Evidence of meeting #101 for Health in the 44th Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was women.
A video is available from Parliament.
February 12th, 2024 / 5:30 p.m.
Liberal
Marcus Powlowski Liberal Thunder Bay—Rainy River, ON
If I could ask a kind of pre-emptive question—because I'm going to ask a whole bunch of other ones—we've heard quite a bit about the Canadian Task Force on Preventive Health Care and its recommendations with regard to breast cancer. How involved is it in making recommendations on other kinds of gynecological screening and/or treatments, like salpingectomies?
Maybe I could ask you, Dr. Salvador, since you cover all of these and you're here.
5:30 p.m.
President-Elect, The Society of Gynecologic Oncology of Canada
In terms of salpingectomies, Dr. McAlpine, did they actually come out with a statement directly on that?
5:30 p.m.
Professor and Division Head, Division of Gynecologic Oncology, University of British Columbia, As an Individual
Not that I'm aware of.
Dr. Hanley, do you...?
5:30 p.m.
Associate Professor, Department of Obstetrics and Gynaecology, University of British Columbia, As an Individual
5:30 p.m.
Liberal
Marcus Powlowski Liberal Thunder Bay—Rainy River, ON
Okay. That's kind of interesting, because certainly we've heard, on the breast cancer study, questions about its recommendations.
Can I go to Dr. Hanley—the real Dr. Hanley, not the useless guy sitting beside me?
5:30 p.m.
Voices
Oh, oh!
5:30 p.m.
Liberal
Marcus Powlowski Liberal Thunder Bay—Rainy River, ON
I think it was you who talked about a JAMA study, I think it was, on salpingectomies. There were 26,000 women who had salpingectomies, and none of them got ovarian cancer. Then you did mention.... How many were in the control group? I assume there was a control group of 26,000. How many were there, and was that statistically significant?
5:35 p.m.
Associate Professor, Department of Obstetrics and Gynaecology, University of British Columbia, As an Individual
Yes, for the control group, we included basically the surgeries that women would have gotten prior to the recommendation that salpingectomy be included. Those were women who had hysterectomies alone, so their Fallopian tubes got left behind, or women who had tubal ligations, so their Fallopian tubes were tied rather than removed. That was our control group. There were 32,000 of them, and there were 15 cancers in that group.
Again, because these women are still quite young, this is not reflective of the number of cancers we expect to prevent. The average ages in these groups were 42 in the salpingectomy group and 41 in the other group, so we're nowhere near, with the follow-up that we have, the upward age of diagnosis of ovarian cancer. However, we've already seen the statistically significant difference in these groups at this very early stage, so that's very promising in terms of the risk reduction that we can expect.
5:35 p.m.
Liberal
Marcus Powlowski Liberal Thunder Bay—Rainy River, ON
Correct me if I'm wrong, but actually having worked quite a few years in developing countries where I did surgery, did tubal ligations and operated on a fair number of ectopics, am I right that it's not technically very much more difficult to just take out the whole tube? Is there like an extra tie? How much more work is it?
5:35 p.m.
Professor and Division Head, Division of Gynecologic Oncology, University of British Columbia, As an Individual
We did a study on it. On average, it adds about eight minutes, and it's minimal blood loss. With regard to the developing country point, my resident just came back from Kenya, where they're doing opportunistic salpingectomies.
5:35 p.m.
Associate Professor, Department of Obstetrics and Gynaecology, University of British Columbia, As an Individual
Yes. In our colorectal surgery trial, the colorectal surgeons see that the average additional time in the OR has been four and a half minutes to remove the Fallopian tubes, so it's not difficult and it doesn't take long.
5:35 p.m.
Liberal
Marcus Powlowski Liberal Thunder Bay—Rainy River, ON
My question, then, is this: What's the problem in getting greater uptake? I think you said something about.... What is the number? Is it 80,000 people per year who get tubal ligations? If those were all salpingectomies, you figured it would decrease the number of cases of ovarian cancer by 1,000. Is that right? Can you just repeat those numbers?
5:35 p.m.
Associate Professor, Department of Obstetrics and Gynaecology, University of British Columbia, As an Individual
That was a study we did that looked at hysterectomies and tubal sterilizations across Canada. What we found was that between 2017 and 2020, 80,000 Canadians received a tubal ligation or a hysterectomy without a salpingectomy, so they missed the opportunity to have their Fallopian tubes removed. This is well into the time when we were recommending opportunistic salpingectomy: The SOGC formally recommended it in 2015. That will translate into a possible thousand future cases of ovarian cancer that could have been prevented if that opportunity had been taken to remove those Fallopian tubes.
5:35 p.m.
Liberal
Marcus Powlowski Liberal Thunder Bay—Rainy River, ON
Why isn't there greater uptake of surgeons doing a salpingectomy instead of a tubal ligation? Maybe I could get several people to comment. Is it the lack of evidence, or what is it? It doesn't seem like it takes much more time at all.
Maybe I can start with you, Dr. Hanley, and then I can ask a couple of the other gynecological surgeons.
5:35 p.m.
Associate Professor, Department of Obstetrics and Gynaecology, University of British Columbia, As an Individual
You know, I think there was some hesitancy. There were some concerns around possible additional complications. I think the research has really addressed those concerns and shown that complications are not a risk. I do think there were some surgeons who were waiting to see the evidence of effectiveness. Now we have evidence of effectiveness, and so I hope that will change minds.
Then I think that there's just some degree to which the message still has not reached all surgeons, which is unfortunate and something that we're trying very hard to change. We've been speaking with all the provinces where rates have been lower.
5:35 p.m.
Professor and Division Head, Division of Gynecologic Oncology, University of British Columbia, As an Individual
I would say it's knowledge translation. If you're not talking about it and your patient is not asking about it and your residents aren't bugging you to do it, it's easier to just not do it. I think that speaks to some themes you've heard today—that if there's good science, you still need to talk about it and bring it to the places where people are maybe too busy to go to that national meeting or haven't been taking part in CME. How can we notify them and keep people educated?
5:40 p.m.
Liberal
The Chair Liberal Sean Casey
Thank you, Dr. McAlpine.
Dr. Salvador, I'll get you to hold that thought. Dr. Powlowski's actually going to get another turn, and he probably will give you some time then.
Ms. Larouche, you have the floor for two and a half minutes.
5:40 p.m.
Bloc
Andréanne Larouche Bloc Shefford, QC
Thank you very much, Mr. Chair.
Dr. Salvador, you talked about HPV vaccination to prevent cervical cancer. In fact, I'd like to hear the opinion of other witnesses who would like to comment on that.
The World Health Organization has called for the global elimination of cervical cancer. Do you think Canada is on track to meet the WHO targets by 2030?
5:40 p.m.
President-Elect, The Society of Gynecologic Oncology of Canada
That's a very good question.
Under the CPAC there is a very distinct guide and layout on Canadian goals on how to eliminate cervical cancer and meet our World Health Organization goals. Currently, if you go through year by year, you see we've fallen behind on those goals that were laid out in that very distinct and quite comprehensive document because this was first created as COVID struck.
The vaccination rate is one of the biggest concerns that they highlighted in that layout. Right now the main part of that goal is to get our vaccination rate back up to over 90% by the end of this decade, and that is not on track right now for us.
There are also parts about being screened—again to 90%—for HPV. We've fallen quite some way behind there. Access to colposcopy is the one thing we are maintaining, but that's also because we're not seeing the numbers that we were expecting to see. The colposcopy clinics are meeting their goals of being able to see people very quickly once they're diagnosed with their HPV.
For us to meet that 2040 goal with the WHO, we have a lot of work to do. I think Canada can still do it. It just requires us to really get back on track and meet together, as the invested parties at the table, to look at that document again and meet these goals that we've already set as a nation.
5:40 p.m.
Liberal
The Chair Liberal Sean Casey
Thank you, Dr. Salvador and Ms. Larouche.
Next is Ms. Barron, please, for two and a half minutes.
5:40 p.m.
NDP
Lisa Marie Barron NDP Nanaimo—Ladysmith, BC
Thank you.
Dr. Salvador, in your opening comments, among other things, you had mentioned.... I wrote down the words that you said. You said that there is a “backsliding” of prevention. I'm wondering if you can expand a little bit on what you meant by that.
5:40 p.m.
President-Elect, The Society of Gynecologic Oncology of Canada
That is related to the cervix cancer issues. When you look at the numbers pre-2015, you'll see that our cervical cancer rate was actually dropping very nicely. It was going down right on track and in the way that we were expecting it. If you look at the projected numbers that were going out from the previous cancer report, you'll see that they were expecting it to continue to drop. That's why this report that came out in 2023, just a few months ago, was quite eye-opening to all of us, because that had not happened.
That is where I see the backsliding. We need to pay attention again. I think we've gotten a little bit lax and have thinking, “Oh, okay.”
As we all commented, this is the easiest, most preventable cancer. We have a vaccination, and we have a long prodromal period in which we can identify people with precancer lesions.
I think it's just a matter of telling ourselves to wake up again. It does require all of us to re-educate ourselves.
5:40 p.m.
NDP
Lisa Marie Barron NDP Nanaimo—Ladysmith, BC
Thank you.
There's another thing that I'm curious about, if you can expand on it, Dr. Salvador. You were talking about the costs associated with the HPV vaccination after 18. I believe what you said was that there is a cost for those 18 and older. I'm wondering whether you can provide some reflections on the impacts of these costs and the ripple effects of people having to pay for these vaccinations once they are over 18 years of age.
5:45 p.m.
President-Elect, The Society of Gynecologic Oncology of Canada
If someone has not been vaccinated as a child, then once they're past the age of 18, they will incur those costs themselves in most of our provinces. There are some provinces that will help to cover the vaccination for people who have already been diagnosed with a lesion. That's a little bit of a backstep—just because they have been diagnosed with a lesion, you don't want them to miss the boat. The hope is that they can get vaccinated before that is the case, but definitely offer it to everyone.
For some of the women I've met in the colposcopy clinic, it is a detriment to being vaccinated. They cannot afford it. We discuss it. I even have a very dedicated nurse who negotiated with our pharmacy group there to actually offer the vaccination at a reduced cost for them. This is how much we valued it and how important we thought it was to get it done. It is definitely preventing some women from being able to get vaccinated themselves.