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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.
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.
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