Dr. Paula Gordon: pleas for better breast health screening

GUEST POST BY DR. PAULA GORDON

Covid 19 has magnified the crisis in health care all across Canada. There aren’t enough family doctors, nurses and other health professionals. Long-term care is in shambles and much of this is caused by the predictable grey tsunami which has long been ignored by governments.

October is Breast Cancer Awareness Month and you should know that these factors are just some of the reasons why it’s been next to impossible to advocate for better breast care all across the country, not to mention delivering timely care for critical things like breast biopsies.

Breast cancer screening came to a halt at the beginning of the pandemic and only urgent cases had access to diagnostic exams. It took over a year to get caught up, during which time, any cancers that were present had more time to grow and spread before being diagnosed and treated.

Radiologist scrutinizing a mammogram. Photo: BC Cancer

All of these relatively recent challenges are layered over the long-existing ones, including the fact that most provinces still do not allow women to attend screening mammography until age 50, even though it is known that annual screening starting at 40 saves the most lives. BC is one of four jurisdictions where women can self-refer starting at 40, but only 25% of eligible women in their 40s attend. Even for women 50 plus, attendance is low; it’s never reached 60%. And it’s worse elsewhere in Canada.

My colleagues who work in provinces that don’t screen until age 50, regularly see young women with big cancers that have already spread by the time they are detected as feelable lumps. Recent Canadian research confirmed that in provinces where women aren’t eligible for screening until age 50, the proportion of advanced cancers at diagnosis is significantly higher for women aged 40 to 60, than in provinces that screen in the forties.

Women can no longer self-refer annually in BC unless they have a mother or sister with breast cancer. That may seem reasonable at first glance, but 85% of women who get breast cancer have no family history, so that means that the majority of future breast cancer patients would not
have the same opportunity for early detection. Some of us on the committee that reviewed the policy protested, but the rest of the ministry-appointed members overruled us. Political interference with science?

Mammograms aren’t perfect and can miss cancers in dense breast tissue. That’s why it’s so gratifying that women are now told their breast density in six provinces/territories, thanks to patient-led advocacy. Women need to know that if they have dense breasts, it’s even more important to do breast self-exams. Because if they find a new lump, they need to have it tested. They cannot assume that their recent normal mammogram means it can’t be cancer. And just as mammograms can find cancer too small to feel (in non-dense breasts), ultrasound can find many of the 50% of cancers missed on mammograms in women with dense breasts. But in BC, where screening ultrasound is covered by insurance, it’s not widely available because of the lack of both trained technologists and specialized radiologists.

What is at the root of these errors in Canada? A federally-funded organization called the Canadian Task Force on Preventive Health whose panels make screening guidelines on Breast, Prostate and Lung Cancer, Depression, etc. With an official title like that, you might assume that they would have experts on the panels, as was the case for Covid advisory groups. Even the government is under the incorrect impression that is the case with the Task Force. But the panels have deliberately excluded experts. Even when experts offer advice, the Task Force is under no obligation to use it. They claim that experts are biased, and motivated by greed. Can the Ministry correct that? No, they made the task force “arm’s length,” with no accountability!

Many of the medical specialty societies disapprove of the Task Force’s published guidelines, but they remain in force. And even though many provinces know that they are harmful, the guidelines are a convenient default for those that prefer to save money than lives. In BC, political,
academic and economic inputs prevent the implementation of better access to early detection: annual mammograms starting at 40 for all average-risk women and added ultrasound for all women with Category C and D densities.

Experience has shown that policymakers ignore experts. But elected representatives listen to voters. Experts from across Canada are working to improve the early detection of breast cancer for more women, but we need the public to get involved. Any progress to date has been thanks to women who spoke or wrote to their elected representatives at the provincial or federal levels.

You can find more details on how to advocate for yourself with your doctor or nurse practitioner, and see template letters to send your elected representatives here: https://densebreastscanada.ca/be-an-advocate/.

ABOUT THE AUTHOR:

Dr. Paula Gordon is a Clinical Professor in UBC’s Department of Radiology. Her research interests include breast ultrasound for diagnosis and supplemental screening of women with dense breasts. In 1995, her paper in the journal, Cancer, was the first to show that ultrasound could find cancers missed on mammograms in women with dense breasts. Her mission is for early diagnosis of breast cancers, to give women more options for less aggressive therapy, and to reduce breast cancer mortality.

Dr. Gordon has been the Chair of the Early Detection Committee of the Canadian Breast Cancer Foundation, BC/Yukon Division, Chair of the Academic Committee of the Screening Mammography Program of British Columbia, and Co-Chair of the Workforce Committee of the Provincial Breast Health Strategy. She has been a member of the Steering and Prevention Committees of the Provincial Breast Health Strategy, the Provincial Radiology Expert Committee, the Provincial Screening Policy Review Committee and the BC Breast Imaging Services Working Group.