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Kelley Bush
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Kelley Bush
2015-06-18 16:07
Good afternoon. My name is Kelley Bush, and I am the head of radon education and awareness under Health Canada's national radon program.
Thank you, Mr. Chair and members of the committee, for inviting me to be here today to discuss radon as a cause of lung cancer and to highlight the work of the Canadian – National Radon Proficiency Program.
Through the ongoing activities of this program, Health Canada is committed to informing Canadians about the health risk of radon, better understanding the methods and technologies available for reducing radon exposure, and giving Canadians the tools to take action to reduce their exposure.
Radon is a colourless, odourless radioactive gas that is formed naturally in the environment. It comes from the breakdown of uranium in soil and rock. When radon is released from the ground in outdoor air, it gets diluted and is not a concern. However, when radon enters an indoor space, such as a home, it can accumulate to high levels and become a serious health risk. Radon naturally breaks down into other radioactive substances called progeny. Radon gas and radon progeny in the air can be breathed into the lungs, where they break down further and emit alpha particles. These alpha particles release small bursts of energy, which are absorbed by the nearby lung tissue and lead to lung cell death or damage. When lung cells are damaged, they have the potential to result in cancer when they reproduce.
The lung cancer risk associated with radon is well recognized internationally. As noted by the World Health Organization, a recent study on indoor radon and lung cancer in North America, Europe, and Asia provided strong evidence that radon causes a substantial number of lung cancers in the general population. It's recognized around the world that radon is the second leading cause of lung cancer after smoking, and that smokers also exposed to high levels of radon have a significantly increased risk of developing lung cancer.
Based on the latest data from Health Canada, 16% of lung cancers are radon-induced, resulting in more than 3,200 deaths in Canada each year. To manage these risks, in 2007 the federal government in collaboration with provinces and territories lowered the federal guideline from 800 to 200 becquerels per cubic metre. Our guideline of 200 becquerels per cubic metre is amongst the lowest radon action levels internationally, and aligns with the World Health Organization's recommended range of 100 to 300 becquerels per cubic metre.
All homes and buildings have some level of radon. It's not a question of “if” you have radon in your house; you do. The only question is how much, and the only way to know is to test. Health Canada recommends that all homeowners test their home and that if the levels are high, above our Canadian guideline, you take action to reduce.
The national radon program was launched in 2007 to support the implementation of the new federal guideline. Funding for this program is provided under the Government of Canada's clean air regulatory agenda. Our national radon program budget is $30.5 million over five years.
Since its creation, the program has had direct and measurable impacts on increasing public awareness, increasing radon testing in homes and public buildings, and reducing radon exposure. This has been accomplished through research to characterize the radon problem in Canada, as well as through measures to protect Canadians by increasing their awareness and giving them tools to take action on radon.
The national radon program includes important research to characterize radon risk in Canada. Two large-scale, cross-Canada residential surveys have been completed, using long-term radon test kits in over 17,000 homes. The surveys have provided us with a much better understanding of radon levels across the country. This data is used by Health Canada and our stakeholder partners to further define radon risk, to effectively target radon outreach, to raise awareness, and to promote action. For example, Public Health Ontario used this data in its radon burden of illness study. The Province of British Columbia used the data to inform its 2014 changes to their provincial building codes, which made radon reduction codes more stringent in radon-prone areas based on the results of our cross-Canada surveys. The CBC used the data to develop a special health investigative report and interactive radon map.
The national radon program also conducts research on radon mitigation, including evaluating the effectiveness of mitigation methods, conducting mitigation action follow-up studies, and analyzing the effects of energy retrofits on radon levels in buildings. For example, in partnership with the National Research Council, the national radon program conducted research on the efficacy of common radon mitigation systems in our beautiful Canadian climatic conditions. It is also working with the Toronto Atmospheric Fund to incorporate radon testing in a study they're doing that looks at community housing retrofits and the impacts on indoor air quality.
This work supports the development of national codes and standards on radon mitigation. The national radon program led changes to the 2010 national building codes. We are currently working on the development of two national mitigation standards, one for existing homes and one for new construction.
The program has developed an extensive outreach program to inform Canadians about the risk from radon and encourage action to reduce exposure. This outreach is conducted through multiple platforms targeting the general public, key stakeholder groups, as well as populations most at risk such as smokers and communities known to have high radon.
Many of the successes we've achieved so far under this program have been accomplished as a result of collaboration and partnership with a broad range of stakeholder partners. Our partners include provincial and municipal governments, non-governmental organizations, health professional organizations, the building industry, the real estate industry, and many more. By working with these stakeholders, the program is able to strengthen the credibility of the messages we're sending out and extend the reach and impact of our outreach efforts. We are very grateful for their ongoing engagement and support.
In November 2013 the New Brunswick Lung Association, the Ontario Lung Association, Summerhill Impact, and Health Canada launched the very first national radon action month. This annual national campaign is promoted through outreach events, website content, social media, public service announcements, and media exposure. It raises awareness about radon and encourages Canadians to take action. In 2014 the campaign grew in the number of stakeholders and organizations that participate in raising awareness. It also included the release of a public service announcement with television personality Mike Holmes, who encouraged all Canadians to test their home for radon.
To give Canadians access to the tools to take action, extensive guidance documents have been developed on radon measurement and mitigation. Heath Canada also supported the development of a Canadian national radon proficiency program, which is a certification program designed to establish guidelines for training professionals in radon services. This program ensures that quality measurement and mitigation services are available to Canadians.
The Ontario College of Family Physicians as well as McMaster University, with the support of Health Canada, have developed an accredited continuing medical education course on radon. This course is designed to help health professionals—a key stakeholder group—answer patients' questions about the health risks of radon and the need to test their homes and reduce their families' exposure.
The national radon program also includes outreach targeted to at-risk populations. For example, Erica already mentioned the three-point home safety checklist that we've supported in partnership with CPCHE. As well, to reach smokers, we have a fact sheet entitled “Radon—Another Reason to Quit”. This is sent out to doctors' offices across Canada to be distributed to patients. Since the distribution of those fact sheets began, the requests from doctors offices have increased quite significantly. It began with about 5,000 fact sheets ordered a month, and we're up to about 30,000 fact sheets ordered a month and delivered across Canada.
In recognition of the significant health risk posed by radon, Health Canada's national radon program continues to undertake a range of activities to increase public awareness of the risk from radon and to provide Canadians with the tools they need to take action. We are pleased to conduct this work in collaboration with many partners across the country.
Thank you for your attention. I look forward to any questions the committee members might have.
Kelley Bush
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Kelley Bush
2015-06-18 16:31
I'm not aware of any comparison like that being done within Health Canada. Smoking is definitely a bigger contributor. I think I should make that statement very clearly because we've worked with our colleagues on the tobacco side. With regard to a comparison, from an economic perspective, no.
Tom Kosatsky
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Tom Kosatsky
2015-06-18 16:43
You know, anyway, that smoking causes lung cancer in smokers. You probably also know that to a degree it causes lung cancer in people who live with smokers. I won't really talk about either of those things, but if you can get to the slide that's marked “Lung Cancer in Lifelong Non-Smokers”, you'll see that there is a new thing that's been described only over the last, about, 10 years, which is lung cancer in lifelong non-smokers, something which, before this committee invited me to speak with you, I didn't know much about. It turns out that it's a whole other disease. It has some similarities to smokers' lung cancer but some very important differences.
The geography is different. It's a huge phenomenon in Asia and in Asians in Canada. It has a female predominance, so there are far more lung cancers in female non-smokers than in male non-smokers. The age distribution is different, so it tends to present itself at a much younger age than smokers' lung cancers do. The cell types, the cancer types are different. The typical small cell squamous lung cancer that you see in smokers, you don't get in non-smokers. You get a whole different cell type and cell shape. The genetics are different, so there is some family relationship. It's not very strong, but there's a very strong genetic relationship based on genetic analysis. You can almost predict who's going to get it, which is a really important thing. Further, it tends to be much more symptomatic at diagnosis than is lung cancer in smokers. The five-year survival, oddly, is better, even though it presents later, for non-smokers' lung cancer than for smokers' lung cancer. In many ways it's a different disease.
Radon-related lung cancer is somewhere intermediate, because, as I'm going to say, most radon-related lung cancers occur in smokers. The question of whether it is more cost-efficient to stop smoking was right on the mark.
The next one is called “Principal risk factors (excluding occupational exposure)”, only because you asked. There are a number of conditions, including radon exposure, that are associated with non-smokers' lung cancer, like the history in your family. It's associated with hormone use in women. It's associated with environmental tobacco smoke. It's associated, to a degree, with air pollution. It's associated with cooking-oil fumes, so indoor cooking over a long period of time. It's associated in Asia and Africa with domestic heating by wood and wood products in the home. Those are also associated with lung cancer. Something that I didn't know much about before is that it's associated with lung infections like tuberculosis and other lung infections over a long period of time. It's also, like so many of the other bad things in life, associated with being poor. Getting lung cancer is associated with being poor, even if you eliminate all the other stuff. To a degree it's mitigated or prevented by a diet high in fruits and vegetables, so eat your leafy greens, eat your fruit, and you're less likely to get lung cancer no matter what else you do.
The next one is an American slide. It has a little American flag, and it looks at the attributable percentage of lung cancer by cause. For active smoking, it's 90%. For radon exposure in the U.S., it is between 9% and 15%, and in Canada it's estimated at 15%. For workplace carcinogen exposure, it's 10%. For air pollution, it's 1% to 2%. That adds up to more than 100% because, as you'll see, some of those causes add to or multiply each other. If you're exposed to radon, don't smoke. If you smoke, don't be exposed to radon.
Non-smokers' lung cancer is a really important cause of lung cancer. It's about number six in terms of all the causes. Radon-related lung cancer—this is U.S. data but for Canada it would be the same—is number eight. How could that be? It could be because smoking and radon exposure are interactive, so one multiplies or adds to the effect of the other. That leads, in any case, to non-smokers' lung cancer being a very bad issue.
Any radon exposure is bad news, not just at over 200. An artificial limit, no matter what it is, is not very useful for lowering the whole population's exposure. It would be better if we were all exposed to less radon rather than picking one area, maybe for convenience, or one level. It may be good for convenience, but it's not a really useful population health measure. For the whole population, it would be better if we were all exposed to less radon. It's a linear relationship. The more radon you're exposed to and the longer you're exposed, the more likely you are to get lung cancer.
The other thing is that, as I was saying, the more you smoke the more it interacts. On the last slide, which I made up using Canadian data, most radon-associated lung cancers occur in smokers. If you've never smoked, as you get up to high levels, like interior B.C. levels, of radon about 36 people out of 1,000 exposed to those levels would get lung cancer. On the other hand if there was no radon exposure and you did smoke, about 100 people would get lung cancer. If you add the two together, you're exposed to a high level of radon and you smoke, 270 people exposed to those two for their whole lives, smoking and radon, will get lung cancer. It's 270 out of 1,000 people; that's tremendous.
How can you lower it? The number one way to lower it is to stop smoking or to never have smoked. The number two way to lower it is to lower your radon exposure, and you'll do that for everybody in the population. The less smoking there is, the less radon there is, the less lung cancer there will be, to the point that as we lower the level of smoking exposure, radon will become a more important cause of lung cancer. But there will be a lot less lung cancer. If we eliminate smoking, there will be less lung cancer in general, but all of these other causes other than smoking will increase in focus. The big issue is the interaction, the doubling, tripling, quadrupling, or really octupling effect, because it's an eight-time effect, of smoking and radon will go away.
What's been the Canadian public health stance on radon? Before the year 2007, it was pretty passive and largely seen as a private issue. Health Canada was helpful. They gave advice when people asked for it. That was at the time of the 800 becquerels per metre cubed, or 800 disintegrations per second per metre cubed level, which is what a becquerel is. Then when the level was lowered a more active stance was taken. Health Canada was involved with large-scale testing across the country to establish a radon profile across the country so that we knew what our levels were likely to be. They were much more active in terms of giving advice, and with this lower guideline, they promoted it and they encouraged “test and remediate”. Test and remediate to me is not the way to go. The way to go is to build it out in the first place.
If you look at this complicated Ontario slide, Ontario looked at levels of radon across the province and how many cases of lung cancer could be saved by doing something for those above 200 becquerels per metre cubed, by adopting 100 becquerels per metre cubed, by adopting 50 becquerels per metre cubed—all of which are attainable—or by going to as low a level possible and getting close to outdoor air levels, which are relatively benign. At 200 becquerels per metre cubed, if every Ontario resident got their house from that point down to outdoor levels, 2% of all the lung cancers in Ontario would be averted. If you got down from current levels above 200, if everybody tested and remediated and they successfully got their house down to background or no radon, it would avert 2% of all lung cancers. If all houses in Ontario with any level of radon in them could get down to outdoor levels, we'd get rid of 13% of all Ontario lung cancer deaths. If there were a way to do it, why not do that? Why not get it down lower?
The next slide looks at the change in levels of radon over time. This is Dutch data. Canada would be the same. Yes, as we've made our buildings tighter, radon levels have increased. This is even more reason to look at the joint effects of building changes on radon.
Sarah Henderson
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Sarah Henderson
2015-06-18 16:55
Good afternoon.
There is a slide deck for me as well. The first page of that slide deck should say, “Radon risk areas and lung cancer mortality trends in British Columbia”. I hope that you all have it. I will try to speak to the slides as I go along for those who don't have them.
I want to start by saying thank you so much for inviting me to be here. It's a real honour.
My title at the BC Centre for Disease Control is senior scientist, and I'm really a research scientist. The mandate of my role is to conduct applied public health research in support of good environmental health policy for the province, and that's how I first became interested in radon in British Columbia.
I'm going to show you some real, hard numbers today that come directly from the population data for British Columbia, and that's a bit different from what everybody else has been talking about so far.
If you move to the first slide, it's just a recap of the current guideline values for radon in Canada. We've heard about the number 200 all day, and any concentration lower than that is below the Health Canada guideline. Then if you measure your home and the concentration is between 200 and 600 becquerels per metre cubed, Health Canada currently recommends that you try to remediate that within the next couple of years, whereas if your measurement if over 600 becquerels per metre cubed, they really recommend that you remediate right away. That is the high-danger area for radon.
We've used these values in British Columbia to sort of break up the province into areas that we consider to be low, moderate, and high radon areas. If you are not seeing this in colour, the darkest areas there are coloured in red, and those are the high radon areas.
We're very lucky right now in British Columbia. We have a database of over 4,000 residential radon measurements, including measurements from Health Canada national surveys as well as from a bunch of surveys that have happened in the province, so we were really able to use the data that we have observed in the province to break things up this way. These geographic regions are called local health areas. They're the smallest health geographic unit that we use in British Columbia. We are able to look at deaths that have occurred in this province at this geographic scale, which is why we've used this geographic scale.
We did something quite simple, but I hope you'll agree, also quite effective. We looked at the province by those regions, and over the course of 25 years we summed up all of the deaths attributed to lung cancer in the low, moderate and high regions, and all deaths attributed to all natural causes, and then we divided the number of lung cancer deaths by the number of deaths from all natural causes, and in general, we expect about 7% of all deaths in B.C. to be attributed to lung cancer, which is probably true for most of Canada.
Slide number 4 shows the hypothetical situation. If there were no lung carcinogens in the world other than radon, we would expect lung cancer to be high and steady in the higher radon areas, somewhat lower and steady over time in the moderate radon areas, and then lower still and steady over time in the low radon areas. That's the framework I want you to think about when we go to this next slide.
When we looked at all deaths in British Columbia, we saw something quite different from what one would expect to see under that hypothetical scenario. The bottom line there shows the low radon areas. You might not be able to see that if you're not looking at it in colour. The middle line, which is just a little bit higher than the bottom line, shows the moderate radon areas. Then that line that is sloping upward over time and is quite distinct from the low and moderate lines is the lung cancer mortality proportion that we see in high radon areas over the past 25 years in British Columbia.
We don't have a lot of data about these people. We're doing this with only administrative data. We don't know whether or not they smoked. We don't know whether or not they lived their entire lives in those high radon areas. There are a whole lot of limitations here that we simply can't speak to.
When we split up these data by the higher and lower smoking regions of the province—we know that smoking rates can be up to 30% in some areas and down to 12% in some areas of B.C.—we still see these same persistent trends. It does seem to be that radon is an important factor here.
Another important distinction, and I think it's probably why I was asked to be here today, is what we see when we look at the trends for men versus women.
To look at men, the low line shown on the slide is the low radon areas, the middle line is the moderate radon areas, and the top line is the high radon areas. There's not as big a difference among those three lines as there was when we were looking at everybody together. In general, the lung cancer rates are going down. That's what we expect as the population stops smoking. When we go ahead and look at women, as shown on the next slide, we see the low and moderate lines towards the bottom there, and then the line for women is just taking off and is quite divergent from the other regions.
We're seeing a pretty big difference with respect to the two sexes here when we split up these data. Speaking anecdotally, it's not very scientific, but those of us who are interested in radon in British Columbia hear so many stories from people who say, “My wife died of lung cancer and she never smoked a day in her life.” This matches up with what we hear anecdotally, although that's not very scientific.
Somebody asked about the burden of radon-related lung cancer in high- and low-risk areas according to the current Health Canada guidelines. On this next slide, what we see is from data published by Jing Chen from Health Canada. There's an estimate of 6% of the housing stock currently being over the 200 becquerels value, and that's related to 28% of lung cancers in Canada, versus 94% of the housing stock being under the guideline value and 72% of all radon-related lung cancers being attributable to homes in that range. The bulk of the burden really remains below what we're currently talking about in terms of the Health Canada guideline.
This very point is something that we've addressed in a new paper. I want to make it clear that this work has not been published yet. It's currently under review, but it's not in the scientific literature and it has not been peer-reviewed. We looked at a bunch of different threshold values. It's really just a line in the sand that we're drawing when we say that 200 is the level or 100 is the level. We took that line in the sand and drew it at 600, 500, 400, 200, 100, and 50 becquerels to see whether or not we could still see a clear distinction between high and low radon areas in B.C. with respect to lung cancer mortality trends when we drew that line in the sand in different places.
Indeed, if you look at the far right-hand side, that top plot shows you lung cancer mortality trends in men and in women at a threshold value of 50 becquerels per metre cubed, and you can see that the trends are still distinct from one another. We still see that sharp increase in lung cancer mortality in women in the high radon areas.
In the final slide, the key message again is that these are very limited administrative data. This is something we've done as a surveillance exercise. It was really an exercise we undertook because a lot of the evidence we use in Canada to build our policy comes from places other than Canada. We're pulling together studies that have happened in Europe, the U.S., and elsewhere. We really wanted to show some hard-hitting data from the Canadian context.
Again, most radon-related lung cancers in Canada happen below the current guideline of 200 becquerels per metre cubed. We see clear temporal trends by radon risk areas of British Columbia. We have not repeated similar analyses elsewhere in Canada, but I wouldn't be surprised to see similar results. The trends that we see at 200 becquerels per metre cubed persist when we drop that threshold to 50 becquerels per metre cubed. This is really supportive of that idea of ALARA, or “as low as reasonably achievable”. As Tom said, the way to pursue ALARA in Canada is really through widespread changes to our national building code to protect the population into the future.
We have estimated that it would take about 75 years to turn over the entire residential building stock in Canada, or most of it, but at the end of that 75 years, you would have a radon-resistant building stock and a population that was well protected.
Finally, there does appear to be a difference between men and women in terms of risk.
Thank you very much for your time.
Tom Kosatsky
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Tom Kosatsky
2015-06-18 17:21
No. There are many types of lung cancer but the basic groupings of lung cancer tend to be different in non-smokers and in smokers so that if you looked at autopsy evidence, you would have a very strong chance of knowing whether the lung cancer you were looking at was occurring in a smoker versus a non-smoker without knowing the status of the deceased.
Tom Kosatsky
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Tom Kosatsky
2015-06-18 17:21
It's a good question. Nobody has done a study like that. One could do it. That would be something that the CIHR, the Instituts de recherche en santé du Canada, should get into, because it's worth it.
You can almost pick them out. Typically, a non-smoker radon-exposed person would have a typical non-smoking cancer. They would have an adenocarcinoma with an early presentation at a late stage that was very sensitive to treatment. They would more likely be a woman. If they're also a smoker, on the other hand, they would tend to approach a smoker's type of cancer, which is a squamous cell cancer, more likely small cell, more likely less advanced at time of diagnosis, presenting based on an X-ray, not on symptoms, and not very responsive to treatment.
If you smoke, it pushes it towards the smoking zone.
Sarah Henderson
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Sarah Henderson
2015-06-18 17:27
That's right. This is all lung cancers. We don't know which ones are attributable to smoking and which ones are attributable to radon. All we can say is that the areas with more radon and the areas with less radon have different patterns.
Natasha Leighl
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Natasha Leighl
2015-06-16 15:37
Great.
Thank you so much. Paul and I are honoured to be here to address the committee. We both are medical oncologists at separate institutions. We treat lung cancer. We have an interest in the treatment of lung cancer. We also volunteer with a charitable organization, Lung Cancer Canada, devoted to supporting people with lung cancer.
As you've heard from Paul, this is a major public health problem. I want to talk a bit more about the toll this has on people who are diagnosed with lung cancer here in Canada. I also want to talk about what holds us back from progress, the very low survivorship rate, and the stigma, which I'll touch on a bit more. This results in a disproportionate amount of public support for people diagnosed with this disease and their families, and a disproportionate amount of research funding. Like Paul, I want to highlight some of the opportunities where we think this group can really help us change outcomes for people with lung cancer in this country.
Lung cancer, as you've heard, is, sadly, the number one cause of cancer in the country. I am quite competitive, but to be number one in this is difficult. Lung cancer is, sadly, far and away the leading cause of cancer-related death.
Although 80% more women die from lung cancer than breast cancer, breast cancer is the women's cancer here in this country. Over 200% more men die from lung cancer than prostrate cancer, and yet prostrate cancer is the cancer people remember on Father's Day and associate with the men in their lives. We feel this really does need to change. It's estimated by Statistics Canada that cancer remains the leading cause of death for Canadians, but lung cancer by itself causes one in fifteen deaths: 8% of Canadians who die every single year die from lung cancer. That's really second only to cardiovascular disease.
Who gets lung cancer today in Canada? Of course, we do see people with smoking histories: 15% of the patients I see smoke currently. But the vast majority, over 60%, have quit smoking at some time, anywhere from the year before diagnosis to as many as 60 years before. A growing proportion of people—in my practice it's up to 25%, and in other people's practices it's as low as 10% to 15%—were never smokers, and never had that association with tobacco.
Most people, 75%, are diagnosed as already at an incurable stage, which I think really speaks to some of the lack of early detection here in this country and some of the lack of awareness of how we can find lung cancer early.
At least half of the people I meet with lung cancer in my clinic must quit working. Only about 15% are actually able to continue to support their families. Lung cancer is a major cause of financial distress for families in this country. More than a third of patients perceive that this has a devastating impact on their family and their finances. We know that people with lung cancer—this is from a study in the U.S.—have a higher rate of bankruptcy than do people without cancer. Of all the cancers surveyed, lung cancer actually has the highest bankruptcy rate. I'm hoping you get a sense of the devastation that lung cancer inflicts not only on an individual but also on a family.
We've also learned that many of the people we diagnose with lung cancer are diagnosed too late to receive treatment. Through some work we've done and recently published, we've found that only a quarter of people diagnosed with advanced cancer are actually well enough to have some of the incredible therapies that Paul has just talked about. Again, this really speaks to the need for early detection and a shift in our mindset to how and when we diagnose this disease.
This is really a high-mortality cancer. Although the five-year survival in lung cancer has risen to 18% with a lot of effort, it's 88% for breast cancer, 95% for prostate cancer, and 65% for colon cancer. You can see the huge disparity here in survivorship alone. With low survivorship, we have a very low voice for advocacy. There's also stigma, the very common public perception that if you have a diagnosis of lung cancer, you smoked, and so you deserve it.
Some of the low survivorship is because of the late detection. I think you'll hear later from Dr. Stephen Lam about the availability of organized screening that, for those at high risk, can significantly reduce mortality potentially to a greater extent than currently existing screening programs for such things as breast cancer and cervical cancer.
This is a virulent disease. While we are making progress, it has a very high case-fatality rate. Currently, most people diagnosed do die. There's a real lack of research funding. The Charity Intelligence Canada report from 2011 suggests that only 7% of the national research funding goes to lung cancer, despite causing 27% of the cancer deaths in this country, and less than 1% of the public donations. I think that speaks volumes about the stigma.
Some of the other work we have looked at suggests that even though lung cancer funding is increasing—between 2005 and 2010 it doubled from $10 million to almost $22 million—it's still only a fraction of the $536 million that was spent on cancer research that year. Again, you can see that's only 4% for a cancer that takes the lives of more than one-quarter of Canadians who die from cancer.
I also looked at just this past year, and CIHR, the Canadian Institutes for Health Research, awarded five grants for lung cancer research, for a total investment of $230,000 per year. That's an organization with $1 billion budget to fund research on all diseases in this country. When we compare this to the situation for breast cancer, over the past five years we've seen over 500 grants for breast cancer research worth over $140 million; by contrast, for lung cancer research there were 159 grants worth $39.6 million. Again, that's a disproportionate amount of funding and support.
At Lung Cancer Canada we conducted a survey. We asked 1,600 Canadians online what they knew about lung cancer, and half of the people did know someone who had had lung cancer. Only one-third knew that it was the leading cause of cancer-related death. Again, most women thought breast cancer was the leading cause for women and prostate cancer the leading cause for men. Most people, including smokers, had not spoken to their doctor about their risk for lung cancer, and only 2% knew that there was a lung cancer awareness month, November.
The association with smoking was very well known, but as you'll hear about later, there are other important risk factors such as radon, and only 1% of the people we surveyed correctly identified that as an important cause of lung cancer, and only 7% of homeowners had had their homes surveyed for radon exposure.
Two-thirds of the people we surveyed felt that people were very responsible for what they'd done to themselves because of their smoking habit, but instead of identifying things like heart disease or even other cancers as a consequence of smoking, which we know they are, they felt that people with lung cancer were the least deserving of their support, and certainly, smokers were the least deserving of sympathy, followed by those who drink too much and overeat. Again, there seems to be this disproportionate stigma against people with behaviourally related cancers and those who have smoked, and for all of those tobacco-related diseases, including heart disease and others, the burden of the stigma really seems to be aimed at people with lung cancer.
So what about screening? About one-quarter of Canadians know that there is a screening test for lung cancer, and 90% said they would support a national screening program for those at high risk. Currently we know that screening is approved and funded south of the border, in the United States. It's been estimated by the Canadian Partnership Against Cancer that 1,250 Canadian lives could be saved every year through the introduction of screening programs. I think this really has a dramatic potential to change survivorship rates.
With that, I want to again highlight some of the priority areas in which I think this group could really help us. We need national leadership to raise awareness and to really raise sympathy, tackling stigma while still working towards a smoke-free Canada. We need a national mandate to reduce lung cancer mortality. The United States has a bill to decrease the incidence of lung cancer mortality. I think we have a similar challenge here in Canada and a similar need. Through the establishment of screening we can really change the face of this disease, change the survivorship rates, and make a major change to the progress we can make in lung cancer. We also need to have a mandate to increase national research funding to an amount proportional to the impact of this disease on our citizens, and also to increase the chance of curing more people with lung cancer here in this country.
We need our own national campaign to combat high-mortality cancers, and the highest of these is lung cancer. Thank you.
Robert Nuttall
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Robert Nuttall
2015-06-16 15:46
Thanks.
I'm Robert Nuttall. I'm the assistant director of cancer control policy. I'll be doing the presentation, but my colleague, Rob Cunningham, a senior policy analyst with the society, will also be here for the question period.
Chair and committee members, I want to thank you for the opportunity to talk to you today about lung cancer. We're here on behalf of the Canadian Cancer Society, a national community-based organization of volunteers whose mission is to eradicate cancer and enhance the quality of life of people living with cancer.
As you've already heard, lung cancer is a significant contributor to the overall burden of cancer in Canada. It's a major concern for our organization. Lung cancer is the most common cancer diagnosed in Canada. It is expected that 26,600 new cases will be diagnosed this year. As well, as we've heard, the five-year relative survival rate for lung cancer is among the lowest of all cancers at 17%, whereas the overall survival rate for all cancers combined is 63%. This year, we expect 20,900 Canadians to die from lung cancer. As we've heard, that's more than the number who will die from breast, prostate, and colorectal cancers combined.
While these numbers are substantial, we have been seeing progress in the fight against this disease. Incidence rates for lung cancer among males have been declining since the 1980s, and the incidence rates for females have finally stopped increasing. This is a reflection of the past trends we have seen in tobacco use. However, even though smoking rates are dropping, 19% of Canadians continue to smoke.
Smoking is the leading cause of lung cancer. It's responsible for more than 85% of all cases, but a number of other factors also cause lung cancer, and these factors can also increase the risk of cancer in people who are smokers.
One of the most significant is radon. It's a colourless, odourless, radioactive gas found naturally in our environment. It's estimated that about 16% of lung cancer deaths in Canada are due to radon. That's more than 3,000 deaths a year. The health concerns from radon are primarily around radon in indoor spaces, where radon can accumulate to high levels. Health Canada has recommended an indoor radon limit of 200 becquerels per cubic metre, although it should be noted that there is no known safe level for radon.
Awareness of radon among Canadians is low. Last fall we did a survey of Canadians and found that only 32% of Canadians were somewhat or very familiar with radon. Sixteen per cent of Canadian had not even heard of it. Testing one's home is the only way to know if a home has high levels of radon. Our survey found that 96% of Canadians have not tested their homes. When asked why, the main reason, most said, was that they had never thought about it. This shows the importance of raising awareness about radon.
The society appreciates the work that Health Canada is doing to raise awareness through their support of the national “Take Action on Radon” campaign, but there are a number of additional initiatives that can take place at the federal level to minimize people's exposure to radon. These can include financial incentives, such as support to homeowners to lower radon through mechanisms such as tax credits; reviewing the radon guidelines set by Health Canada to consider whether 100 becquerels per cubic metre would be appropriate; reviewing national building codes to consider new measures for new home builds; and ensuring that public buildings get tested for radon and mitigation is undertaken when levels are above the Health Canada guideline.
Another major cause of lung cancer is asbestos. Although we no longer have operating asbestos mines in Canada, many workers continue to be exposed to asbestos currently used in products and buildings or through imported raw asbestos and asbestos-containing products. There's still more work that can be done to further reduce exposure to asbestos. This could include developing and maintaining registries related to asbestos, such as building registries that provide a public record of buildings that contain asbestos, and disease registries, so that we know how many Canadians are exposed to asbestos through their workplaces. As well, we'd like to see a phase-out of new asbestos products to ensure that for Canadians future exposures to asbestos do not occur.
In addition, there are a number of other workplace chemicals that cause lung cancer. The sectors that tend to be most affected by these chemicals include the construction and manufacturing industries. The strategies needed to protect workers will vary depending on the specific substance. However, we need workplace policies in place that strive to reduce exposures or that completely eliminate exposures whenever possible.
Another risk factor that we're paying attention to is air pollution. In 2013 the International Agency for Research on Cancer classified outdoor air pollution and particulate matter within air pollution as known carcinogens. Air pollution is a difficult term to define precisely, as it comprises many different components and a wealth of independent factors like weather fluctuations and nearby industries. There are several components within air pollution that are known to cause cancer, such as diesel engine exhaust, benzine, some volatile organic compounds, and other compounds
Protecting Canadians from air pollution can be done through initiatives that monitor releases, reduce emissions, and track diseases in affected communities.
Our organization is also a major organization in research funding. Last year we provided $5.1 million to fund a broad range of lung cancer and smoking-related projects across the country. Some highlights of what we're funding include research to identify genes that might make people more susceptible to lung cancer, particularly among non-smokers; a model that will provide new insights into how lung cancer starts; research on cancers due to working in the mining industry; and a new type of immunotherapy that can target a tumour's microenvironment.
There are two other projects I want to highlight. One project we're funding on occupational cancer in Canada will identify the number of cancer cases due to workplace exposures as well as the economic costs associated with these workplace exposures. The second is more of a population-based approach, looking at the number of cancers in Canada due to lifestyle and environmental factors. Both studies will give us a much better understanding of how many lung cancers in Canada can be prevented.
Your group is also interested in emerging best practices around screening and early detection. As you'll probably hear over the next couple of days, a pivotal study from the U.S. shows a 20% reduction in lung cancer mortality among people who are screened using a low-dose chest CT. The study involved more than 53,000 people between the ages of 55 and 74 who had a history of smoking. Lung cancer screening has the potential to reduce the number of cancer deaths in Canada. It also has the potential to have an impact on the costs associated with treating cancer. This will need to be weighed against the costs of implementing and running programs. Unlike other screening programs that target an entire population within a certain age range, lung cancer screening is most effective when done in a high-risk population. That will make recruitment and participation difficult.
Lastly, we know that smoking cessation is very effective at reducing lung cancer deaths. Lung cancer screening programs should aim to integrate with smoking cessation programs.
A number of initiatives are currently taking place across the country to help planners and decision-makers understand lung cancer screening. The Canadian task force on preventive health care is currently developing recommendations for lung cancer screening. A pilot study on lung cancer screening is currently under way in Alberta. A network convened by the Canadian Partnership Against Cancer brings together experts, including representatives from the society, to share information on the issue. This group was involved in developing a lung cancer screening framework for Canada, which is a tool used to support jurisdictions in their deliberations and/or planning for lung cancer screening. We want screening programs to exercise due diligence in assessing the impact of lung cancer screening to ensure that programs are developed in a responsible and evidence-based way.
Finally, as we've already heard, there is the stigma of lung cancer. The prevailing stigma is that lung cancer is a self-inflicted disease caused by smoking. This stigma is a common experience with lung cancer, and can result in psychological distress and lower quality of life for patients. A study of health care professionals, administrators, and not-for-profit organizations that was done in Ontario just last year found that lung cancer patients feel guilt and shame due to the stigma associated with their disease. Some participants reported that they felt lung cancer stigma resulted in reduced patient care and reduced funding for lung cancer compared with other cancers.
I want to end on something that somebody posted on our website. We have a website called CancerConnection.ca, an online peer support community for people with cancer. One woman wrote the following:
I am a 58 year old woman who started smoking at 13 when everybody smoked and was only finally able to quit just before the lung biopsy that confirmed I had lung cancer in January 2014....I told only essential people at work because I was embarrassed and I am still grateful that I have not had to go back yet...to face the questions. In a relatively small company of less than 200 employees, in a 5-6 year period I had 5 former co-workers, all women, die from lung cancer—smokers, non-smokers, former smokers. It doesn't matter. Lung cancer is a very deadly disease....The stigma is HUGE! No one deserves cancer.
In conclusion, lung cancer is the leading cause of cancer in Canada, responsible for more deaths than breast, prostate, and colorectal cancers combined. Smoking is the greatest risk factor for cancer, but other risk factors that have a significant impact include radon, asbestos, air pollution, and a number of occupational carcinogens. Awareness of radon is low, with only 30% of Canadians somewhat or very familiar with it.
People facing lung cancer often face serious stigma. Regardless of what caused someone's lung cancer, Canadians and their families facing this horrific disease should receive as much support as possible.
Thank you very much.
Natasha Leighl
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Natasha Leighl
2015-06-16 15:58
Thank you. That's an excellent question.
I think Dr. Stephen Lam will outline more of an answer to your question. The best evidence we have for decreasing mortality in people at risk of lung cancer is in people aged 55 to 74 with a significant smoking history, with something that we call “pack-years”, such as 30 pack-years. If you smoked for 30 years at a pack per day, and if you had not quit within 15 years prior to being screened, that's the population where we know most about it. When you look at the ability to detect cancer and what's cost-effective, you might start older; you might start with a higher smoking exposure; you might also add in certain risk factors. I think Stephen will take you through some of the recommendations, but I think the age currently, at the youngest, would be 55.
There are a lot of questions, such as, ““What if I didn't smoke?”, or “What about people with a family history and other occupational exposures?” Currently, the best evidence for that comes from some work done by Martin Tammemägi, a Canadian. He has published a risk calculator, which we can certainly forward to people so they can calculate their risk, but currently the best evidence is in that age group of 55 to 74 with a significant smoking history.
Paul, do you want to add anything to that?
Paul Wheatley-Price
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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.
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.
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