Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 40 - Evidence - May 22, 2013
OTTAWA, Wednesday, May 22, 2013
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:14 p.m. to study Bill C- 314, An Act respecting the awareness of screening among women with dense breast tissue.
Senator Kelvin Kenneth Ogilvie (Chair) in the chair.
[Translation]
The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
My name is Kelvin Ogilvie. I am a senator from Nova Scotia. I will invite my colleagues to introduce themselves, starting on my left.
Senator Eggleton: Art Eggleton, senator from Toronto and deputy chair of the committee.
Senator Cordy: I am Jane Cordy and I am a senator from Nova Scotia. Welcome.
Senator Dyck: Lillian Dyck, senator from Saskatchewan.
Senator Enverga: Tobias Enverga from Ontario.
Senator Eaton: Nicky Eaton from Ontario.
Senator Seth: Asha Seth from Ontario.
Senator Martin: Yonah Martin from British Columbia.
Senator Seidman: Judith Seidman from Montreal, Quebec.
The Chair: Thank you, colleagues. Before I address our witnesses directly, I will remind us that our committee is now beginning a study of the subject matter of Bill C-314, An Act respecting the awareness of screening among women with dense breast tissue.
This piece of legislation was tabled in the House of Commons on October 3, 2011, was studied in the House of Commons Standing Committee on Health and then passed by the house and sent to the Senate on May 9, 2012. The bill was referred to this committee on February 28 of this year, and we need to make a report to the Senate before second reading can proceed further in the Senate chamber.
We have today, starting off our study of this subject matter, three experts with us, one of whom is here to answer questions but will not make a formal presentation, and that is Dr. Stewart, the Interim Senior Executive Director of the Therapeutic Products Directorate, Health Products and Food Branch, Health Canada. It is my understanding he is prepared to answer our questions, but he will not make a formal presentation because the other two witnesses represent those areas of government that deal directly with issues of the regulation and monitoring of issues.
Senator Eggleton: They get more time.
The Chair: Nice try.
I will invite, by prior agreement, Kimberly Elmslie, Acting Assistant Deputy Minister of Health Promotion and Chronic Disease Prevention Branch.
[Translation]
Kimberly Elmslie, Acting Assistant Deputy Minister, Health Promotion and Chronic Disease Prevention Branch, Public Health Agency of Canada: Mr. Chair, honourable Senators, thank you for inviting me here today. I appreciate your consideration of the issue of breast density, particularly as it pertains to raising awareness of screening.
[English]
Sadly, many Canadians are aware of the impact of breast cancer, either through personal experience or through the experience of a family member, friend or neighbour.
As we all know, breast cancer is a devastating disease. In Canada, it is the most common form of cancer among women and an important health issue for Canadian women. Statistics tell us that one in nine Canadian women is expected to develop breast cancer during her lifetime.
Today, many women are struggling to overcome breast cancer, and thousands more family members and friends are coping with the loss of someone close or dealing with uncertainty over the fate of a loved one. However, we know that early detection of breast cancer can lead to timely treatment. We know breast cancer screening can save lives. We also know that women with dense breast tissue face added challenges with breast cancer screening.
Breast density refers to the ratio of fat and fibroglandular tissue in the breast. Dense breast tissue has less fat than fibroglandular tissue.
We understand that this is an issue of importance for many Canadians. The government continues to invest in research, surveillance and monitoring, and information sharing in support of raising awareness and the early detection of breast cancer.
Through raising awareness of dense breast tissue, we can assist Canadian women in understanding how breast density may affect screening for breast cancer.
Let me take a few moments to speak to the importance of breast cancer screening, early detection of breast cancer, and how dense breast tissue affects detection.
First, Canada's breast cancer screening programs, as you know, are delivered by provincial and territorial governments under their jurisdiction for health care delivery. Breast cancer screening is most commonly done with mammography. Mammograms may find cancer early, before any signs or symptoms are noticed by women or by their doctors.
For women with dense breast tissue, changes in breast tissue that may turn out to be cancer are harder to detect on a mammogram. While fat appears as a dark spot on a mammogram, denser fibroglandular tissues, as well as cancer, appear white on a mammogram, making it more difficult to detect the cancer.
We also know that women with dense breast tissue have an increased risk of breast cancer. There is research evidence that mammographic breast density is one of the strongest predictors of breast cancer risk. Only age and genetics indicate a greater relative risk for breast cancer.
Provinces and territories have put in place protocols under their breast cancer screening programs relating to further testing when mammography identifies dense breast tissue. Women with dense breast tissue need to be made aware of their increased risk and the challenges presented. They also need to be aware that further testing is sometimes necessary to obtain a clear result in light of the challenges of imaging dense tissue.
Armed with better information concerning the relationship between breast density and breast cancer screening, women can be more confident in discussing screening practices with their doctors and in their decision making.
One of the key ways the federal government is taking action on cancer is through investment in the Canadian Partnership Against Cancer, which leads the implementation of the Canadian Strategy for Cancer Control. The partnership works with groups and agencies across Canada to generate new knowledge and to accelerate the implementation of existing knowledge about cancer control. It plays a key role in raising awareness and in providing information to women on cancer screening. By providing women with information about breast density in the context of breast cancer screening, they are able to have informed discussions and make decisions with their doctor or health care provider on screening and overall breast health.
Through its investment in the Canadian Partnership Against Cancer, the federal government supports the provinces and territories in raising awareness of breast density and its screening implications through the Canadian Breast Cancer Screening Initiative. Through this initiative, the performance of breast cancer screening programs across the country is measured. All jurisdictions regularly share screening program information, best practices, challenges and mutual questions of importance in an effort to improve their services to Canadian women. This is how we can save more lives — by ensuring women have important information when making decisions regarding breast cancer screening.
Through the federal-provincial-territorial National Committee for the Canadian Breast Cancer Screening Initiative, participating provincial and territorial screening programs collaborate on screening recommendations and approaches, including for dense breast tissue.
The committee also maintains the federal-provincial-territorial Canadian Breast Cancer Screening Database. The database is a source of valuable information on breast cancer screening. Research on dense breast tissue and breast cancer screening can strengthen the information available and address any identified gaps.
The federal government has made significant progress in filling key knowledge gaps related to breast cancer. Investments in health research through the Canadian Institutes of Health Research, or CIHR, are supporting scientific discoveries for all types of cancer, including breast cancer.
You will hear shortly from my colleague Dr. Morag Park on how the scientific research undertaken through CIHR is leading to a better understanding of breast cancer, including breast density, as well as enhanced screening practices. These efforts will enable Canadians to make well-informed decisions about breast cancer screening.
National non-governmental organizations, such as the Canadian Cancer Society and the Canadian Breast Cancer Foundation, as well as women's health organizations, also play integral roles in raising awareness about breast cancer. All of these organizations work to promote cancer prevention, early detection, effective treatments and research. They also provide education and awareness programs and work to improve the quality of life for those living with breast cancer.
Recognizing that many organizations have a role to play in cancer prevention, the federal government encourages collaboration in order to develop better information and raise awareness on breast cancer.
[Translation]
The federal investment in the Canadian Partnership Against Cancer supports working across sectors, mobilizing action to prevent and control cancer, and working to improve the quality of life for those living with cancer. These initiatives address knowledge gaps, improve information, and increase awareness about breast density related to cancer screening. By providing Canadians with better information and raising awareness around dense breast tissue, they can make informed decisions that support the early detection of breast cancer.
[English]
The Chair: Thank you very much, Ms. Elmslie. I neglected to point out that you are with the Public Health Agency of Canada. My apologies.
Now, from the Canadian Institutes of Health Research, we have Dr. Morag Park, Scientific Director for the Institute of Cancer Research.
Morag Park, Scientific Director, Institute of Cancer Research, Canadian Institutes of Health Research: Honourable senators, thank you for the invitation to speak to the issue of research on breast density, particularly as it pertains to raising awareness of breast cancer screening.
As you have heard from Kimberly Elmslie, statistics show that one in nine women in Canada is expected to develop breast cancer during her lifetime, and one in twenty-nine will die of it.
Although new treatment protocols and early detection have improved outcomes, the current mortality rate from breast cancer in Canada is 21 per cent; or, in 2012, 5,200 women died of the disease. This highlights a need to improve the outcomes from the disease.
Risk factors for breast cancer can be both genetic and environmental, and breast tissue density is one of those factors.
Breast tissue density, as you have heard, is related to the amount of fat tissue versus glandular tissue in the breast. Women with dense breast tissue, which has a relative glandular-to-fat-tissue ratio greater than 50, are at a greater risk that cancer will not be detected by mammography, because the radiological signal of breast cancer can then be masked by the dense breast tissue.
Through raising awareness of dense breast tissue, we can assist Canadian women in understanding how breast density may affect screening for breast cancer. At the same time, drawing increased public attention to breast cancer density serves to highlight the impact of research and to generate more support for it.
One of the key ways the federal government is taking action on breast cancer is through the support of research. The federal government has made significant progress in filling key knowledge gaps related to breast cancer and breast cancer density.
Through the Canadian Institutes of Health Research, or CIHR, the Government of Canada is funding breast cancer research. As you are aware, the CIHR is not involved in breast cancer screening. Our role, our mandate, is to support the creation of new knowledge based on rigorous scientific evidence and to foster translation of this knowledge into better health and better health care for Canadians.
It should also be noted that knowledge acquired in one area of cancer research increases the total knowledge brought to bear in all areas of cancer research. For example, in 2011-12, CIHR committed $166 million to cancer research, of which $25 million was focused on breast cancer research. In the last five years, CIHR has funded more than $110 million specifically focused on breast cancer research.
Investments in health research through the CIHR are leading to a better understanding of breast cancer, including breast density, as well as enhanced screening procedures.
So far, CIHR has funded multiple studies on breast density. For instance, CIHR supported a study conducted by Dr. Norman Boyd and his collaborators from the University of Toronto. Dr. Boyd's research has revealed that dense breast tissue is associated with increased breast cancer risk.
Dr. Boyd and his collaborators have also identified that the prevalence of high breast density was nearly three times higher in younger women — and that is defined as women under the median age of 56 years — than in older women, mostly post-menopausal women.
To identify the best technology to screen for breast cancer in women with dense breasts, Dr. Boyd and his team are using CIHR funds to evaluate alternative optical techniques, including magnetic resonance and ultrasound in studies of breast composition in younger women.
Other imaging studies are funded by CIHR, and these include studies by Dr. Lothar Lilge at the University of Toronto. He has evaluated alternative optical techniques to identify breast tissue at increased risk of cancer development, particularly in younger women where exposure to radiation is of particular concern.
CIHR, in partnership with the Canadian Breast Cancer Foundation, has launched a new competition this year with funding of $6 million to support a national research team focused on breast cancer in young women. This new research funding opportunity has been designed to facilitate progress in this research area toward improving the awareness of breast cancer in young women, the clinical outcomes and quality of life for young women with breast cancer.
CIHR is also supporting research on the use of the current mammographic imaging modalities to detect breast cancers.
One such study by Dr. Anna Chiarelli and her team at the University of Toronto used the largest cohort of women to compare traditional film mammography with digital radiography and computed radiography. This included 8,000 women in Ontario undergoing regular mammographic screening. These analyses revealed that screen film mammography and direct radiography performed better than computed radiography. This research will inform policy-makers and will inform decisions for breast cancer screening programs and provide informed choices for Canadian women undergoing mammography screening.
CIHR also invests in innovative new approaches to assess breast cancer risk, including breast density and amongst younger women.
In collaboration with Genome Canada, within the Personalized Medicine Signature Initiative, CIHR has recently funded a team led by Dr. Jacques Simard at the Université Laval and Dr. Bartha Maria Knoppers at McGill University. This team is developing a genomic-based screening clinical trial program aimed at identifying young women with a high risk of breast cancer, providing additional approaches to mammography to identify high-risk individuals.
Increasing clinical trial capacity such as these in Canada is one of the objectives of the Strategy for Patient-Oriented Research. Through this strategy, also referred to as SPOR, CIHR is working with the provinces and territories, health care associations, private partners and patients in establishing and supporting patient-oriented research networks that will help develop our capacity for clinical trials in areas of benefit for Canadian patients, including breast cancer.
As you can thus see, these initiatives address knowledge gaps, improve information and increase awareness about breast density related to cancer screening.
Honourable senators, I am pleased to say that CIHR, within its mandate and in collaboration with various partners, will continue to support biomedical, clinical and evaluative research that will provide decision makers and other federal agencies, such as the Canadian Partnership Against Cancer, with evidence used in raising awareness and in providing information to women on cancer screening.
Thank you for your attention.
The Chair: Thank you very much. I will now open the floor up to questions from my colleagues.
Senator Seidman: Thank you very much. I will ask about the National Committee for the Canadian Breast Cancer Screening Initiative, which I believe Ms. Elmslie referred to. Could you tell us what their role is exactly? You mentioned that they collaborate on screening recommendations and approaches, including for dense breast tissue. If you could give us some information, I would appreciate that.
Ms. Elmslie: The national committee is one that includes the directors of breast cancer screening programs from each of the provinces and territories, along with representation from stakeholder groups, women's groups that are interested in breast cancer. The role of that committee is to share information about issues that screening programs are facing, to talk about best practices across the country so that people who are facing similar problems have a forum to come to and talk about their challenges and issues and work together on ways they can address them.
Importantly, this group oversees the national database that I referred to. That group decides collectively on the analyses that will be performed using the data in the national database, which comes from provincial and territorial jurisdictions.
Each period the committee uses those data to understand the performance of breast cancer screening programs across the country. This is a very important and instrumental partnership in bringing together those who are responsible day to day for breast cancer screening programs not only to look at new opportunities but also to look at ways that, collectively, improvements can be made in breast cancer screening programs. These, as you know, fall under the jurisdiction of provinces and territories. Having all of those representatives around that table is a very important asset for the country.
Senator Seidman: Exactly, and that is precisely why I am asking you the questions. It is critical, because there are jurisdictional aspects to this, as you have put forward.
You say that this committee has put forward screening recommendations and approaches, including for dense breast tissue. What screening recommendations and approaches may this committee have already put forward?
Ms. Elmslie: In that context, in provinces and territories, there are protocols that are in place for further testing of women who have dense breast tissue. Through this committee, discussions have been had that then inform what each jurisdiction puts in place to ensure that women with dense breast tissue, for instance, are getting the appropriate follow-up that is needed. That, again, is an asset of this committee. They do that together and then jurisdictionally, in each province and territory, decisions are taken around the protocols that will be put in place. It is based on science and the best available evidence.
Senator Seidman: You are saying there already are existing protocols that are used provincially and in the territories?
Ms. Elmslie: Yes, there are existing protocols used in the context of breast cancer screening programs.
Senator Seidman: With dense breast tissue?
Ms. Elmslie: Including with dense breast tissue, yes.
Senator Seidman: That is very helpful.
I would ask a question about the technology, because I believe both Ms. Park and Ms. Elmslie mentioned it. You talked about mammograms, but of course there are other technologies as well. You talked about the specific challenges of identifying potential cancers in dense breast tissue.
Could you tell us a bit about the changes in the technology and whether we have advanced beyond the sort of basic mammography into other technologies that are much more helpful in diagnosing cancers in dense breast tissue?
Ms. Park: I can give you some information on the research that is ongoing at the moment that is funded by CIHR and in Canada.
You said ``beyond mammography.'' I think the first important point to make is the study by Dr. Chiarelli, which compared 8,000 women undergoing regular mammography with the different mammographic technologies available at the moment. This is the computed radiology, direct radiology and traditional film-based radiology.
That was a very important study because it identified that the computed radiology approach is less efficient at detecting breast cancers, and this may be associated with the density of the breasts in these women. That information must be computed and compared to the different types of breast tissue density, so this is not clear-cut at the moment. However, that is one position that the computed radiology may be less efficient. I think this information has already been transferred to the provinces and the territories, which may influence their decision making in focusing on using film-based mammography techniques and the digital radiography techniques that already exist in the provinces.
In addition, as I mentioned, Dr. Boyd and Dr. Lilge are using different optical techniques, and some of these include the ultrasound-type technologies, as well as MRI, to compare breast density and to screen individuals with dense breast tissue. These studies are not finalized yet and the data is not available for discussion. That data should be available quite soon.
Senator Seidman: Based on your expertise on the research that is out there, would you say that all women with dense breast tissue should be part of some kind of specialized screening program beyond general basic mammography, or would you say that there are combinations of risk that go beyond the dense breast tissue? It could be, for example, age plus dense breast tissue. I am just putting out possibilities, but that it could be a combination of characteristics as opposed to one general protocol.
Ms. Park: Yes. Breast cancer is actually quite a complex disease. Interestingly, the more we know about it, the more we understand how complex it is. It is not one disease. There are genetic components, epigenetic components, and in addition, there is dense breast tissue. It is a combination of the accumulation of alterations both with breast density plus genetic components that contribute to the development of breast cancer. Not all women with dense breasts will develop breast cancer.
The research would indeed support that, as we mentioned, one of the challenges with dense breast tissue is that it is more difficult to detect breast cancer. In that context, what that means in many ways is that for these individuals, if they do have a breast cancer, the cancer has a better chance of growing more before it is detected. This is one of the challenges.
As I mentioned, there are initiatives under way to use other types of risk factors that are genomic-based, which we have just funded within the Personalized Medicine Signature Initiative. Depending on the outcome of that clinical trial, this may be an alternative way to screen women, particularly young women, where you do not want to subject them to enhanced radiological exposure for increased risk to breast cancer, so that is one alternative.
Senator Seidman: Thank you. That answered my question.
Senator Eaton: Thank you very much. The subject, as you say, gets more and more complicated.
In terms of enhanced screening, let us start with the province of Ontario, where there was a headline the other day saying they will spend another $25 million because they are going to buy more machines. Are they buying the same old machines or are they going toward something new?
Ms. Park: To be honest, I do not know exactly what Ontario will buy, but at least I read the same article. I assume you are referring to the article in The Globe and Mail.
This is based on the study by Dr. Chiarelli on the comparison of the radiological machines used for mammography at the moment, the computed radiology versus the direct radiology versus the film-based mammography.
Senator Eaton: Could you stop for a moment? There are a lot of women sitting here. Perhaps you could explain this to us. When we have a breast exam and we see the technician and the screen comes up, is that what you call a computer-driven mammography?
Ms. Park: We have to be careful there, because the screen will come up even if you have a film-based mammogram, because that is just like an X-ray and you would now see it in a digital manner. I am not an expert on mammography because that is not my research area. However, my understanding is that in the computed radiography, you essentially take an image, which is a radiological image of the breast, and then that is computerized, digitalized, before you would see it, say, on a computer screen. That is the distinction between the direct film radiography and the direct radiography. There is a distinction between the two.
From Dr. Chiarelli's study, the results suggested that the computed radiography predicted 20 per cent fewer breast cancers. My understanding is that the discussion that the Province of Ontario is having at the moment is whether to invest in, to be honest, the older-style direct film or direct radiology mammogram versus the computed radiology.
Dr. John Patrick Stewart, Interim Senior Executive Director, Therapeutic Products Directorate, Health Products and Food Branch, Health Canada: I can provide some additional information on the different mammography technologies if you would like.
Up until around 2000, the vast majority of mammography was done by standard film mammography, where the X- ray going through the tissue would expose an X-ray film, and that would be developed and you would have one copy of a film to look at.
Computed radiography was an advancement that started to come in in 2000. We had a lot of medical device licence applications from 2004 to 2010. You could still use a standard mammography X-ray tube, but instead of an X-ray plate, it had a receptor that generated an image. That was taken and digitalized, and then you had an image in a computer.
The further step, which is now digital mammography, radiography, is where you do not have that plate to take the image. The X-ray goes through the tissue and has a digital receptor and generates a digital image, so that there is less processing of information. It is felt to be more sharp and accurate in producing an image of tissue, and it can be enlarged and looked at in detail.
Presently, licence applications that are coming into the Medical Devices Bureau, since 2010, we have only had digital radiography mammograms. That is presently what we see as the type of technology that companies are bringing to market.
Senator Eaton: I understand that if one has dense breast tissue, you need someone who is trained to read the results of a mammogram. Is that not right? Do we have enough trained people to interpret and read them?
Dr. Stewart: In my role at Health Canada, I am not sure I am the person to answer that. I know there is an accreditation program by the Canadian Association of Radiologists. They accredit mammography programs and centres. I believe there are 450 centres that are accredited. It is within the jurisdiction of the provinces to oversee the practice of medicine and the quality of care delivered in hospitals. There are downstream effects after mammography machines are approved, processes put in place to ensure the quality of that. I think it is critical that the user reading the mammography has a lot of experience.
Senator Eaton: Ms. Elmslie, should women inquire of their doctors whether they have dense breast tissue? Is this something that a woman should know?
Ms. Elmslie: One of the objectives we have in the Public Health Agency and in the work that we do is to raise awareness so that women can choose to have that conversation with their health care provider. That is why it is important, from our perspective, to use the existing programs that we have federally to better inform and to identify gaps so that we can provide that information to women. Then women can make their own decisions about the conversations they want to have with their physician.
Senator Eaton: If someone finds out they have dense breast tissue, should their next question be this one: How many times should I be screened a year? Is there an onus on the doctor to push for more breast examinations or for more screening or a different kind of screening? Should that be part of it?
Ms. Elmslie: I would say that the onus is on the doctor and the patient to talk about what is the best course of action for that particular patient. I do not think that there is a cookie-cutter approach. It will depend on other risk factors, and it will depend on other concerns that the individual patient may have in that context. However, by doing things that raise awareness, we are informing that conversation.
Senator Eggleton: With respect to the technology again, I am hearing that the direction for mammography seems to be in digital form now instead of film. Is that proving to be much more successful? Supposedly, it is a better detection system. Is there any study to indicate that in the usage of it? Dr. Stewart, I think you said that nothing but these things were being bought since 2010. What do we know so far about how well it is working?
Ms. Park: I can refer again to the study by Dr. Chiarelli with 8,000 women in Ontario, which identified that the digital radiography performed better than the computed radiography, even adjusting for other factors. These other factors would be age-related, weight-related and other components.
Senator Eggleton: What about the ultrasound? This is something the U.S. Food and Drug Administration apparently has approved. How does that relate to the digital mammography, or is it a replacement?
The Chair: Before we come to that question, Dr. Stewart, did you have something to add to his last question?
Dr. Stewart: If you look at that study and the actual techniques being used, there are numbers of how many women were screened by digital radiography, computer radiography and standard film radiography. It gives you a sense of the different types of technology that are in the Ontario health care system. These are not straightforward things to change over. They are fairly large and expensive, so in moving forward, if a regional health body or province wants to change focus on which technology to use, it does require planning.
There are presently, from what we understand, a number of different mammography technologies in the health care system in Canada.
Senator Eggleton: What about ultrasound? Where does that come into play here?
Dr. Stewart: If I can speak from the Health Canada licensing perspective, there are presently three technologies licensed and labelled for mammography: the standard film mammography, the computer mammography and digital.
Ultrasounds are licensed for general ultrasonography, so they are licensed for a number of different indications to image different parts of the body. There is only one ultrasound that has been reasonably authorized by Health Canada for the use in assessing breast tissue. It is not, as far as I understand, endorsed in any of the provincial screening programs as an accepted technology.
The same is also true for MRI. MRI is approved and licensed for imaging different parts of the body. None of them at this point have an indication as a mammography screening tool.
Senator Eggleton: Is there anything we can learn from other countries or sub-federal jurisdictions somewhere else in terms of leadership on this issue? Where might that be, and why would they be doing so well with this issue, unless you think we are number one in the world?
Ms. Park: I can comment from a research perspective, and I can state with confidence that Dr. Boyd is a world leader in understanding breast density. His studies on breast density and the impact of breast density for risk are cited worldwide. He does work with international teams, and that includes both Europe and the United States.
Senator Eggleton: Ms. Elmslie, you mentioned a number of endeavours, for example, the Canadian Partnership Against Cancer, the screening initiative, et cetera.
Could you briefly comment on how these are interrelated? Who is the Canadian Partnership Against Cancer? Who formed it and who is part of it?
Ms. Elmslie: The Canadian Partnership Against Cancer was formed in 2006, established by the federal government in order to implement the Canadian Strategy for Cancer Control. Its mandate is to bring together partners from across the country to accelerate the use of existing evidence on cancer prevention and control overall, to accelerate research and to provide a forum where we can come together as a country and share best practices to get things going across the country.
I think you may be hearing from that group.
The Chair: They are coming tomorrow.
Ms. Elmslie: That is wonderful. That partnership is a federally funded non-governmental organization that works to bring together partners in the prevention and control of cancer.
Senator Eggleton: Since they are coming tomorrow, I will save any other questions for them.
Senator Enverga: Thank you for your presentations. I just heard that there are more women with high-density tissue that have breast cancer. Can you give me the ratio? What percentage of people have high-density tissue? Is it 50 per cent or 60 per cent?
Ms. Park: I cannot give you absolute ratios because this does vary by age. All younger women tend to have denser breasts, and as women age, their breasts become less dense. It is part of the aging process.
Post-menopausal women tend not to have dense breasts, so it is difficult to have an absolute number.
Senator Enverga: Have we categorized those who have breast cancer?
Ms. Park: It is very difficult to categorize women as to who gets cancer. In addition to breast density, there are genetic factors which could be environmental or could be related to lifestyle. Many factors have to be calculated for breast cancer risk.
Nowadays, we are beginning to look from a genomic perspective at genomic risk factors that we can then follow through time, and these studies are just starting now. This is one of the studies we have just funded at CIHR. This again has been an international collaboration with multiple countries to identify these genomic risk factors, a little bit like heart disease that we have heard about for 20 years. One goal we should learn over a 10- or 15-year period is how that could impact our understanding of breast cancer and risk.
Senator Enverga: If there are a lot of factors to consider, could it be that it is not because of the density that it is happening?
Ms. Park: There are two components to be aware of from a research perspective on breast density. One is that we have heard it is more difficult to identify the breast cancer in dense breasts with screening technologies such as mammography. One challenge is that you just do not see it.
The other, from a research perspective, is that dense breast tissues have more cells that give rise to breast cancer cells; these are called ``epithelial cells,'' and because there are more of them, by chance, you will have a greater chance of having an alteration in one of these cells that will give rise to breast cancer. There is a strong association, but if you have dense breast tissue it does not mean you will develop breast cancer.
Senator Dyck: I was also going to ask the question that Senator Enverga brought up as to the incidence of dense breast tissue and whether it is high enough to create a problem that needs to be addressed critically. It sounds as though it is difficult to say whether the incidence of dense breast tissue is high because of other factors that might contribute to the detection or the development of cancer.
Ms. Park: Studies by Norman Boyd have identified that twins tend to have very similar breast densities. What that would say is that this is genetically associated. If twins have low breast density, they both have low breast density. If they have high breast density, they both have high breast density. Those types of studies would support that this is not something that is influenced by the environment or other cancer-causing conditions. This is something we are born with, and it is part of our own physiology.
Senator Dyck: You looked like you wanted to add something.
Dr. Stewart: From the licensing point of view, there are a number of standards we look at in approving mammography devices. Presently in Canada, there are no mammography devices labelled as being particularly sensitive for dense breast tissue. However, when the licence application comes in, they have to demonstrate that the clinical studies that were done to show that it is an effective tool for diagnosing breast cancer had a population of patients that were representative of the Canadian perspective. Some of the information in the literature around screening tools for breast cancer says that there is something called a BI-RADS scale, which goes from 1 to 4 and rates the density of breast tissue. Our understanding is that, in a population where screening is happening, 80 per cent of women fall into either a BI-RADS 2 or 3. The high-density breast tissue would be a 4, and breast tissue that was predominantly fat would be a 1. The files that come in and that are authorized are evaluated based on whether the studies evaluated a spectrum of women who represent the Canadian population. It is approved as a general screening tool but not licensed specifically for its effectiveness at picking up high-density breast tissue.
Senator Dyck: If a woman has had a mammogram and it looks as though she has dense breast tissue, what happens now? Does her physician tell her that that is the case and that she might need some additional follow-up? What would happen after the passage of this bill? How would the passage of this bill change what is happening currently?
Ms. Elmslie: Yes, in the case where a woman was found to have dense breast tissue, protocols are in place in the provinces and territories to ensure that the appropriate follow-up is done, depending on the discussion with the patient and the findings of the radiologist.
In terms of the importance of awareness raising and filling gaps in information, that helps women to understand what it means to have dense breast tissue but also what the gaps in information are. It is all about better-informed women being able to have a better-informed discussion about their overall breast health and about breast density and what it means for that woman as she considers her screening options.
Senator Dyck: As a practical example, then, would there be standard information or a way of getting that information to the patient that is not there now?
Ms. Elmslie: There could be. That could be part of what would be built on under the existing initiatives — giving more attention to providing information through either breast cancer screening programs or even looking at other sources of information and ways of getting information on this issue out to women that recognize that this is not about alarming women. It is about ensuring that they have information that empowers them to have a discussion. It could be a variety of different ways of using existing sources to get information out.
Senator Dyck: What about men? Men develop breast cancer too. Is there such a thing as dense breast tissue in men? I would think that, because of the different function, perhaps there would be more epithelial cells in men than in women.
Ms. Park: I have not seen any literature on that. To be honest, how men develop breast cancer is poorly understood compared to how women develop breast cancer.
Senator Seth: Thank you for your presentations. It is a very interesting topic and very important for women.
I know technique is very important in detecting breast cancer. Bill C-314 suggests awareness of screening in women with dense breast tissue and also correction of the gaps, which we have not been doing in the past. That is the follow- up. Then the patient goes for the breast screening, and, if the physician or radiologist finds that the patient has dense breast tissue but no cancer, will we have a follow-up, sending a letter to the patient and calling the patient and making them aware of the importance of dense breast tissue? Do we have this kind of procedure in practice?
Ms. Elmslie: The answer to that question resides within provincial and territorial jurisdiction around how they run their organized breast cancer screening programs. That is a question for a province or territory or the director of a breast cancer screening program.
The raising of awareness relates to the broader issue of empowering women, through existing federal initiatives, to better understand what dense breast tissue means in the context of screening and of their overall breast health so that women are informed and can have that conversation with their health care provider.
Senator Seth: It is not a routine practice, you mean?
The Chair: Senator, tomorrow we have Dr. Wilson from the B.C. centre, to whom I think your question will relate directly.
Senator Seth: Okay.
Senator Eggleton asked about the automated ultrasound imaging, which is in conjunction with digital or the usual mammography and is supposed to have given good results, from what I have read so far and from what I understand, especially in the younger patient group. Mammography is damaging, given the X-ray radiation and all of that.
Dr. Stewart, maybe you can answer, as a scientific person. Would it be just a single use of automated ultrasound imaging in young women to detect dense breast tissue for cancer?
Dr. Stewart: I do not think I am the right person to answer. The role of Health Canada is to approve devices to ensure that they are safe and efficacious for their use. Presently, the vast majority of ultrasound machines licensed are licensed for general use in hospitals for imaging different parts of the body. The decision of a physician or a screening centre to use it to screen for cancer would be outside the indication that Health Canada said it is useful for. As I mentioned, there is one ultrasound machine that has recently been approved with an indication of an adjunct to mammography. As for its actual role in evaluating breast disease and breast cancer, I think you would have to ask the screening programs. From Health Canada's perspective, the evidence has been put to us, as a regulator, to approve indications. We have not had it come forward as to that type of technology having that role in screening for breast cancer. If the evidence is there and a manufacturer would wish to bring it forward for that indication, we would evaluate it, but, to date, that has not come to our attention. I cannot support that because we have not seen the evidence that might indicate that it is a useful tool to screen women maybe at a younger age when they are worried about the lifelong exposure to radiation and the challenges of mammography, women under 50.
[Translation]
Senator Verner: I have a number of questions about various things. My first has to do with technology. The breast disease clinic at the Hôpital du Saint-Sacrement in Quebec City serves eastern Quebec. One of the doctors there told me that they intend to privately acquire a machine that could do a sort of radiograph on a section of tissue in the case of dense tissue. Are you familiar with the concept? They are talking about getting the device from the United States, California to be precise, if I am not mistaken. Are you familiar with this technology?
Mr. Stewart: It depends.
[English]
There is a CT-like technology. A standard mammography involves imaging the breast in two planes after it is compressed. A CT scan involves taking slices of tissue. There is a new technology called digital breast tomosynthesis, which is a 3-D mammogram. It is currently indicated under Health Canada licences as an adjunct to conventional 2-D mammography.
Its role in screening needs to be determined. Because it involves more images, it exposes the breast to more radiation, but it probably has some imaging advantages. However, its role in the broader screening of breast cancer I think still needs to be determined. There are some technologies authorized in Canada for an indication of adjunct.
[Translation]
Senator Verner: My next question has to do with other jurisdictions. I understand that, in the United States, some states have some kind of regulation that ensures that women are systematically informed whether they have dense breast tissue. If they do, when doctors get that information, they refer those women for a test that is different from the conventional mammogram, which is considered a waste of time and money, as it does not detect anything that might be concealed in woman with dense breast tissue. However, it seems clear that that is not the case here. There is no legislation or regulation to do this.
You have to respect the jurisdiction of the provinces and territories. Quebec is almost always alone, on the grounds that it is its jurisdiction. I do not want to get into government discussions. However, I am thinking about the women. I am a woman from Quebec, and I would like to know whether there is a way to get best practices and information to women, the various jurisdictions notwithstanding. In other words, I suppose the information and best practices can be given to medical bodies without going through the government. I am thinking of the Canadian Association of Physicians, among others. There must be groups or associations that dialogue with one another, regardless of provincial boundaries.
[English]
Ms. Elmslie: You are absolutely right, there are groups. Just coming back to the Canadian Breast Cancer Screening Initiative, that is precisely why that initiative is in place, so that the directors across the country, the directors of breast cancer screening programs, systematically come together to share best practices and bring up questions that they may be facing in one jurisdiction so that other jurisdictions can become involved in the conversation. That is why that group is so important in the country.
The Chair: They are coming tomorrow.
Ms. Elmslie: It seems you will hear more about that tomorrow.
It is really important because the jurisdiction for the delivery of breast cancer screening services, as you have said, is with provinces and territories. It is very important that these mechanisms for partnership exist. Through the Canadian Breast Cancer Screening Initiative, through the Canadian Partnership Against Cancer, which you also, I understand, will hear from tomorrow, you will get a really good sense of how information is coming together and best practices are being shared. In that way, the decisions taken on what to do in individual jurisdictions is based on the best available scientific evidence and also on what works in practice.
Senator Cordy: Just going back to Senator Eaton's comments about young women, or just women generally who have dense breast tissue, how does a woman find out whether or not she has dense breast tissue? If she does, her chances of it not being detected increase significantly. Does she find out at a doctor's appointment or the first time she would go for breast screening? How does she find out?
Ms. Park: That would be the first time she would go for a mammography screen and that is how she would find out.
Senator Cordy: I guess it depends on the doctor whether or not she had been told that the mammography may not work as well.
What percentage of women actually have regular breast screening, whether they have dense breast tissue or not? What is the percentage? Certainly that seems to be an indicator of early detection for breast cancer.
Ms. Elmslie: It actually does vary a bit across the country. Because of the work that the Canadian Breast Cancer Screening Initiative is doing, and the data that group collects, we have information on that. I just do not have it at my fingertips, but I can give it to you and ensure you have it. You may want to raise that question tomorrow when you speak to the chair of that initiative. Yes, that information does exist.
Senator Cordy: Thank you. That would be good, if I remember to ask tomorrow.
Ms. Elmslie: If you do not, I will remember to have it sent to you.
Senator Cordy: Thank you. In relation to new advances and studies, Dr. Park, in your comment you said that the studies by Dr. Chiarelli showed that screen film mammography and direct radiography performed better than computer radiography for women with dense breast tissue.
Ms. Park: Women with breast cancer in general.
Senator Cordy: It has nothing to do with the density?
Ms. Park: Density will be a component, because the population has a variety of breast density, but it was not specifically targeted to look at women with dense breasts.
Senator Cordy: It was overall.
Ms. Park: There are some studies ongoing by Dr. Boyd and Dr. Lilge that are directed to look specifically at dense breast tissue, but that study was general mammography in the province of Ontario.
Senator Cordy: Out of curiosity, does the new technology still require compression?
Ms. Park: I believe so.
Senator Cordy: You spoke, Dr. Stewart, about the role of Health Canada in terms of mammography and breast screening. Is your role strictly approval of the machinery?
Dr. Stewart: Basically our role lies in our mandate under the Food and Drugs Act and the Radiation Emitting Devices Act and ensuring that devices that are sold comply with those acts and their associated regulations. We evaluate them. The applications are brought in with a proposed indication and we look at the information provided in the file to look at the information around the safety and efficacy. We look to international standards, electrical and radiation standards, preclinical standards, as well as our own safety standards to ensure that the devices are in fact in the best interests of the patients, that they are able to do what they say they do and that they will perform consistently and will not put the patient or the users at undue risk.
Senator Cordy: Before the provinces can buy a breast screening device, it would have to pass Health Canada standards?
Dr. Stewart: Yes. Before a medical device can be imported and/or sold in Canada, it has to have a medical device licence. Once that is there, it would be up to purchasing bodies to decide what technology they would want to buy for the uses they are looking to use the machine for.
Senator Cordy: What about the role of the Public Health Agency and CIHR in terms of breast screening? What is your role? CIHR, I am assuming, is just to fund research.
Ms. Park: CIHR's mandate is not in breast screening, but we fund the research. This study we have been talking about by Dr. Chiarelli was funded by CIHR, as was Dr. Boyd's study. These new technologies to detect dense breasts are funded by CIHR, but it is primarily research.
Senator Cordy: Not doing, but funding the research?
Ms. Park: Yes.
Senator Cordy: And the Public Health Agency of Canada?
Ms. Elmslie: At the Public Health Agency, our role is working to ensure national coordination and to support those efforts. That is why we support the Canadian Breast Cancer Screening Initiative and the national committee, working in partnership with the Canadian Partnership Against Cancer. We are trying to bring together across the country those individuals who are working in breast cancer screening so they have the benefit of each other's experience and expertise.
We have also for a long time been housing the Canadian Breast Cancer Screening Database, which is a database that provincial and territorial jurisdictions provide information to, and that is the basis upon which those jurisdictions look at the performance of breast cancer screening programs.
Senator Cordy: Would you do the education programs, perhaps to bump the numbers up of women who get regular breast screening, or would that be Health Canada? I know you work closely together, but who would be responsible for that kind of initiative?
Ms. Elmslie: In terms of awareness raising for women, the Public Health Agency would work in collaboration with the provinces and territories and with other national organizations — for example, the Canadian Cancer Society and others — in raising awareness.
Dr. Stewart: It would be delinquent not to point out that we also monitor authorized medical devices in the post- market environment. We do have a problem-reporting surveillance system. We do monitor how devices, once marketed, perform. If there are safety or performance concerns, we will evaluate those on an ongoing basis. If there are studies that bring up new information around effectiveness of various tools, we will monitor. We continue monitoring whether the device and the information around the device still supports.
Senator Cordy: Are all the machines in hospital settings? I would assume so, but are they?
Dr. Stewart: Again, that is a provincial jurisdiction, but I believe that some of the breast screening programs are in the free-standing clinics.
Senator Cordy: Or clinics, yes; clinics or hospitals.
Ms. Elmslie: I was just going to add one thing. I should also have mentioned that another role of the Public Health Agency is cancer surveillance. Again in collaboration with our partners, we monitor trends in cancer across the country, including breast cancer. Each year, the agency, along with Statistics Canada and the Canadian Cancer Society, publishes a report on cancer in Canada. It is a comprehensive report that looks at the rates of various types of cancer. Are we seeing increases? Are we seeing decreases? That is the basis upon which we do monitor cancer over time.
Senator Martin: I think my colleagues have asked a lot of good questions, and many of my questions have been answered. I still want to understand the ``how'' of valuable information being transferred to the people who need to have it in order for this informed discussion to take place between the doctor and the woman.
In terms of this Canadian Breast Cancer Screening Initiative committee, which I think is important in bringing together the federal and territorial partners and stakeholders, who sets that agenda? If there is a need for education, for instance, how would that come to the table? From there on, how would certain action plans be implemented?
Ms. Elmslie: That is a great question. In terms of who sets the agenda for the committee, since its membership includes all provinces and territories, as well as stakeholders from other organizations, such as the Canadian Breast Cancer Network, for instance, it is a collective setting of the agenda. The committee decides collectively what the important issues are that the group should address together. If the need for greater education or filling gaps in information is brought forward to that committee, then they, as a group, would determine the best mechanisms for providing more information or filling knowledge gaps. They may, for instance, identify a research gap that is important in order to help us learn more about breast density and its impacts. That, then, through the work that Dr. Park does at CIHR, can be brought into the research conversation.
Because of the expertise of that committee and because its members are, shall I say, on the ground, working at delivering, through provincial and territorial health care systems, breast cancer screening programs, they are very well placed to know what are the information gaps we are facing and what are the education issues or awareness issues that need to be raised in the context of helping women understand, in this conversation, breast density, and how we can do a better job in getting that information out.
That committee, under the leadership of the Canadian Partnership Against Cancer, and being facilitated under that partnership, enables it to take advantage of other educational mechanisms to get the message out.
Senator Martin: I am curious to analyze and take a closer look at this.
My other question is with regard to some effective models that we have in this country. In B.C., for instance, at the Royal Columbian Hospital, there is a breast clinic. I do not know the actual name. I have seen it. It is a one-stop centre for women. I admit that I was supposed to have gone many times, and I did not. I have thought about the centre, because I can go and get everything done there.
These are shared best practices. Are such centres being established? Are they available in every province? Would you talk a bit about these centres that do exist and that are very effective?
Ms. Elmslie: I am not the best person to answer that question. Perhaps Ms. Park will have something to add. Again, that resides within the jurisdictions. As you have more conversations with people from provinces and territories, I think you will get the answer to your question.
Ms. Park: I can just add — and it is partly because I am myself a breast cancer researcher — that research has identified that having those centres that are one-stop shopping provides a more fulfilled and integrated environment that helps the understanding, both from the individual and from the clinicians. However, I cannot judge from a provincial basis.
Senator Martin: One last question. This is just some information that I have, and I do not have the details. I know we talked about how high breast density can be linked to an increased risk of breast cancer. However, a recent study indicates that the fatality rate may be higher among women with less dense breast tissue. I do not know whether you are aware of that study and whether any of you can comment on this discrepancy or conflicting information.
Ms. Park: I personally am not aware of that study. I would have to look at that publication. Quite a few studies have just been published recently, some saying that when breast cancer is detected in younger women, it is more advanced. I think I would have to look at the evidence for me to comment on that.
The Chair: We will get information on that latter question because there have been some recent studies on what we have suggested. Perhaps there is an age factor as well, and as you have already indicated, density changes with age and there are some significant factors there.
I would like to put a question to you, because this is an important issue with regard to advice that anyone receives for any particular disease, but in this case we are talking about breast cancer: In the area of dense breast tissue, are the numbers of false positives higher than in the general population?
Ms. Park: This is my opinion, but I would predict no. Because it is more difficult to detect cancer in dense breast tissue, you would have an increased number of false negatives.
The Chair: That is interesting. I will not put you on the spot; we will probably hear some evidence that indicates both false positives and false negatives may be higher in dense breast tissue for the difficulties that you have all indicated, but I thought you might have some specific figures on it, which is one of the issues with regard to advising women. One of the concerns that the medical practice has is the issue of aggressive treatment of false positives with regard to these issues, so we will look into that.
We know that in breast cancer, there are a number of different types. Indeed, the more we learn about the basis of breast cancer, it has reached the point now that it is even known that certain genetic bases of breast cancer will not respond to certain types of treatment and others will respond very well.
My question is this: In women with dense breast tissue, when they develop cancer, is the range of cancers they develop the same as the distribution in the general population, or do you know?
Ms. Park: I can comment on that. Again, it is linked to age. There is no strong evidence to show that there is a distinct sub-type of breast cancer that develops in women with denser breasts than non-dense breasts.
There is some evidence to show that in younger women, there is a higher prevalence of what is called triple-negative breast cancer. There is also some evidence to show in younger women that when breast cancers are detected, they are often at stage IV, so they appear to be a more aggressive disease. That is not directly linked to dense breasts, but younger women do have denser breasts. Therefore, it may be that the disease in younger women is somewhat different than the disease that progresses in an older woman in a post-menopausal situation.
The Chair: You touched briefly on the genetic issue wherein twins are likely to have the same breast structure development, and the studies that are just starting with regard to the genetic basis of breast cancer probably do not lead to the point where the question I was going to ask would be meaningful, so I will switch to Dr. Stewart. You made a statement that caught my attention, and that is that you deal with post-market surveillance of these instruments.
We have been looking into this issue in another area of medicine, and I was struck by your comment. How do you monitor the equipment that is designed to be used to detect breast cancer? What are you looking for? Are you looking for how well the equipment simply lasts and its character when you investigate it, or are you looking at how well it is doing in terms of detecting actual breast cancers?
Dr. Stewart: The post-market surveillance program for medical devices falls into the post-market directorate, which monitors drugs, biologics and medical devices. For the medical device program, they look at problem reports coming out from hospitals and physicians. We have a sentinel network of hospitals that commit to regularly reporting on issues, so if they are seeing issues with the functioning or performance of a medical device, including related to mammography, we would see that as an individual report or as a series of reports that might trigger an issue with a group of devices or a specific manufacturer's device.
The HECSB, the Healthy Environments and Consumer Safety Branch, also has an area that inspects the post- market performance of radiation-emitting devices. I cannot speak to their inspection program, but they do inspect to ensure that the device is supposed to emit this amount of radiation in this focused area and does not scatter. They would monitor that type of performance.
Regarding the question of efficacy, I think we would look to evidence that is coming out either from individual reports or from studies like the one that came out from Cancer Care Ontario looking at the relative sensitivity of various devices. It would not be something we would necessarily take action on with one report, but if there is building a mass of scientific evidence around the relative advantage of various tools, then we would certainly look at changing labelling or releasing a communication that would alert health practitioners to the evolution of our understanding of the role of the various devices.
The Chair: Thank you. That is very helpful.
Senator Seidman: If I might ask you about the U.S., over the last couple of years, increased attention has been paid to exactly this kind of raising-awareness program. In fact, there has been legislation in at least seven states regarding this, and the idea is exactly the kind of thing we are discussing here, where women should be notified after mammography that they have dense breasts. It was kind of awareness raising so they could discuss it with their physicians.
The American College of Radiology in April 2012 produced a position statement that raised a multitude of controversial issues related to this kind of awareness legislation. Among them, for example, were things such as the assessment of breast density is not reliably reproducible; we may convey a false sense of security about negative mammography results; the significance of breast density as a risk factor for breast cancer is highly controversial; and the inclusion of breast density information in a lay summary could result in demands for additional non- mammographic screening, which then leads to enormous numbers of false positives.
I know this is a lot of information, but the fact is that there is some degree of controversy around this, especially in the United States where they are already well into this kind of approach with awareness legislation. I would be interested to hear what you have to say about that.
Ms. Elmslie: Thank you very much. You raise a very important issue. It is precisely why we need to be looking at this issue within the context of the important institutions that exist in the country, to both promote and undertake research and also to come together as professional communities around the issue of breast density and breast cancer screening.
This is not about just holus-bolus providing information. It must be given in a context, and it must be given in a way that women can have a very balanced discussion about what this really means.
By using existing federal initiatives, such as the Canadian Breast Cancer Screening Initiative, which is a well- established initiative that is respected across the country, we will be able to, in a very responsible way, ensure that information is being provided in the context that it can be used appropriately.
It is an important issue that you have put on the table, and we need to be sensitive to it. As the discussions continue around filling gaps in information and providing women with the information they need, we need to think about the best settings to do so and the best sources of support around women as they receive that information. Thank you very much for raising that.
Senator Seidman: If I could ask, further to what you are saying, do you think it would be a good idea to use the same process here? You are saying that the setting is important, how women are supported, how the subject is broached and how it is discussed are important. How do you do that?
In the U.S., following mammography, women are sent a letter saying they have dense breasts, and this causes a whole series of complications for them. How do you see this happening? Ultimately, what would be your proposal for supporting, informing and raising awareness of women without enduring the kind of controversy that the U.S. has had with this kind of legislation?
Ms. Elmslie: Clearly, we can learn from the U.S. That is one point.
The other point I would make is that as we think about how to inform women through existing federal initiatives, then we will be bringing forward the advice from experts, those working in provincial and territorial screening programs who are on the ground knowing what kinds of issues women are facing and who have the experience to best advise on how to do this.
As we go down this road, we need to use those experts and design with them and with women's groups interested in this issue information-giving processes.
Senator Eggleton: Bill C-314, the Breast Density Awareness Bill, has passed the House of Commons and is presently sitting in the Senate. What we are doing here is discussing the subject matter of that bill, but I want to ask you specifically about the proposals under that bill — as I understand it, there are three — that would require the federal government to identify information gaps pertaining to breast density in the context of cancer screening, to identify approaches for improving the provision of information to women to address the challenges of detecting breast cancer and dense issue, to raise awareness about those challenges and to share information via the Canadian Breast Cancer Screening Initiative about identifying dense breast tissue during screening and whether there are follow-up measures to be taken.
Do I take it that all three of those proposals would come within the jurisdiction of the Public Health Agency of Canada? Would the agency be responsible for implementing those?
Ms. Elmslie: With partners. We would rely on partnership with the provincial and territorial agencies that are delivering breast cancer screening programs.
Senator Eggleton: You would be taking the lead role since this requires the federal government for that?
Ms. Elmslie: Exactly, yes.
Senator Eggleton: What is different from what you do now as compared to those three proposals?
Ms. Elmslie: The proposals put an emphasis on this particular aspect of the work we are doing in a way that has not been done before. It is the emphasis.
Senator Eggleton: You are doing it, but this adds emphasis. Okay.
The Chair: Thank you all very much. I think this has been a good start to our study, and you have helped us with the issues from your roles in dealing with this.
I think your last comments, Ms. Elmslie, put this into perspective in terms of relating it back to the act. I think we understood what you have said.
I want to thank all three of you on behalf of the committee for the clarity of your answers. With that, I declare the meeting adjourned.
(The committee adjourned.)