicated in many aggressive human cancers, including breast, prostate, lung and pancreatic, but more importantly, we recently reported that Kaiso levels correlate with disparities in breast and prostate cancer outcomes in Black women and men respectively.

In 2008, I heard for the first time about the aggressive triple-negative breast cancer, or TNBC subtype, that was disproportionately affecting young premenopausal African-American and West African women compared to white women.

Currently, most studies and data about breast cancer and triple-negative breast cancer in Black women are based on U.S. data. As a Black Caribbean woman, I was intrigued by these studies. In 2011, during my second research leave, I began studying TNBC in Caribbean and West African women, since there was no published literature about triple-negative breast cancer in the Caribbean or Canada, and Canadian hospitals were not collecting disaggregated demographic data for cancer or any disease.

My research team is specifically interested in determining if there's an ancestral genetic predisposition or susceptibility to triple-negative breast cancer in women of African ancestry. The TNBC prevalence in West Africa ranges from 40% to 70% in Ghana and Nigeria. It ranges from 20% to 22% in the Caribbean and the U.S., but prevalence is only 10% among white women in the U.S.A., suggesting that this could be something inherited from our ancestral slaves from the transatlantic slave trade.

What is most concerning, however, about breast cancer in Black women is that despite having a lower incidence of breast cancer compared to white women, Black women have the highest mortality rate from breast cancer. Black women under age 50 have twice the mortality rate compared to white women. This is possibly due to the fact that there are no targeted therapies for triple-negative breast cancer, which is most prevalent in Black women.

In contrast, white women tend to be diagnosed with estrogen receptor-positive breast tumours, which are effectively treated with the drug tamoxifen.

Because there are no targeted or specific therapies or drugs to treat triple-negative breast cancer, any woman—be they indigenous, Black, Latina, Asian or any other ethnicity—diagnosed with triple-negative breast cancer has a poor prognosis, because they can only be treated with radiation therapy, which targets the breast itself, and standard chemotherapy, which affects all proliferating cells in the body, such as our hair and intestinal cells.

Earlier this month, we were excited to read a published article by Wilkinson and colleagues from the University of Ottawa, which was the first study of breast cancer incidence and mortality by age, stage, molecular subtypes, race and ethnicity in Canada. They reported that compared to white women, other Canadian women had an earlier peak age of breast cancer diagnoses, and more cases were diagnosed under the age of 40. They also reported that Black women have statistically more breast cancer diagnoses at stages 3 and 4 combined, at 26%, versus 17% for white women.

Notably, the proportion of aggressive triple-negative breast cancers among Canadian Black women was twice that of white women, with 20% versus 9.5%. It is a statistic that is very similar to the U.S. data comparing African-American women to white American women.

Wilkinson and colleagues concluded that “Initiation of [breast cancer] screening at age 50 would likely disadvantage women who have greater proportions of BC diagnosed [before the age of 40] and may partially explain the higher proportions of advanced BC cancer diagnoses]...among many younger women of race and ethnicities other than White in this study.”

One size does not fit all, and on behalf of The Olive Branch of Hope, Black Canadian and other racialized women, I urge the Canadian task force on breast cancer screening and the Standing Committee on the Status of Women to consider revising the recommendations to account for populations that are at risk for early onset and aggressive breast cancer subtypes.

I would also like to say that I concur and agree with Dr. Caron, who has pointed out that the criteria for being classified as high risk do not consider the lived experience of marginalized communities in Canada.

Thank you.

[The Chair, Conservative, Shelby Kramp-Neuman]

That was excellent. Thank you all for your testimony this morning.

At this point, that does conclude all opening remarks.

I would like to move to our first round of questions.

We will begin this morning with Michelle Ferreri. You have the floor for six minutes.

[Michelle Ferreri, Conservative, Peterborough—Kawartha, ON]

Thanks, Chair.

Thank you to our witnesses today for attending the status of women committee as we continue our study on breast cancer and the recommendations by the national task force. Your testimony is obviously very important in this study, and you've brought up some very good points.

In the second half of today's meeting, we're going to have the chair of the task force here. I think it would be very useful to hear from you guys what you would like to ask that chair. I know you've given your recommendations.

Dr. Caron, you said something that really jumped off the page to me. In this world of Parliament, one word can make a world of difference. You said that there is a very big difference between “available” versus “recommended”.

I'm going to give an opportunity, if I can, to both Dr. Caron and Professor Daniel to put on the record what you would like to ask the task force and its chair. We've heard a significant amount of testimony from breast cancer survivors and from doctors throughout this study, who weren't consulted. They're not happy with the recommendations of this task force and they'd like to see them changed. What would you like to ask her?

I'll start with you, Dr. Caron.

[Dr. Nadine Caron]

Thank you.

I really appreciate your acknowledging what I said, in terms of words. There is so much in the power of words to heal, to harm, to clarify and to confuse.

I have had so many patients over the years. As a female breast cancer surgeon, I have seen hundreds of women with breast cancer or who were along that pathway. They were confused that they were simply not recommended to have a mammogram.

[Michelle Ferreri, Conservative, Peterborough—Kawartha, ON]

I'm sorry to interrupt you. Could you clarify what the average age of those women would have been?

[Dr. Nadine Caron]

For the most part, unfortunately, I'd like to say that it was women in the 40- to 49-year-old age group who were not recommended to have it because it was simply something they could “consider”, and it “could” be made available to them should they want to pursue that after a discussion with their primary care provider.

Unfortunately, in British Columbia and across the country, when it comes to accessing and discussing this with a primary care provider, that age group also includes any woman who should be considering a screening mammogram. There is the lack of understanding what a screening mammogram does and what it's for. There is the fear—and I'm speaking from the indigenous perspective of my indigenous patients and of my family members—of pursuing care in the health care system. There is the lack of cultural safety and the lack of access to a health care provider to talk to about this. All of that becomes something that then creeps into the 50-plus age group, where it is strongly recommended in the guidelines to start screening mammography.

However, most of my patients don't search the website to find out what BC Cancer is recommending or what is being recommended. They don't have the access to a primary care provider who says, “Hey, you're turning 50. I strongly recommend that you have a screening mammogram.”

[Michelle Ferreri, Conservative, Peterborough—Kawartha, ON]

I'm sorry. I don't have much time. Go ahead and finish up what you were going to say.

[Dr. Nadine Caron]

When it comes to women in their forties, they're not actively recommended to have it in most cases. Therefore, it's upon them to find a primary care provider or to search for this information and have the courage to enter the health care system when it's something that is available to them but not strongly recommended.

[Michelle Ferreri, Conservative, Peterborough—Kawartha, ON]

Thank you for that, Dr. Caron. You brought up a very interesting point, which is access to a primary care provider. We know that is probably one of the largest issues, if not the largest issue, across this country. We still have a massive health care crisis in this country.

If I can, I'll move to Professor Daniel.

Why would a chair of a national task force have recommendations different from those of every province and every witness we've heard from? It doesn't add up. It doesn't seem to make any sense to me. I think a lot of the members on this committee feel the same way.

Can you give your two cents on what you're seeing and what you think, or what you'd like to ask her?

[Prof. Juliet Daniel]

Thank you.

I forgot to look up the composition of the task force, but that would be one question: What was the composition of the task force? Were there any cancer survivors or caregivers? Was there diversity representing the multicultural and multi-ethnic nature of Canada?

Also, how open-minded was the task force itself in the consultations that they conducted? As you noted, many people have complained or pointed out that they were not consulted.

Another question I would have for the chair is whether they are aware that the American Association for Cancer Research, or AACR—three or four years ago, so not that recently—added racism as a social determinant of health and a risk factor for cancer development. That means marginalized communities that experience significant levels of racism. Here in Canada, that would specifically pertain to Black and indigenous communities.

What it means is that this racism has resulted in epigenetic changes to our DNA. Those aren't mutations; they're just marks that are added to our DNA that are passed on through the intergenerational trauma from that racism. In Dr. Caron's case, for example, these epigenetic marks could have been from her ancestors and how they were treated in residential schools. In my case, they could be from how my ancestors were treated as slaves. I have inherited those epigenetic marks without even knowing it was happening—