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Standing Committee on Health
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EVIDENCE
Tuesday, January 31, 2012
[Recorded by Electronic Apparatus]
[English]
Good morning, everyone. We have a quorum, so we're going to start right on time, pursuant to the order of reference of Friday, December 9, 2011, in regard to Bill C-314, an act respecting the awareness of screening among women with dense breast tissue.
We are going to have our witnesses until 10 a.m., when we will suspend for about a minute just so Mr. Brown can take his place on committee. Then we'll do the clause-by-clause.
Our first witness, for a ten-minute opening statement, will be Mr. Brown.
Welcome. Congratulations on your bill, Mr. Brown.
Thank you, Madam Chair. It's great to have the bill here at the health committee.
It's my pleasure to present some opening remarks about Bill C-314. I want to explain to the committee the genesis of the bill and why I think this is an important initiative to take up.
Over their lifetimes, one in nine women will be diagnosed with breast cancer. According to the Canadian Cancer Society, over 23,000 Canadian women will be diagnosed with breast cancer this year alone. Sadly, over 5,000 of them will lose their lives in this very difficult fight.
In the part of the country I come from, the city of Barrie, health care is of the utmost importance, as it is in most cities. When I was thinking about the type of private member's bill I could undertake, I thought that something in the health care field would be appropriate given the interest that exists in my community.
Every year we have a CIBC Run for the Cure, an annual breast cancer fundraiser, and the incredible numbers who gather to stand up and raise funds and build awareness of the fight against breast cancer always astonish me. There are always thousands and thousands who participate. Right now in Barrie we're also building a regional cancer centre to service all of Simcoe-Muskoka, and battling breast cancer obviously is going to be a key component of that new service.
I consulted the health care community in Barrie and asked what types of initiatives we could undertake to further broaden our health services. A number of issues were identified, but one initiative identified on which we can certainly move the yardstick forward was breast cancer screening. That's the genesis of this bill. I spoke with some of the top doctors and health care administrators in my riding and also with individuals from the Ministry of Health here in Ottawa, and I believe this is a means by which we can make a positive contribution in regard to breast cancer.
I feel that it is important not only for women but for all of us to be aware of the fact that screening for breast cancer can save lives. Providing women with accurate information about screening is critically important and will ultimately help them make the decisions that are right for them. That is the essence of Bill C-314.
Breast cancer is more easily treated--and in most cases curable--when found early. Dense breast tissue is one of the top risk factors for breast cancer. It is important for women to be informed of this. This can be done when they are screened for breast cancer by a mammogram. Women who have dense breast tissue should also know that potential cancer may not be detected because it cannot be seen on a mammogram and therefore cannot be diagnosed by radiologists. It appears white on mammograms and therefore is more challenging to detect.
What Bill C-314 will do is highlight the importance of being informed and of working with the provinces and territories through the national screening program in order to ensure that women receive this information. For many women--especially young women, who have a higher incidence of dense breast tissue--having this information is essential to the decision-making process. This knowledge will provide them with the tools they need to make personal health care decisions. Women who are informed that they have dense breast tissue may need to go for a different type of screening, such as an ultrasound or an MRI. Possible cancers may be deciphered more readily by a specialist using this type of diagnostic testing.
We are fortunate in Canada to have screening programs for breast cancer. Our provinces and territories deliver these programs to detect breast cancer early, before it has spread, so that treatment can be started. Providing more information through these programs will further help women and their doctors make well-informed decisions regarding breast cancer screening.
Through this piece of legislation, targeting dense breast tissue is one of the means by which I believe we can make a tangible difference in the fight against breast cancer. We all know too many loved ones, friends, and even colleagues on the Hill who have been touched by cancer. Through this bill, I believe we will make a positive step forward for individuals who unfortunately have to fight breast cancer.
Think of that overall number of 23,000 people every year in Canada who face breast cancer--believe it or not, both men and women--and of the 5,000 of them who pass away. If even a small percentage of them can have early detection through proper screening, it will make a huge difference.
There has been incredible progress in the fight against breast cancer in Canada. With survival rates up into 80%, it's an accomplishment for our country, but we can do much better. We're at 80% today, but with early diagnosis, with more effective screening, I believe the sky is the limit in terms of the survival rate levels we can achieve here in Canada.
I appreciate that the health committee is looking at this today. That's my brief introduction to what this bill is about. I hope that it can receive favourable support from the health committee and that when this becomes legislation we can all have paid a positive contribution into enhancing health care in Canada.
With the committee's permission, is it okay if I ask Mr. Brown a quick question before he leaves?
Some hon. members: Agreed.
The Chair: Okay.
In your presentation, you were saying that mammograms cannot always catch breast cancers that are there. Often women are referred for mammograms. How do women know that they do have dense breast tissue? How do they know that a mammogram is not sufficient? Where is that point of decision-making made so that they know to go to the right place? They may go to a mammogram thinking that they're cancer-free and they're not.
Therein lies the challenge with the screening in Canada right now. Thank you, Madam Chair, for that question, because I think it's very appropriate, Joy. It speaks to the inadequacy in screening.
Mammograms are great for many females, but for many Canadians they don't work. That's why if a female has dense breast tissue the physician or the health care worker who is performing the screening can provide that advice. Under this suggestion, they would inform the female that they have dense breast tissue and that they should, if they feel it's appropriate, engage in additional screening. That's not part of the screening protocol right now.
Thank you, Mr. Brown.
I'll suspend for just one minute so that the committee can begin their questions. We'll suspend....
Yes, Ms. Davies.
Just on a point of order, are we going to question Mr. Brown? Or how does that happen? Do we get to ask him questions about his bill?
Okay.
First of all, Mr. Brown, if you don't mind, I'm going to ask the other presenters to make their presentations, and then I'll ask you to go back with the people during the question period. I'd just like to hear all the presentations first.
Thank you, Mr. Brown.
Could I ask the other witnesses to come up, please? We would like to begin the ten-minute presentations.
We have with us Cathy Ammendolea from the Canadian Breast Cancer Network. She is chair of the board of directors.
From VIP Breast Imaging we have Tina Ureten, founder and president. I believe Tina will be speaking. Susan Quinn-Mullins and Feather Janz are both here as representatives today.
Will you be doing the full ten-minute presentation?
If you're going to share, be mindful that I am very strict with the time. You have ten minutes, so just watch your timing.
We also have with us Mr. Bruce Cole, as an individual. Welcome, Mr. Cole.
We will begin with the Canadian Breast Cancer Network.
Madam Chair and everyone, good morning.
I'm very pleased to be invited to speak here this morning on behalf of the Canadian Breast Cancer Network and to offer our support for Bill C-314, an act respecting the awareness of screening among women with dense breast tissue.
The Canadian Breast Cancer Network is the only national survivor-driven and survivor-focused organization in the breast cancer sector and is the voice of breast cancer survivors in Canada. We represent the concerns of over 225 partners and member organizations across Canada, as well as those of all Canadians affected by breast cancer and those at risk. CBCN's main goals are to improve access to quality breast cancer care for all Canadians and expand the influence of breast cancer survivors and families in all aspects of the breast cancer decision-making process.
It is estimated that over 23,000 women will be diagnosed with breast cancer this year and that over 5,100 of them will die from the disease. The Canadian Breast Cancer Network supports efforts made by the federal government to help women make decisions that will increase their chances of survival. As a breast cancer survivor myself, I know first-hand the importance of education and awareness around screening and treatment of breast cancer.
We are pleased to support this bill, as it encourages the use of existing programs to increase awareness, to determine gaps in information, to improve information and education to women undergoing breast cancer screening, and to address the challenges of screening with dense breast tissue. We encourage any pan-Canadian efforts by the federal government, as this will ensure that all Canadians have equal access to breast cancer programs, therapies, and services.
We applaud the efforts brought forward by the member for Barrie in Bill C-314. We would like to see a more clearly defined approach for implementing this bill that will ensure the desired outcomes are met. The member for Saskatoon—Rosetown—Biggar mentioned that there is currently a tool available through the Canadian breast cancer screening initiative to assist in decision-making pertaining to breast cancer screening. She indicated that this tool--“Information on Mammography for Women Aged 40 and Older”--will be revised to include breast density information. While we believe this to be a beneficial step, we would like to see additional mechanisms in place, clearly outlined, to indicate how this bill proposes to ensure that it meets its objectives.
One of the mechanisms the Canadian Breast Cancer Network would like to see clearly identified is an increased awareness and education for practitioners around screening women with dense breast tissue. The practitioners play an integral role in educating the patients and helping to recommend the appropriate type of screening that would most benefit those with dense breast tissue.
The Canadian Breast Cancer Network agrees that patient education and awareness are imperative when trying to provide necessary information to women being screened with dense breast tissue. We do, however, echo the concerns of the member for Vancouver Centre and the member for St. Paul's: while we want to see increased awareness around the issue, we need to ensure that we are not increasing anxiety in this population.
We are pleased with the federal government's continued commitment to work with the provinces through the Canadian breast cancer screening initiative and to provide education and awareness to Canadians through the Canadian Partnership Against Cancer.
The member for Scarborough—Rouge River identified recommendations the Canadian Breast Cancer Network has put forward that will make a difference for Canadian women. We would like to highlight how they relate to breast cancer screening for women with dense breast tissue.
While there are now more digital mammogram machines available across Canada, we need to continue to ensure that we invest in state of-the-art technology. Digital mammograms and MRIs are some of the diagnostic tools that are available to help address the challenges of screening women with dense breast tissue. We urge the federal government to continue to invest in new technologies to help Canadian women.
Currently there are no established or travelling screening facilities available in Nunavut. The federal and territorial governments must work together to establish a screening program for Nunavut that includes technologies that will address the needs of women with dense breast tissue.
In closing, the Canadian Breast Cancer Network would like to add our support for this bill, and we are encouraged that the federal government is taking a step in the right direction. However, we need a commitment from the government that this bill will be implemented in a timely manner in ways that will benefit women fighting this disease.
On behalf of the Canadian Breast Cancer Network, I would like to thank the committee for this opportunity to speak here this morning. Thank you.
Madame Chair and dear members of this committee, I would like to thank you for this opportunity.
I support the Breast Density Awareness Act because I believe this act will provide very important information for Canadian women with regard to their breast health. This act can help save lives and can prevent advanced stages of the cancer.
When we talk about breast density, we are referring to the percentage of glandular tissue versus fatty tissue. That's just an explanation of breast density. Glandular tissue consists of milk-producing cells.
Breast density affects quite a large percentage of women, regardless of age and race. Women with dense breasts have five to six times more risk of having cancer. However, women are not informed after having mammograms as to whether or not they have dense breasts. That's why this act is so important.
Dr. Norman Boyd, a leader in breast cancer research at Princess Margaret Hospital, says, “Cancer turns up five times more often in women with extremely dense breasts, signalling the importance of a risk factor rarely discussed with the patients. It has been ignored to an absolutely unbelievable degree.” A poll in 2010 showed that 95% of North American women don't know their breast density. Less than one woman in ten over age 40 was informed by her doctor about breast density issues.
The important facts behind breast density are that 66% of pre-menopausal women and 25% of post-menopausal women have dense breasts. Women whose breast tissue density is over 75% have five to six times more risk of having cancer. Cancer originating from dense breasts is more aggressive, and breast density is one of the strongest predictors of failure of mammography screening programs.
It's obvious we need an adjunctive screening tool to screen dense breasts. It needs to fulfill WHO's criteria for screening. Since the mid-1970s researchers have been looking for the role of ultrasound as a screening tool. All of the results show very promising numbers for screening dense breasts after mammograms. Some authors of studies have even suggested that ultrasound should be the initial imaging used for younger women.
There is a table in your handouts. It shows how over 52,000 women were screened using mammogram and ultrasound. In the end, 186 cancer cases that were missed by mammograms were diagnosed through ultrasound. That's a significant number.
We have two different types of ultrasound these days. One is general ultrasound. We call it hand-held ultrasound. Those machines are used for general purposes. They are good. They save lives. They improve quality of life because they catch the cancer in the early stages, and they also save the cost of treating patients at the advanced stage, but they are very operator-dependent and time-consuming.
They came up with new machines. They are designed just for screening breast tissues, and they are called automated 3-D whole breast ultrasounds. These machines are really fast. They provide high-resolution three-dimensional images. They eliminate the human factor, and the radiologist can see the slices of the whole breast, so if there are multicentric cancers, they can see them in one image. Of course the sensitivity is much higher than that of the hand-held ultrasound, and they are reliable for following up with the survivors.
As my conclusion, I will say that Canadian women definitely need to be informed and educated about breast density. They are supposed to know what other tests are available for them.
The life-saving strategy should be catching the cancer in the earliest possible stage. We can't prevent this disease yet, but early diagnosis saves lives. Ultrasound is capable of detecting dense breast tissues, but automated 3-D ultrasound is a better tool for that purpose. Of the cancers detected by ultrasound, 93% are in the early stage and easier to treat.
As my recommendations, I will say we definitely need a standard mammography reporting system nationwide. We need to educate women. We need to educate health care providers. Women should know about their breast density after they go through a mammogram test. Also, they have to be informed about supplementary tests. Advanced technology with higher sensitivity should be used for effective screening and early diagnosis, and timely action for the changes is necessary before we lose many more lives.
Thank you for your attention.
I'd like to thank you, Doctor. That was a very insightful presentation and gave us a much better understanding of this issue. So thank you very much.
We'll now go to Ms. Quinn-Mullins.
Thank you, Madam Chair, and thank you to the committee for allowing me to provide you a patient's perspective. I'm not going to take too long, because Dr. Ureten has already outlined things.
I am a breast cancer survivor with dense breast tissue. I had two instances when I actually had small areas on my right breast. One was a non-cancerous nodule and another one was DCIS, which is a sort of pre-cancerous stage. So I actually was someone who was very breast-aware and also did know that I had dense breasts. That was something that kind of came up in conversation. What I didn't know was anything about the risk factors, about what having dense breasts meant. This was a term like many other terms that are kind of thrown around when you have a diagnosis.
I was actually very religious with mammograms, as anyone who's been through this experience was, and in March 2007 was very relieved when my mammogram came back as clear. Then I felt a lump in my breast in August 2007, so four months later. An ultrasound at that point revealed that I had a fairly large tumour that was nestled between cysts and sort of sat in that dense breast tissue and obviously hadn't shown up on the mammogram.
Despite regular attention to my breast health, I was diagnosed with stage 3A breast cancer, locally advanced breast cancer. To quote my oncologist, the tumour was “a little bit larger than we'd have liked it to be”, and unfortunately it had also spread to my lymph nodes. As importantly—and as you've just heard—it was a very aggressive cancer. My next year was about a mastectomy, chemotherapy, radiation, and 15 months of Herceptin. Without Herceptin, to be quite honest, I wouldn’t be here today, because the cancer was that aggressive.
I believe my tumour was there in March 2007. And though I can never know for sure, I believe it would have been smaller, it probably would have been contained, and my survival odds would be better. Had there been a protocol for women like me with dense breasts that included ultrasound as part of my routine follow-up, perhaps my journey would have been different. Even today, as a survivor with dense breast tissue, ultrasound is not part of my annual follow-up because it's not part of the generally accepted protocol. I believe that's very wrong.
I can only tell my story, but I have heard many similar stories from other women, as I facilitate a monthly peer support group in Burlington, Ontario.
We need to educate women and health care professionals about the increased risks faced by women with dense breast tissue. We need to provide better tools for monitoring those of us who are facing those risks. Breast density is a serious issue. As you have heard, it affects all women, regardless of race and colour. We know that we are in fact at higher risk of getting cancer and that the cancer will be more aggressive.
Please, I would ask the committee on behalf of all breast cancer survivors to support this bill and ensure that this information does get out at the provincial and territorial level.
Thank you for listening.
Thank you so much. We're so glad of the outcomes that we see before us today.
We'll now go to Mr. Cole.
Thank you, Madam Chairman.
I would like to thank Mr. Patrick Brown for asking me to speak to the Standing Committee on Health regarding Bill C-314, an act respecting the awareness of screening among women with dense breast tissue.
My mother passed away from breast cancer at age 72. Up until then I had heard of breast cancer but did not take much notice. I really took notice when my wife was diagnosed with breast cancer at age 36 and passed away at 40, leaving children aged 17, 15, and 13. Her family had no history of this terrible disease.
Family and friends have spoken to me on many occasions regarding this terrible disease, and I have been able to help and guide individuals through their tough times.
Since my wife passed away from breast cancer, I have been involved with the Canadian Breast Cancer Foundation as a donor and volunteer. Among other important parts of its mission, the foundation provides reliable, evidence-based information to help women make informed decisions about their breast health. I was fortunate enough to attend the world forum on breast cancer last June in Hamilton.
If Bill C-314 is passed, it will help to improve the quality of information provided to women as part of Canada's organized breast screening programs. This will help raise women's awareness about breast density and its implications for their health. If we could identify women with dense breast tissue, they could be monitored with regular breast cancer screening, and we would be in a position to detect and treat breast cancer earlier, when health outcomes, survival rates, and quality of life are usually better.
Collaboration and information sharing is essential between the Public Health Agency of Canada and the provincial and territorial governments through the Canadian breast cancer screening initiative. Let's enhance this sharing of information to benefit women's health. The passing of Bill C-314 would enhance knowledge and understanding of breast density screening, follow-up, and women's health outcomes.
The existing breast cancer screening programs in Canada differ somewhat province by province and from territory to territory. To improve women's health, the organized breast cancer screening programs should be uniform, offering all Canadian women access to the same services wherever they live.
Breast density increases a woman's chances of developing breast cancer. A woman with dense breasts has a three to six times greater risk of breast cancer than a woman who does not have dense breasts. Breast density is higher in younger women who have not gone through menopause. Given this, the women who most need our attention are those in the 40 to 55 age group.
Breast density is diagnosed by mammography. It cannot be diagnosed by touch. A woman's first mammogram will indicate whether she has dense breasts. For women diagnosed with breast density, regular screening by digital mammography or MRI as part of an organized screening program is recommended. Research shows that digital mammography is more effective than screen-film mammography at detecting breast cancer in dense breast tissue. Digital mammography is gradually replacing screen-film mammography in Canada.
Further research is required to better understand the biology of breast density and its role in the development of breast cancer. Further research is also needed to define measures of breast tissue density, optimal imaging modalities, and the frequency of screening.
Knowing about breast density is an important part of a woman's overall breast awareness. If multiple members of a woman's family have been diagnosed with dense breasts, she is encouraged to speak to a health care provider about having a mammogram to assess for breast density.
Women in their 40s, women who are 50 years plus and have not gone through menopause, and women with clinically diagnosed dense breasts are encouraged to ask to be referred to a facility with digital mammography to assess breast density and for regular breast cancer screening.
My wife was 40 when she passed away from breast cancer. She did not have access to the screening technology and knowledge that we have today. I ask you to consider Bill C-314 as a way to raise women's awareness about breast density, how it increases breast cancer risk, and the importance of screening to diagnose breast density and to monitor the breast health and breast cancer risk of women with dense breasts.
I thank the committee for letting me speak today.
I thank you very much for that.
We've come to the end of our witness presentations at this time. I would like to ask Mr. Brown if he would be so kind as to join us, because I know there are some committee members who want to call on his expertise to answer questions. Thank you.
We're now going to go into a seven-minute Q and A. We will begin with Ms. Davies.
Thank you very much, Chairperson.
First of all, congratulations to Mr. Brown for getting his bill through second reading in principle. We're here at the committee today and we're very happy to be going through the bill, because it's a very important bill. Thank you for bringing it forward, and congratulations on the first vote.
Also, thank you to the witnesses for providing such detailed and very thorough information. I think it has really helped us understand the issue and what we need to do. Thank you for that.
I have a couple of questions. First of all, to Mr. Brown, going though your bill.... It's a short bill, and it really focuses on increasing awareness and information, which I think is really important. Hearing from the witnesses, it seems to me that we need to go a bit further. We've heard very important information today. I was surprised to learn that ultrasound is not part of a general follow-up.
I think a lot of women are really confused now about what the heck is going on. We keep getting contradictory information about mammograms, such as “Mammograms are no good, don't worry about them”, or “Yes, you should go”. I do think there has been a lot of confusion, maybe because there is new information coming out.
Mr. Brown, when you talk about increasing awareness concerning the implications of heterogeneous or dense breast tissue, I wonder what you mean specifically. In your mind, how does your bill spell out how that should be followed up? Is that something you think would be left to the screening initiative, provincial health authorities, or whoever? It's not quite clear. Clearly, you are saying that awareness should be raised and we have to figure out what information gaps there are, but how does the bill address what actually needs to be done in terms of follow-up?
Based on what we've heard today—I don't know whether you were able to consult with any of these organizations prior to this—it seems to me they have identified a few things here. I would ask you that, and I hope you are open to the idea that we could strengthen the bill based on what we've heard today. I know the NDP has some amendments.
If you could just address that in terms of.... Yes, it's about raising awareness and looking at implications, but what does that actually mean in terms of what is followed up, whether it's with better training for practitioners, or better technologies or tools, or whether it's the ultrasound or the automated machine? How do you see that fitting in with your bill?
Thank you for the question.
I appreciate all of the testimony and suggestions today and I appreciate hearing about the collective support that exists for the bill.
You are correct that a major component of the bill is about raising awareness, because there is a lack of awareness regarding the inadequacy of current screening, but I would note that it goes beyond raising awareness. It's not about breast screening in general; it specifically targets dense breast tissue, since that, in my opinion, is where the weakness in the screening exists, and it's about putting a particular focus on those Canadians with dense breast tissue whose health care needs are not currently being met when it comes to breast cancer.
The goal of the bill is to identify approaches that are needed to improve information that is provided to women. Providing that information to women will allow them to make informed health care choices. Doing so would also help determine where there are information gaps relating to breast density in the context of breast cancer screening. The bill also advocates sharing with the Canadian breast screening initiative information related to the identification of dense breast tissue during screening as well as approaches to follow-up.
Obviously, a lot of the screening is done through provincial and territorial governments. We can, I guess, provide guidance, but the actual screening will depend on the goodwill of the provinces and territories, because obviously it's under their jurisdiction. I do think that through the federal Parliament we can provide effective guidance and leadership in this area.
Unless I'm interpreting it incorrectly, your bill seems to say that it is the responsibility of women to sort of figure out that they need to be more aware of dense breast tissue issues--and that's very clear in the bill--and that responsibility rests with patients to follow up. It seems to me we've heard today that it's also about education of the practitioners and about the medical system itself regarding adequate follow-up.
For example, I know that in B.C. you can get regular screening once you reach age 40. You don't even need a referral from a doctor; you just go to the screening. Probably many of the women going for screenings do not have a physician, so this whole issue of who they follow up with and who does that follow-up is a very pertinent issue.
I'm just concerned that the bill sort of leaves you with the idea that you should become aware, but then what do you do? Whose responsibility is it then? It seems to me we all have a personal responsibility, but the system also has to be able to respond, for example, with these new tools that we've heard about today. I wonder if you think your bill can address that as well, so it's not just that we have the information, but we don't know what to do now.
I believe the bill would provide females or males who have breast cancer with the information that doesn't currently exist. I suspect that a lot of breast cancer patients are not being provided that early feedback that the mammogram may not provide the certainty they suspected it would. Providing the information to the patient is an important step forward.
Provision of breast cancer screening services falls under provincial and territorial jurisdictions, as I've said. The federal government facilitates the identification and adoption of effective practices and the sharing of information on screening methods and research.
I just wanted to highlight the component we can change, which is the adoption of best practices for screening.
Thank you very much, Madame Chair.
First of all, I want to thank Patrick for bringing this very important issue forward.
I do have some concerns. As my colleagues said, I think here in the committee we'd love to do everything to make sure things were put in place, but we do acknowledge that the bill has a certain scope.
Susan, I was concerned that you are a person who is very aware and you took all of the regular steps, but then there was no protocol for follow-up.
There seems to be a gap in the knowledge out there that would be appropriate for women and health professionals. So as I said, I commend Patrick for bringing this forward at the national level.
I actually have a question for Dr. Ureten. Does your company take extra steps to raise awareness about dense breast tissue within the medical profession as well as with the provinces? It seems to be--and I know I wasn't aware of it the way I should be--that the professionals and the provinces and territories are responsible for this. Does your company do anything to raise their awareness at all?
That's our main goal, to make Canadian women aware of breast density issues. We work with a group of volunteers for that purpose. We go to women's health shows. It just started last summer, a couple of months ago, so we are working on that.
Do you focus on the provinces and territories too, or at the ministerial levels or anything like that?
We have only one mission in Toronto right now, but we are capable of putting extra missions in big Canadian cities and giving that opportunity to Canadian women to get supplementary tests after they have their mammogram.
The mammogram is the gold standard. In order for a woman to say that she has dense breasts, she has to go through a mammogram. There is no other test that will give us that information. After we see dense breasts, then we can direct them to supplementary tests to see if there is something hidden in the mammogram pictures.
Thank you, Madam Chair, and thank you to all the witnesses for coming out today.
I also want to thank Patrick for his important initiative and applaud his effort in raising awareness on this important issue. I too have two close family members who were affected by this disease.
My question is for VIP Breast Imaging. What sort of equipment is available out there that can help detect dense breasts?
The initial test is a mammogram, all the time.
As a second test, the ultrasound plays a really good role, especially automated 3-D ultrasound, because you get the picture of the whole breast and the radiologist can see different planes of the lesion. If they catch something, they can look from different angles.
An MRI is definitely another supplementary test, but it's not cost-effective. The other test is a biopsy. After they find something with an ultrasound or an MRI, they go for a biopsy. There are not many tests, but an ultrasound and MRI are the supplementary tests.
Your website also says that your equipment is radiation-free. Is this the norm now with equipment in clinics across the country?
Well, there are some women who stay away from mammograms because of the radiation. They get that information from the media, not from their health care provider.
Some women will visit their naturopathic doctor and mention that, no, they won't go for a mammogram because radiation is involved with a mammogram. That's a personal choice. At least they know there is another tool for them if they choose not to go for a mammogram. That's why we mention it's radiation-free. That's the same ultrasound they use for pregnant women.
Is your organization also doing anything in terms of creating awareness on this issue, or are you aware of any other organizations that are also involved in maybe creating awareness on this topic?
Our organization definitely is working on educating women and health care professionals. I am not aware of other organizations....
You are involved, Feather. Are you aware of any organizations?
Feather is from B.C., and she was diagnosed at age 23.
I was diagnosed with breast cancer for the first time 17 years ago. I worked as an advocate as much as possible, learning as much as I possibly could, and this was the first time I was even made aware of it.
I was diagnosed again with breast cancer at 35 years old, with a different form of the disease, a much more aggressive form, and I'm very fortunate to be approaching a five-year cancer-free mark myself. This was the first time I had heard that my extremely dense breast tissue was what made me so at risk of getting breast cancer twice at such a young age. It shocked me, because I was so informed, and this was the first I had heard of it.
We met in October at a women's health show. That was the first time Feather heard from us about the dense breast-tissue issues.
Okay.
For a mammogram, the recommendation is for women over the age of 40. In some provinces, the recommendation is for women over 50.
For an ultrasound, there is no limit; it's for any age. If a woman is high-risk, she can have this test at any age, but for screening purposes, I think it should start after the age of 40. As for the frequency of having an ultrasound, I would recommend annual testing, but I can show you some papers from Europe that recommend having an ultrasound every six months, especially for a high-risk woman.
Thank you very much, Madam Chair.
I just want to congratulate Mr. Brown. As you know, I support your bill, and what I'm pleased with in your bill is the fact that you didn't create a panic, in terms of having women everywhere begin to worry very much about screening, etc. I think that's very important.
There is one thing, however, that I would like to see in the bill—I am going to put this in as an amendment—and that is to add that the federal government should form a clearing house for best practices. As we see, in some provinces there are different approaches; British Columbia, for instance, has the best record in terms of breast cancer outcomes in Canada. If we can create a clearing house of best practices, it would allow provinces to look at the clearing house and see the best ways to deal with this.
As they say, the jury is out on whether or not more screening does, in fact, help, and we know there are no international standards that say that having MRIs all the time will help, so we want to make sure that we find the fine line in that balance. I think that looking at best practices and having that clearing house in the federal government is a really important thing that we can do to improve on this bill. I think that it's a good bill; it's a start and it has some very important points in it.
Do you have a comment on that?
Thank you, Hedy, for your support, and thank you to your colleague, Carolyn Bennett, for her comments in the House on this. I appreciate the support.
In terms of a clearing house, I think that is the role the federal government can play in terms of identifying best practices. Maybe the vehicle to do that is the Canadian breast cancer screening initiative. I know that one of their mandates is to create a Canadian breast cancer screening database that would see non-governmental organizations and provincial and territorial screening programs contribute to a national database, which would be used to monitor and evaluate breast cancer screening programs. Hopefully, this bill could put that focus on the dense-breast-tissue patients, about whom there is a lack of information.
The only thing that I want to be careful about—I stress this with the NDP amendments too—is that if it's viewed as changing the scope of the bill after the second reading, that would make it non-receivable in the House, and the last thing that I want to see is something that would kill it in its tracks.
Obviously, the clerk's opinion and the department's opinion on this are very important. We don't want to see the work on this lost.
Thank you very much, Chair. It's good to be back with all of you. I missed the special meeting last week, so it's the first time that I'm seeing the committee again.
I was pleased last night to see Feather's name on the witness list. I know you have connections to British Columbia, particularly to Chilliwack.
You started to share your story, and I wanted to give you an opportunity to continue, if you're willing, to share with the committee about your personal journey, as well as about your advocacy work and about how you came to be involved with VIP Breast Imaging.
Thank you for the opportunity.
Thank you, Madam Chair.
My name is Feather Janz, as I said before. I was first diagnosed with breast cancer at the age of 23. I detected a lump in my breast when I was 20 years old and had gone for numerous tests, including an ultrasound, that did not detect what was occurring in my breasts due to a highly dense breast situation that I was not aware of.
The three lesions grew in my breast. At the time I was scheduled for surgery and was convinced it was not cancer, the largest mass in my breast was five centimetres in diameter. I went in for surgery and then was told, at the age of 23, that I in fact had highly aggressive grade three breast cancer that quite likely could threaten my life. I underwent a radical mastectomy and thankfully didn't need any subsequent treatment at that time, and I would remain cancer free for many years.
I felt very passionate about really changing the face of breast cancer in our country. Being a 23-year-old athletic young woman, I was not expecting to fall into this diagnosis.
Twelve years later, I had continued on with my life. I got married and had a couple of beautiful daughters. When they were turning two and four years old, I wasn't feeling especially well. I had chosen to maintain my right breast because I really believed that because I had had breast cancer, all of our medical procedures and testing would catch it in time for me. I really believed that. I had been going for tests for four years and telling them that I didn't feel my breast felt normal, but I did not have another breast to compare it to.
I went to mammography continually--every six months to twelve months--and nothing was detected until I started to not feel well. I actually went to have a prophylactic mastectomy because I was quite convinced that something wasn't right; a doctor convinced me to go for a mammogram and an ultrasound prior to that. I have my reports sitting in front of me, which highlighted in my mammogram “high dense breast tissue, too dense, quite dense, not able to see any abnormalities” and an ultrasound stating quite similar things as well, unfortunately. Then my pathology report from my mastectomy one month and three days later stated that it was an advanced, aggressive disease that had already spread to my lymph nodes.
Thankfully, the surgery and the subsequent six months of aggressive chemotherapy, two months of maximum radiation therapy, and another year of Herceptin treatment did what they needed to do. That robbed my family of a lot of precious mommy time, but I'm here today, a 40-year-old healthy woman, and in every way I feel stronger.
But I was shocked when I found out in October that probably the base reason for this happening in my life was this extremely highly dense breast tissue. I had never been informed. I had never been told, and I had been working for an advocate and working with Canadian Breast Cancer Foundation, travelling around the country speaking and raising awareness. I knew that young dense breast tissue didn't work as well in mammography, but I was not informed of my increased high risk of being five to six times more likely to get another breast cancer because of that. I had no idea. I was a highly informed, trained woman with the B.C. Cancer Agency who was teaching workshops on breast health, and even I didn't know that.
So something needs to change. I implore you to help make that happen for women like me. We represent only a small portion of a lot of women who are affected in this way.
Thank you.
Dr. Tina Ureten: May I...?
These survivors are not financially connected to our organization. I work with them on a volunteer basis. I met Feather and asked her to help us educate women. That's why she's here today.
Given that some women have gone through mammography and ultrasound, am I to understand that the technology you use might have detected this earlier, that it's even more specific? It's more able to see through that dense breast tissue to detect those cancer cells early...?
Thank you for that question. It's a good point.
Feather had a hand-held ultrasound. As I mentioned, that kind of ultrasound really depends on the skills and the experience of the operator, and there's no human being who can take 300 images with every millimetre of the breast. That's what automated breast ultrasound does. We see some patients who have had their ultrasound done in regular medical facilities, and when they come for an automated breast ultrasound, we diagnose lesions. That's the difference between two tests.
Are there others like it in Canada, or is this one on the cutting edge: you have it, and that's where it is right now in Canada?
The manufacturers are working on those machines in the direction of just making machines for one purpose. I'm sure that, in the future, there will be some more.
We have very compelling evidence here today, and it's very important to a lot of people.
Now we'll go into the five-minute round with Ms. Quach, please.
[Translation]
Thank you, Madam Chair.
My thanks to Mr. Brown for introducing this bill and for tabling it in the House. Thanks also to all the witnesses who have given us additional information. I learned a lot as I listened to them.
This bill is a good step forward. It allows us to talk and to get more information. In light of the testimony we have heard today, I wonder whether the federal government should not go a little further and not just target people with dense breast tissue.
Not all provinces have systematic diagnostic programs in place. Basically, that limits screening. We also hear a lot about access to diagnostic tests, be they mammograms or other less common tests. Often access to tests like mammograms or X-rays is inconsistent because some tests are done outside hospitals. So women do not necessarily have the means to get access within a reasonable time. We know how important an early diagnosis is in providing greater chances of survival.
I know that people with dense breast tissue have five to six times more chances of dying, or of drastic consequences. But shouldn't our strategy be broader? Shouldn't we be providing more information, in fact, and providing better access to doctors and to diagnostic tests? My question goes to Ms. Ammendolea, since she was the one who first brought it up, and to Dr. Ureten. Mr. Brown can answer too.
Without changing the basic nature of the bill, we could perhaps broaden it in order to provide a better outcome for more women.
[English]
If I have understood your question, I would say yes, we should broaden to have sort of like a partnership. The physicians need to be educated, and radiology needs to be reported properly. It's like everybody working together. The patient needs to be informed, but it doesn't have to fall on the patient alone. This needs to be, as I said, a full picture.
There are gaps across the country. In my area—I come from Montreal—where there are teaching hospitals, it's not as widely gapped, because in bigger, larger cities with teaching hospitals these are standards that are applied. They fall under studies, and they fall under research projects, etc.
I would think that the gaps across the country are what we're listening to today from our witnesses. It's a part that has to be played out and played by everybody who comes together with the patient.
I agree with her. The health-care providers definitely need education, because most of the time when dense breast is seen but no cancer is diagnosed, it comes back as a normal report.
We might end up having staging--whether it is 25% of dense breast or it is 50% of dense breast. The risk increases with that, and that information should be shared with the patient. Also, the patient should know what other choices she will have after being informed that she has dense breast.
Can I add just one thing very quickly?
I think standards are important. To have it in one area and not to have it in another area causes a lot of confusion. That's where our gaps happen. There have to be standards.
Yes, if I could just quickly add in--and thank you for the questions, Anne Minh.
I think the cases that Susan and Feather have enunciated aren't that rare. In some stats I've seen that up to 40% of females diagnosed with breast cancer have dense breast tissue. So it is a huge issue in itself.
We talked about whether we need to broaden it. This bill is specifically about that gap in service. My concern is that if you broaden it after second reading you change the scope of the bill and it is non-receivable. It's very important that we don't make any amendments that would make this non-receivable in the House. I believe that tackling dense breast tissue alone is an important advancement that we need to make in itself.
Feather's story, as someone who is so involved in this and yet didn't know, speaks volumes to the gap that exists in breast cancer screening, particularly on dense breast tissue.
Thank you very much, Madam Chair.
I want to thank my colleague Patrick for introducing this very important bill and I thank all of the witnesses who have come here today.
By introducing this bill, you have already accomplished much, I believe, by raising the awareness of this issue around this table as well as in the House of Commons.
I am from Saskatchewan, and I recently turned 50 years old. So in the past three months I received a letter from the breast screening program in our province telling me to make an appointment to come in and start that process. Due to the death of my mother to cancer about 15, 16 years ago, I did have a mammogram a number of years ago. I had the mammogram done, was basically told everything was okay, and never was really given any more information.
I was one of the speakers, as the member for Saskatoon—Rosetown—Biggar, who debated this issue in the House. As I said, it's raised awareness for many of us that this is an important bill to get passed in the House.
I do want to address the fact that speculation has been made that the federal government needs to go further than this bill. I would just say that this is a first step, an important step. If it creates an opportunity for more dialogue and for us to begin to look at different ways to go further, I think that's something we need to focus on.
I also want to comment again on the federal-provincial-territorial national committee for the Canadian breast cancer screening initiative. I know my colleague mentioned that they are encouraged to share best practices on raising awareness of dense breast tissue. I'm wondering, Mr. Brown, if you could go a little bit further about that initiative, in terms of what our federal government is doing to encourage those conversations.
Thank you, Kelly.
Thank you for raising the Canadian breast cancer screening initiative, because that does comprise federal, provincial, and territorial representatives on this committee, where they look at best practices. This bill, in paragraph 2(c), specifically suggests working through that vehicle.
I would note that this Canadian breast cancer screening initiative also works with medical professionals and a variety of stakeholders. So when we talk about Ms. Fry's idea of best practices, this is the vehicle that can do that. We don't need to reinvent another committee with the same purpose; this could be that clearing house. I know they've already looked at screening through that viewpoint. So if they focused on dense breast tissues, I think that would achieve the goal we're all talking about.
I don't have any more questions. I just would like to thank Ms. Quinn-Mullins and Ms. Janz for being here and sharing their stories. I think by hearing stories like this, it compels us even more to ensure that this bill gets passed.
I'm not sure if any of my other colleagues have follow-up questions to use my remaining time.
Good morning.
Thank you very much for coming here.
Thank you, Patrick, for your introduction of this important bill.
I have a question for Feather. When you were diagnosed, did you have a history of cancer in your family? Did you have reason to be extra cautious?
My maternal grandmother did have breast cancer very young but had always felt silenced on the issue and never actually told our family until I was diagnosed at 23. That propelled me to want to take every opportunity to expose the disease of breast cancer on behalf of my grandmother, who always felt silenced about this disease.
We were talking about the power of the pink ribbon, and I'm grateful that has opened up the opportunity to speak about this disease.
Her mother also passed away at 39 years of age from a different form of cancer. The family didn't talk about it. My medical professionals believe that the first breast cancer I had was the same kind my maternal grandmother had, and the second was the same kind my maternal great-grandmother had. The only genetic link that we know of now would be the fact that we probably all have dense breast tissue. I now have two young daughters, and I am relieved to know that there will be tests such as those performed with the automated breast ultrasound machines available for my girls.
[Translation]
Thank you, Madam Chair.
First, I would like to wish the whole committee team a happy new year. May I also extend those good wishes to everyone seated here and behind us.
As a GP, I am very familiar with the breast cancer issue. I also know that dense breast tissue is associated with a greater risk of breast cancer. I am also aware that dense tissue also decreases the reliability of mammography screening, the standard test, as it is called, in detecting breast cancer in women aged 50 and over.
I have already said in the House that I support this measure introduced by my colleague, Mr. Brown. It is a good thing to talk about this problem that, as Ms. Janz mentioned, is unfortunately taboo in families where illness, let alone cancer, is not talked about. My grandmother died of cancer, but I never found out which kind of cancer, because the word cancer was never even used. But customs and habits may well change with time. Without any doubt, awareness and information are very important.
Equal access to standard testing is something that concerns me. I have heard that Nunavut does not even have a screening centre. It concerns me greatly that such a situation exists in our country.
In addition, a point has been raised that affects me personally. It is all very well to talk about innovative methods and so on, but we have to have the people who can operate the equipment. Unfortunately, as you know, the health care system is suffering from a lack of specialist staff. Generally speaking, Canadian families do not have enough doctors to go round. This issue affects me personally and is one of the factors that led me to seek public office.
I am from Quebec, and I am very concerned. I think everyone has heard of the biopsy tests that had to be redone because of a fear that they have been improperly conducted. In 2007, 400 tests in Newfoundland were incorrectly done. The principle is good, but how are going to go about it?
Don't you think that first, we should find the people to work on awareness and information, or on getting the tests administered, and so on?
[English]
Who would like to take that question or that comment, and make a comment on it? There's one minute left.
Dr. Ureten, would you like to address that?
Well, staffing is a problem everywhere. I would still say we can train or educate women, maybe not using health care professionals, but using real survivors.
I was really surprised in October and November when I attended two women's health shows. I couldn't believe there were so many Susans and Feathers out there. They approached me and said, “I am a survivor. My cancer was missed by a mammogram and it was diagnosed at a later stage.”
Thank you very much, Dr. Ureten.
I want to thank all the witnesses for their presentations today. It's been very insightful and very helpful to a lot of people. And of course I want to thank and congratulate Mr. Brown for bringing this to the forefront. This is a very important discussion this morning.
We're going to suspend for one minute. The witnesses may stay, but please take your seats elsewhere. I would like the committee to prepare for the clause-by-clause.
I call the committee back now, and I will ask the witnesses not to carry on conversations during this time if they wish to stay, because we do need to get to this bill and get it organized.
Let's take a look at the bill right now, committee.
Pursuant to Standing Order 75(1), we're going to postpone the preamble and the short title.
We will now go into the amendments. We have the first amendment here in a package, and we have a subsequent amendment that will be added on at the bottom. So for the NDP, on page 1, the first amendment is brought forward by Ms. Quach.
Would you like to speak to it, Mr. Quach?
[Translation]
[English]
Excuse me one minute. Does everybody have this package in front of them? I want to make sure you all have it. This is what we're working from to deal with these amendments. I notice some of you don't have them out, so I'll start over again.
Ms. Quach, go ahead.
[Translation]
It is just to make sure that it will be considered for all women. As we were saying earlier, there is a lack of information among women with denser breast tissue, but there is also a lack of information among Canadians in general. Mr. Cole came to testify to the fact that this is an area where even men could help.
If everyone could be aware of the consequences of heterogeneous or dense breast tissue, I think it would be useful.
[English]
I want to thank my colleague for her amendments. We have looked them over, and I appreciate her getting them to us in a prompt manner, but we don't support the amendments to the bill.
The amendments would change the intent and scope of the bill.
We're doing one amendment. Be patient, Ms. Davies.
Dr. Carrie, we'll focus on just this amendment right now.
Okay.
Basically, it would force the federal and provincial governments to spend money on surveys, information gathering, and on awareness campaigns. The bill, as it stands now, raises awareness of dense breast tissue with existing resources and funding.
As Mr. Brown was saying earlier, it's very important that the bill gets through as it is. Otherwise, women with dense breast tissue become the side thought, whereas the original purpose of the bill was to raise awareness of dense breast tissue. The provinces and territories already have policies in place to screen women with breast cancer.
I'm just trying to get to people. Other hands have gone up, so you kind of just have to trust me to put the names down--
Oh, I'm very relaxed.
The Chair: Ms. Davies, of course on this amendment.
Ms. Libby Davies: So on this amendment, I'm actually not clear, Mr. Carrie, why you think this amendment is beyond the scope of the bill. My understanding of the amendment, as Ms. Quach explained it, is to ensure that just as we want to make women who have dense breast tissue aware, we need to make sure that this is part of the overall screening--so for all women.
I think it's really just a clarification. I cannot see how it changes the scope of the bill. I'd ask you to offer some direct evidence or something about how it changes the scope of the bill. I think it's more of a clarification to make sure that it includes all breast screening.
If we could maybe get that--
Thank you.
I just wanted to suggest that I agree: it does change the scope of the bill. The bill at its very inception, as shown on the very first page, says it's “An Act respecting the awareness of screening among women with dense breast tissue”. So to move into breast cancer screening in general really does change the scope and the intent of the bill.
I can't support this either.
Yes.
(Amendment negatived: nays 7; yeas 4)
The Chair: We will now go on to page 2.
Ms. Quach, this is yours.
[Translation]
This amendment is along the same lines as the first one. Its intention is for information to be made available across the country to all women of all ages, because the disease can affect any woman of any age, regardless of dense or heterogeneous tissue.
[English]
Similar to what Colin said, we've researched these amendments, and the opinion we've received from the department is that this would change the scope of the bill. Ms. Fry is absolutely correct; it's very clear in the bill that this is about dense breast tissue.
I'm sure this is not your intention, but unfortunately all of these amendments, including this one, would make it non-receivable in the House. I know it's not your intention to kill the bill, but these amendments would be that poison pill.
That's why I can't support this. I don't want to lose the work that we're focusing on for dense breast tissue by saying breast cancer screening “including” breast density. That makes the patients with breast density a sidebar rather than the focus, and that changes the scope. That's the opinion so far that we've received.
Yes.
(Amendment negatived: nays 7; yeas 4)
The Chair: Let's go on to the next one.
Ms. Quach, would you present your motion on page 3?
[Translation]
This is along the same lines and is consistent with everything else. Also in light of the information we received today, the amendment seeks to increase awareness. The goal is certainly to increase awareness among women with denser breast tissue, but also among all women who could be affected by breast cancer. I think we should start with general information and then focus in on specific information.
[English]
We'll do them all as recorded votes, Ms. Davies.
Ms. Libby Davies: Okay.
(Amendment negatived: nays 7; yeas 4)
The Chair: We'll go to you again, Ms. Quach.
Madam Chair, before you get to amendment NDP-4, I do have an amendment that pertains to line 15, so that would be before line 20. Would you want to deal with that one first?
This amendment is put forward today based on what we heard from the witnesses, so that's why it wasn't submitted earlier.
I thought the witnesses made a really important point, and that is that we not only need to increase awareness and information for women who are going through screening and dealing with the issue of dense breast tissue, but we also need to provide awareness and education for practitioners.
Yes. Line 14, in subparagraph 2(b)(ii), reads,
(ii) raise awareness concerning these challenges; and
Before the word “and”, my amendment would read,
...including increased awareness and education for practitioners;
I'll just hand that over to you.
I would just say that there is nothing in the existing clause that precludes increased awareness for practitioners, and in fact including it would raise that particular issue above any others. I think the current wording is sufficient. I would be voting against that amendment.
In terms of awareness and best practices for practitioners, the existing bill provides that. If you're talking about specific education programs to train provincial health care workers, that's obviously beyond our role as a federal government.
If I could just respond, it's very disappointing that I can see the government members are unfortunately going to turn down every attempt to actually support this bill and strengthen it. We're going to vote for it anyway, but this is a very genuine attempt to try to address some of the issues that have been brought forward by the witnesses. By flagging this, I think we're flagging a very important point they made about practitioners that isn't really clear in the bill. On that basis, I think it's a very supportable element to the bill. It doesn't change the scope of the bill or anything like that. It just makes it clear that we have to raise awareness for practitioners.
So I'd really ask members over there to think about supporting the amendment, because I think it will help to make the bill better.
(Amendment negatived: nays 7; yeas 4)
[Translation]
This is about establishing national standards for systematic breast cancer screening for women who are 50 years of age or older. It goes back to the need to provide more information. Earlier, a number of witnesses stressed the extent to which we have no uniform standards across Canada. In some provinces or territories, women do not automatically have the information or the access to diagnostic testing or to specialized health care professionals who are able to provide appropriate advice. That would allow all women, including those with higher density breast tissue, to find out what that density is and to be screened earlier and more effectively.
[English]
Thank you, Madam Chair.
I would like to speak against this amendment.
In the comments I made to the witnesses earlier, I think I referred to the fact that at 50 years of age, I am receiving letters from the provincial screening program. This amendment is actually redundant. Most provinces and territories already have breast cancer screening in place. The screening happens every two years for women between the ages of 50 to 69.
Again, we've talked about the jurisdiction of the provinces. They set policy and standards related to breast cancer screening, not the federal government.
[Translation]
Actually, we heard earlier that, in some provinces and territories—Nunavut was mentioned—there is no screening. In Quebec, screening is done automatically for women after they turn 50. Just now, we heard a doctor recommend that it be done, not only starting at 40, but even annually as well.
Between 1996 and 2006, the mortality rate dropped by 25% in Quebec as a result of this systematic screening. The government of Quebec is responsible for it. In terms of improvements, I feel that the goal is exactly to reduce the mortality rate and increase prevention. That is precisely what this amendment seeks to do.
I do not understand why there is so much reluctance from the members opposite. Everyone should be working together, supporting this bill and trying to improve it. That is what we are trying to do with the provisions we want to add. We want it to be more effective. We can take inspiration from several provinces. We have been told about advances in British Columbia, for example.
[English]
I'm not voting against these amendments because I don't agree with them; I just think they completely change the intent of the bill. While I don't necessarily agree with Kelly when she says that it's going to be usurping the role, because it says “in collaboration with”, I still think that expanding it to breast cancer screening for women who are 50 years of age and older changes the scope and the intent of the bill, and that's the reason I'm going to vote against it.
[Translation]
I actually wanted to follow in the footsteps of my colleague Anne, but Dr. Fry took the words out of my mouth when she said that there was no attempt to usurp provincial jurisdiction over health. It is very clearly indicated here that this would be done in collaboration.
We want to standardize the system so that we can do more screening of Canadian women everywhere. There is no question of usurping an area of provincial jurisdiction. That is all I wanted to point out.
[English]
I actually just have one point. Could we get an opinion from the legislative counsel here as to whether or not this clause is within the scope of the bill?
Can we go to the vote now? It will be a recorded vote.
(Amendment negatived: nays 7; yeas 4)
The Chair: We'll now go to--
Well, no. The clerk will tell me where it's supposed to go. Has the clerk seen it? I'm asking because I have to place it in wherever..... These fit in here, and I want to make sure that your amendment is in the right place.
This amendment, Madam Chair, would create a new paragraph 2(d). We just defeated one amendment on paragraph 2(d), so I'm submitting a new amendment that would create a new paragraph 2(d). I'll read it to you and then give it to you. I'm well aware that you have to do it in sequence. That's why I interrupted earlier--
--before we passed that line.
I'm sure this amendment is within the scope of the bill. Again, it's to get at this issue that we really need to address, that it's not just about information and awareness, but that we need to try to ensure there is follow-up. The new paragraph 2(d) would read,
...and including the need for more systematic follow-up procedures for women with heterogeneous or dense breast tissue.
I'll hand this over to the chair to take a look.
Again, the reason it was not submitted in writing earlier is that it is based on the testimony we heard today.
We would just take out the word “and”, and start with the word “including”, so it would be correct grammatically.
Thank you very much, Madame Chair.
I think it's important that we all keep perspective here. We would all like to fix the system as well as we can, but any follow-up would be within the provincial jurisdiction. Actually, this could possibly infringe on the practice of medicine regarding the appropriate follow-up, so I would not be supporting this.
[Translation]
It seems to me that this could come into the area of best practices. I think that Patrick Brown said himself that the federal government could pay a role in establishing best practices. I don't see how this would conflict with the federal role.
Since the procedural clerk has confirmed that all the amendments are in keeping with the spirit of the bill and do not contravene it in any way, I am very hopeful. I hope that we will be able to make amendments to the bill in order to improve it.
[English]
Thank you.
Paragraph 2(c) of the bill says just that. It says that through the Canadian breast cancer screening initiative, we'd share information regarding dense breast tissue during screening and any follow-up procedures. It actually says the words, “any follow-up procedures”. I think the vehicle can be used federally, but I don't think we can tell the provinces how to do follow-up procedures. That's not our role. However, the Canadian breast cancer screening initiative has provincial and territorial representatives and non-governmental representatives, and I think this is the vehicle the federal government can contribute to, and we are currently contributing. I think this bill would simply prod that focus on dense breast tissue.
I just wanted to respond to Mr. Brown's last comment, because I did read paragraph 2(c), and I read it just slightly differently.
When you read paragraph 2(c), it says “sharing through the Canadian Breast Cancer Screening Initiative”, etc., etc., “during screening and any follow-up procedures”. I interpret that to mean follow-up procedures that may already exist. We've heard that they're not great, but I'm sure there are some. I read it slightly differently, and that's why in my amendment I put in the key words, the need for follow-up; it's the issue of trying to have a more systematic follow-up, based on the need to do that. There's a slight difference, and that's why I actually put it in as an amendment.
I think my amendment is based on what we need to look at, whereas I read your paragraph 2(c) as what's sort of here and now, what the status quo is. So it's just a slight difference, if you could relate to that.
I just think that this enters into the scope of practice. It's not something that a government should be telling physicians—how to practise medicine. That's something that has to come through clinical guidelines that are set by researchers and others who do that kind of work. I think it's an intrusive thing to do.
Thank you.
(Amendment negatived: nays 7; yeas 4)
The Chair: We'll now go to the last amendment. Dr. Fry, go ahead.
Thank you. This is the friendly amendment I referred to. I don't know how Patrick will feel about it.
On line 20, I just wanted to add a paragraph (d) that says “adopting within the Canadian Breast Cancer Screening Initiative a clearing house for best practices in terms of screening and detecting cancer in persons with dense breast tissue.”
Line 20, which would be a paragraph (d) that we'd add there, would be "adopting within the Canadian Breast Cancer Screening Initiative a clearing house for best practices in terms of screening and detecting cancer in persons with dense breast tissue."
Yes.
Can I just make a comment before we go into any further discussion?
It has been brought to my attention that there are some concerns with regard to a possible need for a royal recommendation for this amendment. That came from our expert here. I just want to raise those flags.
It's not so much that, as it is the term "clearing house". It's not sufficiently defined. I don't know what that would entail. Is that a new section?
I just wanted to suggest that "clearing house" is very common terminology. It's been used within medical practice and within any other practices across this country for many years. It's just a place where you collect things, information, best practices, or whatever. People can then go into it and get information out of it—i.e., provinces or anyone who wants to see what other people are doing well.
He's not prepared to rule it inadmissible, but it's just a red flag that when it goes back to the House, there could be points of order. It could be subject to a royal recommendation on several fronts. That's just a red flag.
Now, do we have more discussion on this?
Dr. Carrie.
Madam Chair, if you could just give us a couple of minutes, we would like to confirm the point that was brought up. When you are suggesting the formation of a clearing house, it may involve expense, which means a royal recommendation. We on our side—and I think everybody—don't want to do anything to slow down the bill.
If you would give us two minutes to suspend, we'll check on that.
Okay. We will suspend for two minutes only.
The Chair: Please reconvene now. Are we set to go?
Do they still need a couple of minutes? I'm just looking at the time. I'd hate to say the committee held this—
No, we have ten minutes now, Ms. Davies. We're on Ottawa time.
The Chair: Dr. Fry, you know that everything is being considered very carefully.
Yes, I know, but the term “clearing house” really concerns me, because it's been in recommendations and reports coming out of this very committee--“recommends a clearing house be set up”. It's a common term.
Okay, I'd like to bring the committee back now, because I think we can go on with this.
Mr. Brown, you're up next.
Thank you, Madame Chair.
The interpretation we're receiving is that.... I know we all use the term “clearing house” in a more innocent manner, but the legal interpretation of the term “clearing house” would require a royal recommendation.
I'm not comfortable with putting any risks or red flags on the bill that would stop it at this point. I know Ms. Fry's intention is a good one, and I appreciate what she's saying. I just don't want to take any risks that would diminish this bill at the last minute. But I think the idea is something we can achieve.
Thanks, Patrick.
I just wanted to say that what is missing from your bill is the best practices. You've got data, you're putting in sharing information through the Canadian breast cancer screening initiative, and you're putting in other things, but you don't have any best practices here. One of the most important things is if you put it in, we can leave it with the Canadian breast cancer screening initiative, or we can put it into the already established public health portal for best practices. We can just put it in there.
It isn't going to incur any costs. It's not as if you're establishing a clearing house from scratch. It's not as if you're creating a brand-new vehicle. You're using a vehicle that's already there.
Dr. Fry, there is a solution here. I would just like to present it to you.
I understand your intent. However, because of the confusion that has happened here and because of the red flag about a possible royal recommendation, you can submit your idea at report stage, when it's in the House. That would not hold the bill up. You could still do it that way, if you would like.
Well, except if it's going to be voted down, there's no point. I mean, I'm just trying to be helpful here--
--to say that there is a missing piece. We heard that from the witnesses. There is a missing piece here and I was just trying to plug that missing piece.
I'm not married to any one model of doing it or any words for doing it. I just want to plug in best practices. If somebody can find the words that will make that happen, it will strengthen Patrick's bill—it won't weaken it—and it will fill in the little piece that's missing.
As you know, we have five minutes, and we have to get through the clauses, so this committee has to make a decision.
If we want to get this bill to the House of Commons—if indeed everyone supports this bill—we have to get this show on the road and make sure we do it.
Do you have another amendment?
I would ask Ms. Fry to formally withdraw this amendment so that we could consider it at a different time.
Maybe that's okay. I'm just concerned that.... Usually, report stage amendments can only be on what you couldn't have done in committee, so unless the committee agrees overall that we look at a report stage amendment, the Speaker may rule it out of order because we could have done it here. Could we just clarify that so we don't actually lose the opportunity?
Can we go to a vote, everybody? We'll have a recorded vote.
A voice: She withdrew--
The Chair: I'm sorry. It's withdrawn. What am I thinking? I know what I'm thinking: I'm looking at four minutes and I want this bill to go through.
All right. Shall clause 2 carry?
Do you need a recorded vote for that, Ms. Davies? Okay.
All agreed? That's carried.
(Clause 2 agreed to)
The Chair: Shall clause 1 carry?
(Clause 1 agreed to)
The Chair: Shall the preamble carry?
Some hon. members: Agreed.
The Chair: Shall the title carry?
Some hon. members: Agreed.
The Chair: Shall the bill carry?
Some hon. members: Agreed.
The Chair: Shall I report the bill to the House? I will it do it tomorrow. All agreed?
Some hon. members: Agreed.
The Chair: That's great. It's done.
Congratulations, committee. You did a wonderful thing today by passing a great bill.
Congratulations, Mr. Brown, for all your work on this.
Thank you to all the witnesses and the committee.
Do you have a question, Dr. Morin?
Yes. I've just realized that there is a last thing: shall the committee order a reprint of the bill?
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