Evidence of meeting #131 for Status of Women in the 44th Parliament, 1st session. (The original version is on Parliament’s site, as are the minutes.) The winning word was risk.
A recording is available from Parliament.
Conservative
The Chair Conservative Shelby Kramp-Neuman
Ms. Thériault, if you could, please continue your testimony and see if it is getting better for MP Damoff.
Physician, Canadian Task Force on Preventive Health Care
Of course, Madam Chair.
Breast cancer is an awful disease that touches too many lives. As physicians, we both have experienced the fear felt by our patients and their families. While tremendous improvements in the treatment of breast cancer over the past decades have resulted in a significant reduction in mortality, we are very conscious that there is much more yet to be accomplished. We strongly believe we can do better for Canadian women.
It is clear that many misunderstandings remain. The one I must mention now is the difference between screening and diagnosis. Individuals with symptoms that could be breast cancer, such as a lump, need to have those symptoms investigated. Even if this investigation includes a mammogram, this is not screening, and the task force guidelines do not apply here. I want to emphasize this. Anyone with a symptom should see a health care provider.
The evidence about screening is complex and nuanced and needs careful and transparent interpretation. That is why the task force undertook a comprehensive look at the evidence, including recent observational studies. From all of this evidence, we found that the decrease in breast cancer mortality from screening individuals aged 40 to 49 over a 10-year period is about one breast cancer death avoided for 1,000 women screened. This magnitude of a benefit was relatively consistent, whether we looked at older randomized clinical trials, recent observational studies or the modelling exercise we commissioned.
What about the harms of screening in this age group? The evidence we gathered showed that screening results in two individuals in 1,000 being overdiagnosed with breast cancer, and 368—more than one-third of women screened—would require additional tests, including follow-up mammograms, ultrasounds and/or biopsies, to be told they did not have cancer. Some refer to these as “false positives”. Many primary care practitioners and patients are surprised by these numbers.
To help us understand what this means to patients, we commissioned a comprehensive review of studies on patients' values and preferences. What would they choose to do, once informed about benefits and harms? The evidence showed that a majority of patients in their forties weigh the harms as greater than the benefits, but we know from the evidence that there is variability. Some want to be screened while others do not.
This is why our recommendation starts by stating that breast cancer screening is a personal choice. It specifically says that if someone is aware of the benefits and harms of screening and wants to be screened, they should have access to mammography.
The task force recommendation, therefore, is about empowering women to make informed decisions about their health. There is no right or wrong decision. The right decision for a woman is the one that aligns with her personal values at that point in time.
I now welcome your questions and comments.
Conservative
The Chair Conservative Shelby Kramp-Neuman
Thank you.
Does Dr. Reynolds have any additional comments?
Physician, Canadian Task Force on Preventive Health Care
Madam Chair, we prepared for a five-minute opening statement by the task force as a whole.
Conservative
The Chair Conservative Shelby Kramp-Neuman
At this point, I would like to welcome MP Vien.
You have the floor for six minutes.
November 18th, 2024 / 12:10 p.m.
Conservative
Dominique Vien Conservative Bellechasse—Les Etchemins—Lévis, QC
Thank you very much, Madam Chair.
We were looking forward to seeing you, Ms. Thériault and Ms. Reynolds. The committee was really looking forward to hearing your perspective. I know there will be many questions about the recommendations you're about to make.
I think I'm reading the room well enough to tell you that the members here quite agree on early detection, starting at age 40.
Furthermore, Ms. Thériault, contrary to what you are telling us, there is unanimity—but it goes against your directive. Everyone who's come to meet with us here, all the witnesses, the survivors, those who've had excruciating difficulties cutting through the red tape to demand screening and who've had to fight to obtain it, all those who have come here, including the expert panel that spoke to us earlier, tell us that screening should begin at age 40.
I am a former MLA and minister in the Quebec government. At some point, things are easy to understand. On balance, there is, on the one hand, the disadvantage of having to go through repeated diagnoses and examinations, and perhaps even the issue of cost, and, on the other hand, the advantage of having a clear idea or picture of what is happening to us, if only to reassure us. It seems to me that screening starting at age 40 is the least we can do today. In addition, this week, I saw newspaper articles stating that more and more 40-year-olds are getting cancers that we didn't see in that age group before. I'm not necessarily talking about breast cancer, but all kinds of cancers.
How do you respond to that? What can you tell us this morning that will convince us that your directive not to start screening at age 40 would be the right thing to do, when everyone, including the provinces in Canada—Quebec is the only one left to join the others—is saying the opposite of what you're telling us?
Physician, Canadian Task Force on Preventive Health Care
Madam Chair and members of Parliament, this gives me an opportunity to talk about our methods.
The task force does the recommendations on different aspects of prevention and screening. The way we approach it is that we look comprehensively at all the data. We have looked at all data, old and new. All the newer observational studies are incorporated into our thinking about these recommendations. I don't know what more to say. We did look comprehensively at all the data, including data on the values and preferences of patients. We had more than 86 studies informing the values and preferences of patients on breast cancer screening, and it was clear—
Conservative
Dominique Vien Conservative Bellechasse—Les Etchemins—Lévis, QC
Ms. Thériault, I don't have much time.
You said you didn't know what more to say. Tell us why the United States, the Canadian provinces, all the witnesses we've heard, all the parliamentarians present… Some of us have been diagnosed or have had mastectomies. What do you say to those people today? You're not convincing anyone right now.
Physician, Canadian Task Force on Preventive Health Care
I'm not here to—I'm sorry.
Conservative
Physician, Canadian Task Force on Preventive Health Care
Madam Chair, I'm not here to convince anyone but to explain our process and how we make our recommendations. This is through a rigorous process of looking at the evidence.
As I said, we looked at all of the different types of studies and put all that together. We looked at the studies informing on the values and preferences of patients and put that together. The decision is not made by one person but by the task force as a whole, which can look comprehensively at all that data.
What I can say to a woman diagnosed in her forties—and I have had patients diagnosed in their forties—is that this is such an awful diagnosis to have. In my opening statement, I related to you the number. I told you that when we look at women ages 40 to 49 and screen them for 10 years, we see that one out of 1,000 will not die of breast cancer because she was screened. Maybe that was her. That's a possibility.
Conservative
Conservative
Liberal
Emmanuella Lambropoulos Liberal Saint-Laurent, QC
Thank you, Madam Chair.
Thank you to both of our witnesses for being here today to answer some questions.
I think I speak for Canadians when I say that the new guidelines were very disappointing for any woman or anyone who's at risk of getting breast cancer.
I have a couple of questions.
What efforts were made to ensure that the guidelines benefit all Canadians who are at risk of getting breast cancer equally?
You've spoken about looking at the evidence. Of course, the United States made a move based on their evidence. Why was their evidence or the evidence that they used not included? Also, from what we've heard, why aren't all Canadians or women living in Canada benefiting equally?
Physician, Canadian Task Force on Preventive Health Care
Madam Chair, I will do my best to address the question.
We looked at every kind of evidence—randomized trials and observational studies of all kinds. We also commissioned a modelling exercise to inform our recommendation. We also looked at Canadian jurisdictional data. We incorporated statistics from Statistics Canada in our evidence review. We also had a one-month opening in the summer of 2023 for anybody who wanted to submit any document. We had a knowledge exchange in September 2023 and we did open for any further comments or documentation for more than two months this summer, in 2024.
I think all of this put together explains the way we tried to gather all perspectives from any interest holders in Canada.
Liberal
Emmanuella Lambropoulos Liberal Saint-Laurent, QC
Thanks.
Women at increased risk because of family history are recommended to begin screening and doing genetic testing earlier, but we heard witnesses today who said that a lot of women don't have access to their family history. A lot of women, specifically indigenous women living in Canada, do not have access to this history very often because of colonialism and because of the different disadvantages that they've had in the last decades.
Was this taken into account or considered? What do we say to these women who don't have access to that, yet are discovering that they have later stage cancer at an earlier age?
Physician, Canadian Task Force on Preventive Health Care
Madam Chair, this gives me the opportunity to clarify what the guideline is about.
The guideline is not, as I said in my opening statement, about diagnosis but about screening. It's for people who have no symptoms. That's the first thing.
The second thing is that it's not about screening women at high risk. If you read the guideline, you'll see that we incorporated women at average risk and women at moderately increased risk. We define “moderately increased risk” as a woman having one first degree or two second degree relatives diagnosed after age 50.
Anything that's more than that or different from this is not considered “moderately increased”, but probably goes into the high-risk strata, for which we don't have a recommendation because that was not our mandate.
Liberal
Emmanuella Lambropoulos Liberal Saint-Laurent, QC
I have another question.
Why is women's choice of a mammogram taken into account when mammograms save lives? Why was there a disclaimer saying that this is the choice of the woman? It makes it seem like it's not really something that could help you prevent death.
Could you could just clarify that? I don't think there's that kind of an asterisk when it comes to men's cancers, so I'm wondering if you can share why you thought that was necessary on these guidelines.
Physician, Canadian Task Force on Preventive Health Care
Madam Chair, it's so interesting that I can provide some precision on this aspect.
For each of our guidelines on cancer screening, we look at the balance between benefits and harms. One of the harms would be to have what's called a “false positive”, a term that we renamed as “additional testing with no breast cancer”.
The other harm is overdiagnosis.
When you look at the numbers for women in their forties that I provided in my opening statement, and which you can find very easily on our website, on the 1,000-person diagram, you see that if you screen 1,000 women aged 40 to 49 for 10 years, you will avoid one death from breast cancer in those 1,000 women. There will be 368 who will need to have additional testing, and two will be overdiagnosed. When we present those numbers to women—and when I say “we”, I'm not saying the task force, but the more than 86 studies on choice about breast cancer screening—we found that women in their forties may weigh the harms as greater than the benefit.
We did acknowledge that there are a lot of variabilities for that. Some women may want to be screened and others may not. That's why we made the recommendation that we made.
Dr. Donna Reynolds Physician, Canadian Task Force on Preventive Health Care
If I may add, this is why breast cancer screening is a personal choice. Women need to know what the purported benefit is and what the harms are. They need to bring that into their values and preferences. There's no wrong answer; it is what's right for the women at that time.
The benefit in family medicine is that we don't see someone just once. If someone changes their mind or if they have additional questions and want to come back, that's fantastic. It's a dialogue.
Conservative
The Chair Conservative Shelby Kramp-Neuman
Thank you so much.
At this point, MP Larouche, you have the floor for six minutes.
Bloc
Andréanne Larouche Bloc Shefford, QC
Thank you very much, Madam Chair.
Ladies, I can confirm that the committee was eager to question you.
Ms. Caron, who was on the previous panel, said that there was a difference between available services and recommended services. Those words stuck with me, especially since they are related to our study.
You are here today, but the Standing Committee on Health also conducted a study on women's health. I've had discussions with my colleague Mr. Thériault, who sits on the Standing Committee on Health. I was part of the women's health study myself, and I know that the recommendation for screening from age 40 is in the report. Other committees have looked at this. We've heard that from a number of witnesses as well.
I'd like to ask you some questions from survivors or people living with cancer. Whom did you consult? Did you make sure that women with higher cancer rates were represented? Did you make sure representation was diverse? We talked about the difference between white women, Indigenous women, racialized women and African women. Women have different backgrounds and different baggage; some of them have a family history and some don't. Have you sought out diverse views from survivors or people living with cancer?
Physician, Canadian Task Force on Preventive Health Care
Madam Chair, these questions allow me to talk about how we incorporate the views of patients and, in this case, female patients.
The task force on updating breast screening conducted its study on three patients, two of whom had experienced breast cancer. What I can say is that these patients were ethnically diverse. We also have a group, which is called—
Now I'm speaking in French. I'm so sorry. I want to speak in English.
Bloc
Physician, Canadian Task Force on Preventive Health Care
I just want to make sure that what I say is well understood by my colleague.
We also have a group called the TF-PAN, the Task Force Patient Advisory Network, that we consult at different moments in our guidelines. There is a diversity of individuals on that task force panel. We have met with the Black Physicians of Canada to discuss our evidence synthesis, and we have also obtained data from Statistics Canada. We are happy that a study was published very recently so that we can share the data as it was analyzed by our group.
For example, in the case of Black women, we know that in their forties there is one more death per 1,000 persons. This is something we will surely incorporate in our upcoming tools and guidelines.
Dr. Reynolds, do you have anything to add to this?