Interventions in Committee
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Paul Wheatley-Price
View Paul Wheatley-Price Profile
Paul Wheatley-Price
2015-06-16 16:00
I think that probably covers the main elements.
You'll be aware of the elements that are required for a successful screening program. Those include a population at risk that you can intervene with rather than just diagnosing someone earlier but not being able to change the course of their disease; we have that. There's having a test that is safe and accessible. We have that in the low-dose CT scan. You need to have an effective treatment; we have that. That's surgery, or in some cases radiotherapy for cancers caught at an early stage. The other element is that it needs to be affordable, which is—thankfully for me—your problem, not mine.
CT scans to screen the whole population would be probably unrealistic. The evidence to date is to go for the low-hanging fruit. We know that 85% of lung cancers are related to cigarette smoking, so we screen people who smoked heavily. That's where the benefits have been seen. If we can prove over the coming years that this is effective, affordable, and acceptable to the population and the public purse, then for sure, if there's good evidence, why couldn't we look to expand that to other groups?
Robert Nuttall
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Robert Nuttall
2015-06-16 16:01
I think the other consideration is that when you're looking at what the right age is, the evidence from the NLST study is that with regard to the 55-to-74 age group and the 30 pack-year criteria, this is where the benefit occurs. So if you were to start, you would start there.
The other issue with over-screening, and we see this for other types of screening, is that we know there are populations where screening doesn't work. A lot of times it has to do with the fact that there are harms associated with it. If you look for something, sometimes you find something that's not cancer, but in order to rule out cancer, sometimes you have to put a person through a lot of what would be considered follow-up tests or biopsies and so on, which potentially put a person at risk for something.
So you want to minimize the harms of screening. You want to make sure you're not finding false positives, which would put somebody through unnecessary surgery or things like that, while still maximizing the benefits. It's always this balance of where you'll get the most benefit in the trade-off with the harms. I think as you look at other age groups or other risk factors, you have the potential, if you don't know there's a benefit, for maybe additional harms. I think those need to be considered in some of the studies.
View Wladyslaw Lizon Profile
I would like to thank all the witnesses for coming here and being at the committee this afternoon.
The first question I have is for both Dr. Wheatley-Price and Dr. Leighl. I want to go back to statistics. I understand you already mentioned that the majority, or 85%, are smokers, and from what I know, in that group the numbers are more or less equal for men and women. However, in the non-smokers group, I understand that the numbers of women who get lung cancer are higher than those for men. I don't know whether my figure is correct, but I heard about 50% more women than men get lung cancer among non-smokers. I might be incorrect there.
Is there any indication as to why that is so? Have there been any breakthroughs on this issue?
Natasha Leighl
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Natasha Leighl
2015-06-16 16:06
I think that's an excellent observation. Some published studies suggest, exactly as you've highlighted, that the risk of getting lung cancer in never-smoking women is twice that in never-smoking men. To date there is no conclusive evidence as to why that is. There have been some questions about estrogen and the potential of estrogen and second-hand smoke but nothing conclusive.
We do know that in patients who were never smokers, we are more likely to detect abnormalities within the cancer itself, driver genes, genes that have become abnormal and that drive cancer and then are more susceptible to therapy that targets that particular genetic abnormality. We have seen that, and there are particular kinds of abnormalities that are more common in women, such as a special mutation called the epidermal growth factor receptor.
So we don't know why, but we do see this in clinical practice.
Stephen Lam
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Stephen Lam
2015-06-16 16:32
Good afternoon, Mr. Chairperson and members of the health committee.
I'm Dr. Stephen Lam from the BC Cancer Agency. Thank you for the opportunity to present to you the current status of lung cancer screening in Canada.
As Dr. Natasha Leighl pointed out earlier, lung cancer screening using low-dose CT scans can reduce lung cancer mortality, reducing the proportion of people dying of lung cancer, by 20%. These are heavy former or current smokers between the ages of 55 and 74. It should be noted that more than 50% of the lung cancer patients we see now are former smokers. These are the people who have listened to our advice, have stopped smoking already for a number of years, and yet have come down with lung cancer. Lung cancer screening will offer the opportunity to reduce the mortality. As Dr. Leighl also pointed out, even in the United States lung cancer screening is cost-effective. On average, the cost is $81,000 per quality-adjusted life years gained in the U.S. In Canada it can be cheaper.
The next thing is that not only can we reduce lung cancer mortality by screening, but screening also shifts the proportion of people from advanced cancer to early cancer, what we call stage I and stage II lung cancer, which can be amenable to treatment with surgery with curative intent. Without lung cancer screening, three-quarters of the patients with lung cancer present with advanced disease and are mainly suited for palliative treatment. But with lung cancer screening, with low-dose CT, we can shift the proportion to the opposite direction so that three-quarters of people have the early stages of the disease, stages I and II, amenable to curative surgery.
A study we conducted in Canada, a screening study from coast to coast, from Vancouver to St. John's, Newfoundland, was supported by the Terry Fox Research Institute, the Canadian Partnership Against Cancer, and Lung Cancer Canada. In this study, we found that if we treat people who have screen-detected stage I and stage II lung cancer, we can actually save $14,000 over two years versus treatment of advanced cancer, stage III and stage IV, by chemotherapy, radiotherapy, or both.
Now, not only can we reduce lung cancer mortality, but we can also save money by reducing the symptom burden. A study in Ontario showed that people who presented with clinical lung cancer have moderate to severe symptoms of loss of appetite, shortness of breath, lack of well-being, and fatigue in over half of the patients. Another third have significant pain, anxiety, or drowsiness, and one-quarter will have depression. If we can find the cancer early, we can reduce the symptom burden.
Another thing is that patients with clinically diagnosed lung cancer utilize hospital resources at a very high rate. Within three months prior to diagnosis, about 40% of them show up at the hospital emergency department. Within three months before their death, three-quarters actually showed up at hospital emergency because of symptoms. Again, we can reduce the proportion of people who utilize hospital resources.
There are four Canadian innovations that would put us onto the world leadership map in terms of lung cancer screening. We have a very innovative electronic web-based lung cancer prediction tool that allows us to identify who would benefit from lung cancer screening. For the ones who come to the screening program, we have a calculator that allows us to determine which spots or nodules on the CT scan need attention, through repeat imaging or biopsies, and to determine how often we should do follow-up CT scans. We have developed a very innovative surgical tool that allows the surgeon to remove small parts of the lung quickly and precisely to treat early cancer. The fourth innovation is a genomic signature that allows us to tell which cancer is aggressive and may benefit from additional chemotherapy after surgery.
Another innovation is computer technology that allows us to automatically highlight abnormal spots and help radiologists make recommendations regarding the management of spots detected on CT scans.
In summary, lung cancer screening allows us to shift from palliative treatment to curative treatment. We can reduce the symptom burden associated with advanced lung cancer diagnosed without screening. We can also transform lung cancer care.
The federal government can help us to improve lung cancer care and improve the outcome of lung cancer patients by funding low-dose CT screening programs—for example, for federal employees like veterans and the RCMP. For those who live in more remote areas, such as our first nations people who live in sparsely populated areas, we can use mobile CT, or combine smoking cessation with lung cancer screening, depending on the age group of the population.
Finally, the federal government can help us by facilitating implementation of screening at the provincial level—for example, through the Canadian Partnership Against Cancer. We now have a Canadian lung cancer screening network that is supported by CPAC and funded by the federal government.
I think I will stop there to answer any questions you may have.
Jason R. Pantarotto
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Jason R. Pantarotto
2015-06-16 16:45
Thank you for having me here.
My name is Jason Pantarotto. I'm the head of radiation oncology at the University of Ottawa and the Ottawa Hospital. I'm here as an expert in the treatment of lung cancer with radiation. Also, I've been involved in the provincial Cancer Care Ontario system, and I can speak to that in a my role as regional lead for radiotherapy for eastern Ontario in the Champlain LHIN, the local health integrated network of 1.3 million people. Further to that, I'm involved in a significant effort at the Ottawa Hospital to address lung cancer wait times. I'll speak to some of the challenges there.
I thought I would reserve my comments for this afternoon to the four components of the resolution passed by the committee.
In terms of the main causes of lung cancer beyond smoking, I think the speakers today have addressed many of those, but I want to make further comments and address as well some of the questions brought up in the last hour.
There are several agents, both man-made and natural, that can cause lung cancer. Many of the industrial agents used in the last 100 years can be inhaled, but frankly, it's difficult to assess the risk of each individual agent. There is clear evidence gathered over the last several decades that agents such as asbestos, diesel fuel, silica dust, and arsenic, whether breathed in or ingested, can cause lung cancer specifically, but there is a latent period of many years between exposure and the actual development of lung cancer.
The findings often show that the insults from these agents work synergistically with the effects of cigarette smoking. Therefore, you see higher rates of lung cancer in smokers rather than non-smokers, given the same exposure. For many industrial exposures, with the effect of cigarette smoking and the fact that it was really so prevalent over the last 60 or 70 years—so many people smoked—it's really quite difficult to tease out the actual impact of many industrial toxins that are out there.
Specific to radon, which of course is not an industrial agent but, as we've heard today, a naturally occurring substance in the earth's crust caused by the natural breakdown of uranium, personally I believe that Health Canada has very good documentation that can be found on their website, but with my patients, and even with my colleagues and my friends and neighbours, radon testing is really not a priority for the general population.
In fact, you can ask yourselves this: how many of you have had your own homes tested for radon? If not, why not? I suspect we have a number of good answers. I think costs are one of the barriers, and if it's a struggle to get people to put four dollars' worth of batteries into a smoke detector, then how do we get people to perform a test, whether it's $99 or $30 or what have you, plus all the things that potentially might need to be done to your home? If there is a synergistic effect between radon and cigarette smoking, then in fact for those populations who smoke more, which typically are those with reduced socio-economic status or less education, their barriers to access or to perform radon testing and then do something about it are arguably even higher.
Moving on to fundraising challenges, there is a general lack of awareness of how prevalent and serious lung cancer is, even amongst health care professionals. With few survivors and hence few advocates to promote research programs, we really haven't been able to get significant fundraising programs to the levels observed for other cancer types. Then again, smoking rates are higher in those segments of the population that I just mentioned, those with a reduced socio-economic status, and historically those groups have not been able to do a good job advocating for themselves, for obvious reasons.
With respect to research related to the causes of lung cancer for men and women, I think there are a number of established causes, cigarette smoking being by far and away number one on that list. I see a lot of research being done on the treatment of lung cancer, which we've heard a little bit about today, and also in terms of prevention and effective screening.
I think screening is key, but it has to be an effective screening program. In Ontario and various other jurisdictions across Canada we have established screens for cancers such as breast cancer, cervical cancer, and colorectal cancer, but if we look at the latest data for Ontario, of eligible women from 2011 to 2013, 62% underwent screening for cervical cancer. For the same period, 59% of eligible women underwent screening, and for colorectal cancer it was much lower, in the range of 30%, despite the fact that colorectal cancer is the number two cancer killer, if you will, in Canada. It's number two of course, with lung cancer being number one. All of that data comes from the Cancer System Quality Index, published by the Cancer Quality Council of Ontario.
To finish off, the emerging best practices for screening was the last item in the resolution. I think we've heard a lot of good information today about how there is some firm evidence behind performing low-dose CT scanning in high-risk populations. I think when you have a screening program, there's a lot of depth there that needs to be addressed. There's accreditation of each facility and the staff that works within them, database management, a recall system for suspicious nodules because you're going to find all sorts of things once you start looking, surveillance clinics, and then of course access to timely lung biopsy. Integration is key.
In Ottawa and the Ottawa area, which has a fairly affluent and well-educated population, according to 2011 data, the time from having an abnormal CT scan to getting treatment for your lung cancer was 117 days for the 90th percentile. That's in Ottawa and that's the story all across the country for various reasons. When you get into some of these other populations, they have a tougher time getting screened once a screening system is set up and a tougher time getting biopsies. That time is even longer.
I just want to finish off in terms of the segments of the population that fall under the jurisdiction of the federal government: aboriginals, the military, incarcerated individuals, and the RCMP. There is evidence in some subgroups of the aboriginal population that smoking rates are high. For the population in Nunavut, and specifically this comes from studies from Professor Kue Young at the University of Alberta, indigenous populations that live around the Arctic Circle in various countries have higher lung cancer rates than do pretty much everyone else in the world. The aboriginal population in Canada specifically seemed to have even higher rates.
Similarly in notable journals like Cancer there is published evidence—though I didn't find any Canadian evidence—that there are higher rates of lung cancer amongst veterans in the American military and Australian military, and that if they get lung cancer, there is a higher likelihood they will die from the disease. I would not be surprised if we saw similar results if studies were performed on the Canadian veteran population, or if they have been performed and I just don't know about them. I would not be surprised if we saw exactly the same thing.
I'll leave it at that, because I believe I'm out of time.
View Terence Young Profile
View Terence Young Profile
2015-06-16 17:16
Thank you, Chair.
Thank you, everyone, for your time today.
Dr. Ricard, I want to especially thank you for your courage in coming in and telling us your story today. It's extremely helpful. Thank you.
Dr. Lam, 28% of our young people in grades 7 to 12 smoke marijuana. Some of them will become regular users. At least 5% will become addicted.
We've heard on this committee that marijuana can cause psychosis and schizophrenia in young people and damage the prefrontal cortex of their brains. We know that marijuana has more known carcinogens than tobacco does, but it's very difficult to tie evidence of marijuana use to lung cancer because marijuana users also smoke tobacco. They either roll it together and smoke it at the same time or they smoke it alternately.
What role do you think the regular use of marijuana would play in causing lung cancer?
Stephen Lam
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Stephen Lam
2015-06-16 17:17
There is a suspicion that marijuana smoking can also increase the risk of lung cancer, but as you pointed out, it's very difficult to provide evidence for that because people smoke different types of marijuana and the number of joints they smoke also varies from day to day. It's very hard to quantify the amount they smoke in comparison with something like the number of cigarettes.
I have bronchoscoped a number of people who smoke marijuana. They have tremendous inflammation in their bronchial tubes and it leads me to think that they must have caused damage to promote lung cancer.
This is something we need to do more research on to decipher the exact problem with long-term smoking of marijuana.
Jürgen Rehm
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Jürgen Rehm
2015-05-26 16:41
Thanks a lot for allowing me to present the point of view of the Centre for Addiction and Mental Health, the largest hospital for psychiatric illnesses.
I would like to start with a definition of “addiction” since we were asked to talk about addiction. Usually this term comprises substance use disorders, but also more recently it has been expanded to gambling and gaming disorders. For example, the DSM-5 and the current proceedings of the ICD-11 will also include something to that degree.
If you look into those addictions, and we take the full spectrum of addictions, we have to say that alcohol use disorders are the most prevalent of the addictions. There is a question mark here with tobacco use disorders, because they're usually not assessed in general population surveys like the CCHS. If you go into how many people are actually concerned with addictions, alcohol again is also the highest. About 1 in 20 men in Canada—and that's of all age groups—would have alcohol use disorders, and it's 1.7% for females.
The second most important addiction would be cannabis use disorders, and all other drug addictions would be about half of cannabis, at about 0.7%. Again, the usual prevalence is higher for men compared to women by a factor of 2:1 for most of those addictions.
In terms of harm, we do have a lot of disorders resulting from the legal substances that are associated with far more [Inaudible—Editor] in terms of mortality and morbidity, but also disability, than the illegal substances, and all of those addictions have a pattern of high comorbidity with other mental disorders. This means we usually have comorbidities with mood disorders. About one in five people with addictions would also have a concurrent mood disorder, and if you go into generalized anxiety disorders, it's about one in ten. Mood disorders, of course, would be what we would normally call depression, and they include a whole number of psychiatrically defined depressions.
Now to your questions with regard to the mental health strategy and how addictions are treated, addictions overall are covered by the mental health strategy, and there are a lot of very important things to be said about them. But if you look into the practice and if you look into the national policies and the strategic approaches, we see that a lot has been regulated by the national anti-drug strategy of the Government of Canada, and that leads to a conflict of objectives and a conflict of different overarching approaches.
When we look at the national anti-drug strategy we welcome the recent addition of non-medical use of prescription opioids and non-medical use of other drugs as a good step. Part of that, as you heard in the first submission, of course is a result of addictions having been caused in part by the medical system.
The two most costly substances from both a health and economic standpoint, however, are tobacco and alcohol, and these remain completely outside the strategy. I would just mention again that gambling and gaming, although lesser in scope and money, are also outside of and not covered by the national anti-drug strategy.
Overall we would like stress that all addictions and substance use disorders should be a health issue, and substance use should be dealt with by a public health approach. That means we should have a four-pillar approach for illicit drugs, prevention, harm reduction, treatment, and enforcement. The same is true for legal drugs.
We also have to state that the current approach to illegal drugs in Canada is overly enforcement focused. That means that if we look into the balance between a four-pillar approach and the current Canadian approach, we have an emphasis on enforcement, both in terms of money spent and the overall efforts of society. We would like to add to this a harm reduction approach, which is currently missing altogether. The more Canada can shift its overall approach into the public health sphere, the better our chances are for reducing the overall harm.
For the first point, I would like to summarize that addictions in Canada should be addressed through a public health approach, more or less in the way we have seen it in the mental health strategy. If we go into this public health approach, we would have to change some of the things in the national anti-drug strategy, but it would be rewarded by better strategies for tackling addictions and reducing the harm related to addictions.
For the second part of my submission, I would like to look at the stigmatization issue. You've asked specifically about stigmatization for addictions, and unfortunately addictions are very stigmatized in our society. We are not alone in the world. Addiction issues are the most stigmatized mental disorders in all high-income countries, in North America, Europe, and Japan.
From surveys, we know that while the overall stigma associated with mental health has been reduced over the past decades, for addictions this is unfortunately not the case. People with addictions are seen as unpredictable and dangerous. The overall causal attributions that are made see them as not being morally intact and as responsible for their own addictions. This, of course, makes a problem not only for the people afflicted with addictions, but also for the health care system in total because it is leading to the lowest treatment rates of all mental disorders.
While the treatment rates of mental disorders are still below the treatment rates of somatic disorders, among the mental disorders, addictions stand out. For example, in people with alcohol use disorders, only one out of ten in Ontario would get adequate treatment, and would be treated.
Contributing to that is our tendency to see the world in black and white, usually as dichotomous people with having or not having a disease, and not as a continuum. The problem of this dichotomous approach, of not seeing addictions as heavy use over time, as one end of a continuum—which we all share—is leading to these people being more stigmatized and more outside of our society. As a result, they do not seek treatment because they do not want to open themselves up to admitting that they're addicted. That leads to problems in the whole health care system, both in primary health care and in specialist health care.
Stigma interferes with a seamless continuum of treatment, and this is part of what is currently plaguing addictions.
I will remain here. I have 10 minutes, and I have used the 10 minutes, and I would like to just summarize.
All addictions should be seen as a public health problem and should be dealt with from a public health perspective. Stigmatization is one of the major barriers not only for mental health in general but also for addiction specifically.
Thanks a lot.
View David Wilks Profile
Thanks, Chair.
I just have a couple of questions both related to the same topic, one for Health Canada officials and then one to CIHR. They both are with regard to electronic cigarettes. As you know, this committee carried out a study of electronic cigarettes and made a number of recommendations on which the minister is moving forward, including that the Government of Canada establish a new legislative framework for regulating electronic cigarettes and related devices.
Has any of the $26.5 million in planned spending for the tobacco program been identified for developing a legislative framework toward this initiative?
Simon Kennedy
View Simon Kennedy Profile
Simon Kennedy
2015-05-07 17:06
Mr. Chair, on the issue of electronic cigarettes, this is something the department is looking at quite carefully. We're grateful actually for the work of the committee and all of the consultations that were done and the recommendations. We've been examining those quite carefully.
At this point I would say we have not dedicated specific funds to that work because we have policy staff, and analysts and so on, who are busy doing that work, but there hasn't been a necessity of, for example, hiring additional staff or setting up a dedicated office. We have specialists who look at these kinds of issues all the time who are actually doing that work.
Depending on the ultimate decision of the government in terms of how to move forward on this, it's entirely possible we would need to make budget decisions to reallocate resources. But when it comes to the policy development work, and the assessment of the work of this committee, and to develop a government response, that doesn't require the movement of money budgetarily. We're able to handle that within our existing resources.
Simon Kennedy
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Simon Kennedy
2015-05-07 17:07
I want to assure the member there's a lot of work going on to come back with a response.
View Marc-André Morin Profile
Thank you, Mr. Chair.
My question is for the deputy minister.
The government receives $700 million in supplementary revenue because of the increased tobacco tax, but it does not use that money to reduce smoking. Instead, the government has cut funds set aside for reducing smoking.
The government has also put forward weak regulations against flavoured tobacco. It isn't following the lead of other countries, like Australia, that impose regulations on uniform packaging.
When will the government get serious about reducing the biggest predictable cause of death in Canada?
George Da Pont
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George Da Pont
2014-11-20 12:20
Thank you for your question.
The government launched a very good campaign to reduce the number of smokers here, in Canada.
When you look at the results, today we have among the lowest smoking rates in this country that we've ever had, both among youth and among adults. They're among the lowest in the world, and that is an indication of the many years of work and campaigning—education and other campaigns—not just by Health Canada but by many other organizations.
At the same time we've taken a leadership role in dealing with issues of flavoured tobacco, which appeals to children and has a significant risk of renormalizing smoking. As you're aware, a few years ago Canada was the first country in the world to put these sorts of measures in place, and the minister has recently announced an intent to augment those measures even further to deal with the innovation of tobacco products by some of the major companies.
I think we are seeing very good results. We are continuing to invest in this program. I am really encouraged by the results we are getting, which are among the best in the world.
View Marc-André Morin Profile
Of course, there has been a drop in tobacco use, but the costs for smoking-related health care resulting from smoking are still quite substantial. When you see people smoking outside hospitals with their IV drips, you have to wonder how many of them are unaffected by this government action and find themselves in this situation.
Shouldn't extra effort be made?
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