Health Committee on Feb. 12th, 2024

[Karen Vecchio, Conservative, Elgin—Middlesex—London, ON]

Are there any restrictions or time frames? As I said, with breast cancer, we saw that there were age verifications. What do we see when it comes to ovarian cancer and time frames?

[Dr. Shannon Salvador]

Typically, for ovarian cancer, we're usually asking women who have that cancer history with family members to go ahead and remove Fallopian tubes and ovaries at a minimum of about 10 years before an incidental cancer in their family or as soon as they are done child-bearing. The reason we say this is that ovarian cancer is so difficult to treat. You do not want to miss an opportunity to intercede and remove those cancers.

Endometrial cancer is also another cancer that can be genetically related through Lynch syndrome. People don't realize how strong a connection that is. About 80% of Lynch syndrome family members can get endometrial cancer. Most people associate it with colon cancer, but the connection is actually just as strong for endometrial cancer.

[Karen Vecchio, Conservative, Elgin—Middlesex—London, ON]

I have a quick question on this, because I'm sure my time is running out quickly: Where would you get this type of screening? We know that to get screenings, we look a lot of times at larger centres. Canada is huge, and we're talking about equity for our patients. Where are these centres available, and how do people get this type of screening and care done?

[Dr. Shannon Salvador]

Most cancer agencies in the individual provinces can run genetic testing within their own cancer agency.

What we would really like to see is family physicians being educated and having access and the ability to send them. That would be the best place be able to go to say, “I really need genetic testing. I have a family member who's been identified in another province, so can we please proceed with testing?”

[Karen Vecchio, Conservative, Elgin—Middlesex—London, ON]

I assume there should be no cost to this testing. It is all covered by the provinces.

[Dr. Shannon Salvador]

Absolutely.

[Karen Vecchio, Conservative, Elgin—Middlesex—London, ON]

It's fantastic to hear that too.

You were talking about the HPV vaccines. I know that they are offered in public schools, and you had mentioned up to age 45. Is there a time at which a women would be too old to have this vaccine? For instance, if a 53-year-old woman presented herself, what would you say? Would you say, “Sure, give her the HPV...”? What would you do?

[Dr. Shannon Salvador]

That's actually a very good question.

We don't have research trials per se to say whether you actually mount an immune response over the age of 45. I can definitely respond because I'm also the head of colposcopy in my hospital. If a woman comes to me because she has a precancerous lesion due to an HPV virus, whether it be cervix or vulva, I absolutely offer her the HPV vaccine if she would like to receive it, no matter what her age.

[Karen Vecchio, Conservative, Elgin—Middlesex—London, ON]

Thank you so much. I really appreciate that.

[The Chair, Liberal, Sean Casey]

Thank you, Mrs. Vecchio.

Next, for six minutes, we have Ms. Atwin, please.

[Jenica Atwin, Liberal, Fredericton, NB]

Thank you, Chair. Thank you so much to the witnesses for being here.

I just want to highlight something that I think Dr. Salvador said. It's that “women's cancers have been orphaned from the traditional” models.

I mean, it should be no surprise to most of us sitting around this table why that would be. I'm just really proud to be here with fellow women, and our allies as well, to really shine a light on women's health. It's been neglected for far too long.

I'm going to focus a little bit on the cervical cancer piece, because it's quite alarming to me that the rates are increasing.

The report lists various factors associated with this increase. You mentioned screening uptake and the vaccination piece. There's also a higher prevalence of HPV due to changing sexual practices. Can you maybe expand on that a little bit? What underpins these increases?

[Dr. Shannon Salvador]

I think one thing we're experiencing is that as people are becoming more sexually free and with divorce rates being what they are, people are re-entering sexual debut in an older generation. These are women who may not have actually had the vaccine or who had the opportunity to have the vaccine earlier.

It would be good for women to be aware that they can get the vaccination up to the age of 45. We do recommend it. It is definitely available if they wish to go to their family physician and get a prescription for it.

[Jenica Atwin, Liberal, Fredericton, NB]

Excellent. I did not know that. That's amazing.

We know that all provinces and territories offer the school-based HPV vaccination programs. I remember that from when I was in middle school. The report also indicates that there is a variance across provinces and territories. We have numbers here of anywhere from 57% to 91%. The report also mentions a lack of disaggregated data on these rates.

Why does the uptake of HPV vaccination vary across those provinces and territories?

[Dr. Shannon Salvador]

I think a bit has to do with the culture that may be present in each province and perhaps even the lack of education about HPV at this current time.

When I was growing up and HPV was first discovered, and then the vaccinations first came out, there were massive nationwide campaigns. I remember them, when I was in my 20s going into my 30s, as they were doing these campaigns.

I've noticed that there seems to be a lack of these campaigns nowadays. We have to keep in mind that every family that is making a decision on whether or not to vaccinate their child changes every 10 years. You're dealing with a new generation that's going into their child-bearing years and making decisions about having children. If we don't continue to carry forward with the education and offer these pertinent points....

It's not just cervix. It's vulvar, anal and throat. It's actually quite a large cancer burden when you look at it. We need to constantly stay on top of the educational component for our Canadian population.

[Jenica Atwin, Liberal, Fredericton, NB]

Thank you.

How about that piece on the disaggregated data? How would that help us improve informing our processes?

[Dr. Shannon Salvador]

I think it's about trying to identify which provinces seem to be falling behind and trying to engage the population, because it could also be due to a lack of family physicians and to disparities in being able to provide the primary education, even in the clinics, as children are growing up and going to see their pediatricians or their family physicians.

[Jenica Atwin, Liberal, Fredericton, NB]

As far as screening goes, I think most of us are familiar with the infamous Pap test. I'm reading here that there's another way. There's the HPV testing, which is compared to the Pap test. Can you explain what the differences might be?

[Dr. Shannon Salvador]

What a Pap test looks for are changes that the HPV virus has caused in the cervix, so it looks for an active lesion. What the HPV tests looks for is an active virus, so it can be more specific and sensitive to be able to identify someone who has an active HPV virus. Not only that, but there are different subtypes of HPV. We know some of them are more likely to cause more aggressive cancers than others.

We can subtype these now. If we find out that someone has an HPV virus, there are guidelines that were just published last year about this in combination with GOC, CPAC and the Canadian colposcopy society. This was all put together through Canada-wide recommendations for HPV testing, as well as what to do when someone has a positive HPV test.

[Jenica Atwin, Liberal, Fredericton, NB]

How many cervical screening programs currently use the HPV testing as a primary mode of screening?

[Dr. Shannon Salvador]

In Canada we are all doing a massive changeover right now. Each province has a plan for rollout. It's supposed to be going on, and I do believe that various provinces are at various stages right now.

[Jenica Atwin, Liberal, Fredericton, NB]

That's very interesting.

I'll go online to Dr. Hanley.

I'm really interested, again, in the disparities that exist across different populations. I'm thinking specifically of those who might be in rural or remote communities, indigenous peoples and those with low income or poor socio-economic backgrounds.

Could you describe how these barriers to accessing cancer care services for women present themselves and what we can do as a federal government to maybe implement some changes?

[Dr. Gillian Hanley]

I think you've heard from some of the other witnesses as well about these inequities. Unfortunately, we do often see in research that where a woman lives dictates far too much in terms of what she gets with respect to cancer care. This goes from prevention all the way to the molecular testing that Dr. McAlpine described, which then dictates treatment.

There are really important inequities, and we do see that rural and remote communities often fall behind. Indigenous communities often fall behind, so as researchers, we're working really hard to try to close many of these gaps, but it can be very challenging without collaboration with governments and other groups to help us address these.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Hanley.

Thank you, Ms. Atwin.

Ms. Larouche, you have the floor for six minutes.

[Andréanne Larouche, Bloc, Shefford, QC]

Thank you very much, Mr. Chair.

I join my colleagues in thanking the witnesses for being with us today.

We all have women around us to whom we can send energy and dedicate the important work we do here in this committee.

Dr. Hanley, your main focus is on ovarian cancer prevention, as you clearly explained in your opening remarks, particularly through salpingectomy, surgery that involves removing one or both fallopian tubes. You also talked about contraception and healthy pregnancies.

The brief that Ovarian Cancer Canada submitted to the committee indicates that the treatments available for ovarian cancer have unfortunately not changed significantly since the 1990s, and that the survival rate for ovarian cancer hasn't improved in 50 years. That's a sad statement.

Can you explain the underlying reasons for the lack of progress in ovarian cancer treatments and the lack of improvement in survival rates?

[Dr. Gillian Hanley]

Part of this is that ovarian cancer is just a really challenging disease. I mentioned that there have been tremendous international efforts to find an effective screening approach for ovarian cancer. We've heard about the Pap test as a really effective screening approach for cervical cancer, so if women get the Pap test, Dr. McAlpine mentioned that there's a long lag from the first sign when we see the precancerous lesion in the cervix to an active cancer. However, that does not appear to be true in ovarian cancer, so that has been very challenging, because we have not been able to find effective screening.

Again, because symptoms often arise when the cancer is already in very advanced stages, we need treatments that are incredibly effective. Unfortunately, we have not been able to make a lot of progress on the treatment front either. Part of this is a result of less funding dedicated to this kind of research, as I and others have mentioned here as well.

We have had a couple of breakthroughs in ovarian cancer. PARP inhibitors have been very important. These tend to work best for the patients who have the BRCA mutations and have tumours that are homologous repair-deficient. Unfortunately, that's just a subset of ovarian cancer patients, so there's still a very large group who have no new, effective treatments for their cancers.

There is a lot of work that is ongoing, and certainly Ovarian Cancer Canada has been a great leader in terms of funding it. We've had a lot of good federally funded research as well, but we need more. We need more work in this area.

Thank you for the question.