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.