HALIFAX, THURSDAY, APRIL 24, 2003
STANDING COMMITTEE ON COMMUNITY SERVICES
9:00 A.M.
CHAIRMAN
Ms. Mary Ann McGrath
MADAM CHAIRMAN: My name is Mary Ann McGrath, I am the Chairman of the Community Services Committee. I would like to welcome Professor Sharon Batt, who is with us this morning. Before we begin, I would like to ask the members of the committee to introduce themselves, please, for her benefit.
[The committee members introduced themselves.]
MADAM CHAIRMAN: Whenever you're ready, Professor.
PROF. SHARON BATT: I would like to thank you for inviting me. I really appreciate the opportunity to be here, and to present my ideas and hopefully engage and find out what your views are on some of the issues that I have been very involved with, and try to see how some of these ideas and issues can be translated into provincial policies and programs.
Just to say the title, Breast Cancer - Causation and Treatment, perhaps might lead you to expect something a little more medical than what I am going to present. I am not a physician, I am not even, in career terms, an academic. I have done most of my work in the community as a community activist and as a journalist. I have held posts at both Dalhousie and Mount Saint Vincent University in the last four years, which has been a wonderful opportunity, but my perspective is very much linked to my own experiences as a woman who has had breast cancer and as somebody who has worked very closely in community groups.
1
I will start by saying a little bit about the Elizabeth May Chair in Women's Health and the Environment, that's the post that I have at Dalhousie. I am currently in the second and final year of this appointment. This is a chair that was created in October 1998. It's housed at the Atlantic Centre of Excellence for Women's Health, which is at Dalhousie and has as its partner group the IWK Health Centre. The chair was set up to provide opportunities for leaders in health and the environment to come to Dalhousie for a period of one or two years to influence a new generation of researchers, advocates and community leaders.
It's very much a policy-oriented chair. It's quite unique and it combines the donor's interest in health and the environment. It was an anonymous donation of $1.6 million to the centre that created this chair. One of the conditions of donation, my understanding, is it was highly desired by the donor that Elizabeth May be the first recipient and holder of the chair, which she was. I am the second holder of the chair. There will be a third person, not next year but I believe the year after there will be another appointment. It's quite different from a typical professor's position in that the chair is expected to do research in health and the environment but very much policy-oriented and there's an advocacy component to the chair's mandate, as well as a teaching and mentoring aspect.
Part of the work that I do and what I brought to my position at the centre is a history of work in women's health activism. I started a breast cancer group in Montreal 10 years ago, Breast Cancer Action Montreal, which was set up as a group that was designed to give voice to the concerns of women with breast cancer about the disease and about policies affecting them. I've since become very involved with a number of coalitions that have the same perspective, a concern about women's health, a preventive perspective, a concern about the overuse of pharmaceuticals, and that's something that I will be talking about, an advocacy with respect to the environment as a clean environment, as a building block for disease prevention.
So, I work very closely with women and men from across the country who have this perspective, and most of that work is done through a group called Women and Health Protection. Women and Health Protection is a coalition that's very much allied with the Atlantic Centre of Excellence for Women's Health, which is one of four centres of Excellence for Women's Health across the country; these are centres that do policy-related women's health research. The whole program is funded by the Women's Health Program of Health Canada. The idea is to ensure that women's health issues are taken into account in federal policies particularly, so we do a lot of gender analysis work. You will see that reflected in the different issues I'm going to talk about.
I'm also involved with a similar group in the United States called Prevention First, which is made up of organizations like the Boston Women's Health Collective, known for the book Our Bodies, Ourselves; Breast Cancer Action which is a group in San Francisco; DES Action, which is a group very concerned about pharmaceutical issues; the National Women's Health Network, which is based in Washington, D.C. These are all advocacy
groups that have a similar perspective that women's health needs have not been adequately reflected in medical policies and in programs and research. We do a lot of very similar work in Prevention First, our concerns are very similar to the concerns of Women and Health Protection, in fact we have a strong link and do a lot of collaboration.
I'm going to highlight some of the key policy concerns that I've worked on with these organizations, and I will give you some examples of what I've done and the perspective. Please feel free to interrupt me if there's something that isn't clear or if you have questions or comments as I go along.
Breast cancer and the environment is an issue that I've been very engaged with over the years. I wrote a book called Patient No More: The Politics of Breast Cancer that was published in 1994. That was one of the early books that raised the point that breast cancer policies had been very much treatment-oriented and there had not been a lot of attention paid to prevention. So this has been very much part of the breast cancer movement's perspective, that we need to pay more attention to prevention and as I'm sure you're all aware, the rate of breast cancer is higher in Nova Scotia than in most other provinces and it's certainly something that I think needs to be looked at very carefully by policy makers everywhere, but certainly in Nova Scotia.
The precautionary principle is a basic policy principle that is fundamental to all of the work that I do. I've taken a real interest in the issue of the use of pills for prevention which is something I've been very concerned about. The most prominent example is hormone replacement therapy that was used for decades as a preventive, supposedly to prevent heart problems, bone loss and other concerns of women's aging which, as we found out last summer, was not the miracle pill that it was made out to be. Drug promotion, drug pricing, drug formularies, drug coverage plans are all issues that I've been concerned with. I'm sure a lot of you heard the item on the news this morning, the new report about the high spending on drugs, that Nova Scotia is spending more on drugs than other provinces. So that's something that I would like to discuss with you.
Public participation and policy is a theme that runs through all my work. When I started Breast Cancer Action Montreal, it was because I was really concerned that women with breast cancer weren't being heard at the policy level, but I've certainly become aware that engaging the public in policy decision making is not easy, it's not straightforward. There are a lot of kinks to work out, and that's something that the groups I'm involved with work on.
I haven't been putting up the overheads because I know you all have copies of the overhead. So is it easier this way? (Interruption) There are a couple with images that I may put up, but I think this is probably just as easy to go this way.
There are three projects that I'm working on as projects in progress which I won't talk about in detail, but I would be happy to discuss them if you want to ask questions about them. The reason I can't say too much about them is that I don't have final results for any of them, but I'm working on a project called Reframing breast health: a pilot study on young women's understandings of the meaning of breast health, and this is being done with Halifax women age 18 to 30.
Another project I'm working on is called Healthy Hospitals: ways of reducing disease-related environmental contamination, and this is being done in collaboration with the IWK. I don't know if any of you have heard of Health Care Without Harm, which is kind of a movement in the United States that has taken up the issue of hospital contamination of the environment. It's kind of ironic that hospitals which we look to to take care of the sick are actually one of the most heavily polluting institutions in society, so Health Care Without Harm - and there's a similar group in Canada - is trying to change this in various ways. Drugs in the water, is a project that I'm currently working on that is looking at a federal program called the Environmental Assessment Regulations which is being set up to address the problem of pharmaceutical drugs and other personally-used chemicals that are being found in our waterways and drinking water.
[9:15 a.m.]
The two groups I talked about, the two coalitions - Women and Health Protection, and Prevention First - have a number of common concerns that we work on. They're health advocacy coalitions and by coalitions I mean they're made up of individuals and groups that are community-based advocates in health, academics, citizens who are concerned about health issues and all of them are independent of industry. This is something we feel is very necessary for the work that we do. All the groups promote the precautionary principle as the basis of environment and health protection.
We promote the safe use of pharmaceutical drugs, the rational use of pharmaceutical drugs. We're very concerned about overuse and over promotion. We promote primary prevention as a fundamental approach to health protection. We're very much opposed to direct consumer advertising, which is legal in the United States; it's supposedly not legal in Canada although we've witnessed kind of an advertising creep that our group has been very involved in trying to turn around. We're trying to get the federal government to enforce the law that's in place and strengthen it. We promote accurate health information for the public and we have a focus on women's health.
You may wonder what's so different about women's health. Well, the work that I do grows very much out of the women's health movement, which I think could be dated to about 1970. A lot of the impetus for the women's health movement came from tragedies, two particular tragedies, the thalidomide tragedy and the DES tragedy, were both drugs that were given to women and women were assured they were safe and effective and, in fact, they were
not. So that in part stimulated women activists in the community in Canada and the United States to take a very critical look at the way drugs are promoted to women and the way they're used and to come up with healthier ways of preventing disease and coping with disease.
Environmental Links to Breast Cancer. I highlighted that as one of the issues that I've been working on for about 10 years. When I was diagnosed with breast cancer, it was quite a shock to me to realize that the rate of breast cancer was increasing steadily, had been increasing since the 1940s, most of the research and money spent on addressing the disease was treatment-oriented. This was kind of surprising when you consider that clearly breast cancer has a strong environmental component, and I use the word environment in its broad sense to include the physical environment, but also the social environment and other environmental aspects. Only 5 per cent to 10 per cent of breast cancers have a hereditary component. There are known risk factors such as late child bearing or not having children, early puberty, late menopause, family history, but these account for only 30 per cent to 40 per cent of the cases of breast cancer. So there's a lot that we don't know about what's causing the disease and it seemed imperative that more attention be brought to this and that political pressure was important in shifting the priorities.
One of the most potent predictors of breast cancer is where you live - the country or the region within a country. There have been migrant studies dating back to the 1950s that showed that breast cancer risks change when a woman moves from a region where the population incidence of breast cancer is high to a region where it's low and vice versa. It's quite region-specific and North America has one of the highest rates of breast cancer in the world; the Asian countries have much lower rates.
In Canada, Nova Scotia's breast cancer incidence rates are second only to Manitoba; I checked the latest statistics from the Cancer Society the other day and we're still right up there with the second highest rate. These incidence rates continue to rise, mortality rates are starting to show a slight decline, and Nova Scotia, as I'm sure you know, has the highest breast cancer mortality rate in Canada.
Another concern is that treatments are increasingly costly and yet the additional benefits that they're offering are quite modest. Still, most research and policies remain treatment-oriented. There are some environmental causes of breast cancer that are either known or suspected. I'm going to talk about three here - I've listed four: ionizing radiation, certain pharmaceuticals, environmental chemicals and alcohol consumption.
As I said, in all the work that I do the precautionary principle is fundamental - that's a background to the comments that I'll make about the causes of breast cancer. A clean environment is a human right; this is something I think that requires us to change our thinking somewhat. We need to make safety a prerequisite for introducing new technologies; we need to re-assess older technologies for safety; and we need to recognize that
environmental links to health are extremely hard to prove, so there's very often a long period of uncertainty as to whether a suspected carcinogen or disease agent is causing the disease or not. In the absence of proof, the approach that we need to take is the best available evidence. We have to realize that we're seldom going to have the perfect evidence that we would like to have to make decisions based on certainty.
The precautionary principle, which I'm sure you're familiar with is that if we're embarking on something new, we shouldn't go ahead unless we're reasonably convinced that it's safe. It's interesting I find that this is such an intuitively obvious principle to most members of the public, but it's been very hard to get it enacted in policy. The precautionary principle also carries the idea of the reverse onus - that it shouldn't be up to the public to prove that something is dangerous, it should be up to the perpetrator of a technology or a substance to show that it's safe.
Another idea that has come out as the precautionary principle has developed and become more and more integrated into policies is the idea of alternatives assessment. This is an idea that's been developed particularly by a woman in the States named Mary O'Brien. She says that instead of risk assessment, which is the standard approach that we've taken to looking at risks in the environment, we should be using something that she calls alternatives assessment; this means we should choose the least harmful way of solving problems. This applies in all kinds of contexts, and an interesting one is dry cleaning.
I get my clothes cleaned at a place on Spring Garden Road that does not use toxic chemicals. I don't think most people even know that this exists. It doesn't cost any more than regular dry cleaning but I've talked to the owner of the dry cleaning agency and they say that the people who mainly use the service are people who have allergies but why don't we require people to have their dry cleaning done in a non-toxic way, given that that's possible.
We should require regular evaluations of alternatives to toxic chemicals and this alternative method of dry cleaning, for example, is something that's relatively recent. When an industry finds that the toxicity of the chemicals they are using is not zero, there should be a finding of necessity required that this process that they are using is a necessary one. We should, at the same time, make active efforts to develop non-toxic alternatives that are affordable and this would mean investing money in research into particular kinds of alternatives where we see that there's a problem. We should provide systems of support for industries that have to make this kind of transition and give high priority to processes that generate the most toxic chemicals. Dioxin is an example. We know that the organochlorine chemicals have a lot of negative health effects.
Looking at some specific causes of breast cancer, ionizing radiation is a known cause of breast cancer and other cancers. Some of you may have read the workshop proceedings in the binder from the National Action Plan on Breast Cancer Etiology Working Group. This was a group, a public-private partnership set up by President Clinton that had a lot of
workshops and research initiatives that were designed to kind of kick-start new approaches to looking at breast cancer and I was part of this etiology working group. In all the years I've been working in breast cancer issues and policy, this is the only event that I've ever gone to where the question of radiation was really taken seriously and looked at in a very detailed way. They had the top scientists in the world working in radiation and cancer attending at the same time that advocates were invited to come and give their perspective.
It's very interesting that the first study that was ever done showing that breast cancer was caused by radiation was done by a Nova Scotia physician who looked at women who had been treated with fluoroscopy for tuberculosis and discovered that they had a higher rate of breast cancer and this was subsequently proven in other studies. It turns out the breast is highly radio-sensitive and all the evidence from different areas of research, animal studies, women's medical exposure, atomic bomb survivors in Japan, have shown that ionizing radiation causes breast cancer.
Most of the man-made exposure, that is the exposure we can prevent, comes from medical uses and it's been shown that both a lifetime dose and the timing of exposure are important. Women who were exposed to breast cancer in their early years, up to age 20, are the most risk, if they are exposed to radiation on their breasts. This is a key point that has come out in the research on breast cancer and environmental exposure. The timing is extremely important. There are sort of windows of vulnerability in breast development that
make it critical to look at not just whether one is being exposed to a chemical or to radiation but when the exposure takes place in the development of the breast; 1.4 per cent of the population is genetically radio-sensitive so these are people who are most likely to suffer cancer if they are exposed to radiation even in small amounts.
[9:30 a.m.]
There are numerous medical procedures that increase breast cancer risks and they tend to be the ones, as you would expect, that expose the breast area. One of the things that came out of this workshop is that experts estimate that a threefold reduction of dose from most diagnostic radiology is technologically feasible and one of the areas where we've seen the most dramatic reduction in radiation dose is in mammography. That came about because the early mammography was shown to be at dangerously high doses so there was pressure on public health officials and on industry to do something if they were going to continue using this technology. In fact, it was quite a hoo-ha that ultimately led to dramatically reduced dosages in mammography. Most radiological procedures haven't been subjected to this kind of scrutiny.
So reducing the quantity and improving the quality of medical X-rays and other radiological procedures is one step that can be taken in the fight against breast cancer. I find it frustrating that whenever I talk to people working, you know physicians and researchers, they cannot get excited about the whole issue of radiation exposure. I find it's kind of a taboo
topic and I think maybe people are afraid that people will be frightened off having procedures that they need to have. It's a very touchy issue in the medical community to talk about medically caused disease and there are liability issues. So certainly it's a difficult topic but it seems tragic that when we know that there are ways that we could reduce risks that this is not being acted on and not even being talked about.
I'll talk about the hormone replacement issue as an example of a drug that has been widely prescribed as a preventive which turned out not to be a wise intervention. This isn't the only drug that I've been involved in looking at as what I think of as a wrong-headed policy. The drug tamoxifen is an effective drug used in treating breast cancer but it has also been promoted particularly in the United States as a preventive drug for breast cancer and I think that's absolutely the wrong way to go if we are going to prevent a disease because we know that tamoxifen is carcinogenic to the endometrium and causes blood clots. So there is sort of a disease substitution that takes place in the name of preventing the disease.
HRT was heavily promoted to women by the industry and by physicians for 25 years without ever having a clinical trial to demonstrate that it was effective in preventing the diseases of aging in women. The first trial that was ever done was the one that was stopped, or a part of it was stopped last July when it was discovered that although it did have some benefits, the harms that it had exceeded the benefits. One particular benefit that had been claimed, the benefit for heart health, was completely wrong. I found it interesting when these results were announced that there was so much astonishment expressed. It was a huge news story all over the world.
Women in the women's health movement have been saying, since HRT was introduced, that this was a drug that had not been demonstrated to be safe and effective. It is certainly effective in alleviating hot flashes, there's no question about that, but the use of the drug as a long-term preventive for diseases of aging had never been demonstrated, and was based, really, on the idea that menopause is a disease and that women who have gone through menopause are deficient of their appropriate level of hormone, which turns out to be wrong but from the beginning it was really based on a misogynist notion of women as being flawed as they get older and that this had to be corrected by a medical intervention.
This is something the women's health movement has been fighting for decades. To have people act so surprised that it turned out that this was an unwise intervention was very interesting. I have an article that appeared in the Canadian Medical Association Journal in February that's in the binder if you want to read about that in more detail, the reaction of the women's health movement to this announcement and the surprise that it provoked.
Just to look specifically at hormone replacement therapy and breast cancer, people who work in breast cancer have suspected for years that hormone replacement therapy causes breast cancer because there's a known link between estrogen and breast cancer. When I had breast cancer - breast cancer treatments often throw a woman into menopause and that
happened to me, I had extremely severe hot flashes, but there's no way that a cancer specialist would give a woman hormones when she had been diagnosed with breast cancer. Again, 14 years ago I was told you can't take hormones when you have breast cancer because it's a cause of breast cancer or a suspected cause. This isn't something that's been secret.
What they found in this randomized controlled trial, which was done to the highest standards of research, was that the risk of breast cancer increased after four years of use. After 5.2 years, which is when they stopped the study, there was a 26 per cent increase in the risk of breast cancer when you compared the women who had taken the drug to the women who hadn't. That worked out, in absolute terms, to eight more cancers every year for every 10,000 women. There was a higher risk for women who had previously taken HRT.
In this one, I think I will put up the overhead. I was at a scientific workshop in Washington in the Fall where the principal investigators of this study did a detailed presentation of other findings. One of the things that was very interesting was that they took a holistic measure, they weren't looking just at one disease at a time. What they did, when they were trying to assess whether the drug was . . .
MADAM CHAIRMAN: Professor, unfortunately, when you stand up, the tape doesn't pick you up.
MS. BATT: Okay. If you look at the first four health problems, breast cancer, heart attack, stroke and blood clots, in each case the drug caused an excess of the problems. For hip fracture and colorectal cancer, the drug was helpful. So it's not that the drug wasn't doing any good at all, but what they found after slightly over five years was that the harm was far outweighing the benefit, and it was at that point that they stopped the study.
One of the responses that has been interesting from people who had been proponents of HRT, and that would include members of the pharmaceutical industry and OB/GYNs, who are the physicians who are the most involved in prescribing hormone replacement therapy, they have pointed out quite accurately that the absolute numbers of excess cancers - and you could say the same for some of these other problems - are not huge. I mean, it's eight extra cases per 10,000 women per year and eight extra cancers per 10,000 women per year is not a huge risk if you're looking at it from the perspective of an individual woman. However, if you look at it from a population point of view - and this was really the way the study was meant to be looked at - that's a huge increase in risk on a population basis and the researchers had worked this out.
Using the numbers of women in the States who were taking HRT at the time that the study ended, there were about 6 million American women taking HRT. So that would be nearly 6,000 more cases of breast cancer every year in the United States and if all 6 million of these women took the drug for five years, that would be about 30,000 excess cases. So when you look at that from a population basis and you consider all of the expense, the trauma
and so on of treating that many extra cases of breast cancer, there's a huge public health issue there. This was a very harmful drug to be giving to so many women for so long, and the fact that any one woman's individual risk of one of these harmful events was not that great is really not the point.
The researchers said - and I agree with them - that given their results there's no way that any woman should be prescribed HRT to prevent the long-term effects of aging, it just doesn't make sense; for short-term use to alleviate hot flashes, it's something to consider because it is effective, but women should first look at alternative, less-invasive methods of trying to alleviate hot flashes - and vaginal dryness is the other problem that hormone replacement is known to be beneficial for. But even in the first year of taking the drug the heart problems were noticeable, and for breast cancer it wasn't until the fourth year, but the heart problems showed up in the first year.
[9:45 a.m.]
MRS. MURIEL BAILLIE: Excuse me, what do you call a short term?
MS. BATT: Short-term would be anywhere from six months to three or four years. I mean that's the length of time that women tend to have hot flashes and then there are issues about how you stop taking it if you're taking it. I mean it's recommended that you go off gradually so that you don't - if you go off suddenly, then you will have hot flashes again and possibly very severe. So there's a lot that needs to be understood in terms of women going off. Apparently when the study results came out, a lot of women just went off cold turkey and then, you know, were miserable and went back on again.
I did just a very quick estimate trying to figure out what the effect might be in Nova Scotia if you adjust to the population base here and I mean, this is very rough, I don't make any pretense of it being scientific, but if you take a population base in the United States of approximately 300 million and a population base in Nova Scotia of about 1 million, you would divide by 300 to get comparable figures for Nova Scotia if you assumed the same level of use and that would come out to about 20 excess cases a year. Now, is that a lot? Well, there's I think over 600 cases a year - 690 cases a year is the current level in Nova Scotia. So 20 extra cases, again it's not huge, but it's certainly, if you look at it from the point of view of cost of treating those people, the personal trauma to those women and their families, it's worth cutting back on 20 cases a year if we know that we can do it.
MADAM CHAIRMAN: Twenty cases per year for breast cancer is one thing and I know that we're talking about breast cancer, but there is also a high incidence of heart disease in Nova Scotia.
MS. BATT: Exactly.
MADAM CHAIRMAN: And the increases in rates of stroke and heart attack are high also.
MS. BATT: Yes.
MADAM CHAIRMAN: So it wouldn't just be the 20 cases of breast cancer, it would be . . .
MS. BATT: It would be the whole bundle of . . .
MADAM CHAIRMAN: It would be the similar number of . . .
MS. BATT: Yes. Exactly. I mean I think there should be active education programs to encourage women to get off hormone replacement therapy if they're taking it on a long-term basis and to tell them how to do it in a way that would allow them to stay off.
MRS. BAILLIE: But then again, when you go to your physician and your gynecologist and you put your trust in that person, you know, how do you argue that - I know that they're often given a choice, I was given a choice whether to go on them or not, but even I can't, I mean, medically I can't make that decision.
MS. BATT: Well, see, this is where I think there's a really serious problem with the medical profession getting so much of their information from the drug companies. I mean we now have a system in place where the drug companies are knocking at the physician's door on a daily basis. They're spending millions of dollars in all aspects of medical education from conferences to free trips and articles in journals that are ghost-written, I mean there's just a chamber of horrors of techniques that are used to convince doctors to prescribe drugs.
My sense is that doctors, since this study, have been much more cautious. I mean they're conscious of, you know, again there are liability issues now that there is actual evidence that this drug is harmful, but certainly before the study came out doctors were definitely telling women that they should take it. I don't know now, certainly I've talked to women who said that their doctor's attitude has totally changed after this study. I've heard doctors interviewed on the radio who say, well, it's the woman's choice. Well, I think that's a cop-out. The doctors are in the position where they're supposed to be giving expert advice and I think they've just been caught in a very embarrassing position where they actually had clinical guidelines saying that women should take this drug for health benefits when the evidence wasn't there.
I think there's an immediate issue of how do we deal with this drug, but there's also a much larger issue of how do we get the drug companies out of medical education and promote the rational use of drugs so that they're being taken when needed, but not overused.
MR. BARRY BARNET: Just on that issue, you've touched on something that I noticed as a patient at a family practice and I found it interesting. I was sitting there waiting to go into the doctor's office and all these people with large briefcases and suits were sitting around me. They didn't look ill at all. I found myself a little bit uncomfortable and I discovered afterwards that they were drug salespeople - people who were hired by specific drug companies to go promote their products to the doctors. Subsequent to that, after getting involved in provincial politics, I realized that they don't just stop at the family doctors. In fact, personally, I've had calls and had drug salespeople show up in my office.
MS. BATT: Really? As a politician.
MR. BARNET: Yes, to talk specifically about drugs and the benefits of those drugs. One of the things that an individual salesperson said to me is it's sort of a double-edged sword because I raised this issue to them too about the fact that they're out promoting this and how do the family doctors know that it is the most appropriate treatment. What he said to me is it's a double-edged sword. If we're not out there promoting it, how do people find out about it?
Am I reading you correctly? Is there a greater role for government to do the job of drug promotion and acceptability rather than leave it up to the pharmaceutical companies to push their wares and if that were the case, if it were more of an independent approach to drug promotion, I guess the viability of drugs, that the patients would be then - I guess - in a safer situation.
MS. BATT: Better served, for sure. Absolutely. The drug information should come from independent sources.
MR. BARNET: How do we, as an entity that lives just north of the great power, with all their media and CNN and everything, filter out this non-stop - I guess for an example, Viagra - commercials that seem to proliferate everything from auto racing to you name it. It's just a non-stop bombardment of drug promotion. How do we prevent that, this cross-border drug promotion by osmosis, essentially?
MS. BATT: I don't think we can prevent it. The groups that I've been working with - I might hand around two brochures of these two groups that I've talked about - because direct consumer advertising has been a really big issue that we've worked on. This is both the Canadian groups and the American groups. I think we're making a difference and it's become a big issue in the United States because they're worried about drug costs too and physicians are worried about inappropriate prescribing. It's become apparent that this was a change in the law that took place in the United States in 1997 to loosen the rules on direct consumer advertising. It was a mistake and they're really paying for it in the States just as we're paying for it here with the bleed in direct consumer advertising.
Our group has actually proposed that the government could be blocking the ads that come over the airwaves. I mean they're not even enforcing the laws that we have in Canada to stop those ads on TV. So I'm not optimistic that they're going to take a step like that, and the drug industry is mounting a huge lobby to keep direct consumer advertising in the States and to introduce it in Canada and to have it legalized. It's a huge political issue right now, and I hope it's one we can win because I think we just have to. Certainly the Romanow report has taken the position against direct consumer advertising in Canada and there are groups in the States that are lobbying really hard against it. The United States and New Zealand are the only countries in the industrialized world that permit direct consumer advertising of pharmaceuticals.
MADAM CHAIRMAN: Should we try to finish the presentation.
MS. BATT: Sure, yes.
MADAM CHAIRMAN: I mean the whole thing is fascinating, but when I flip ahead, I see some more fascinating stuff.
MS. BATT: Just a few points to wind up on HRT. One of the criticisms that has been made by drug companies and physicians who were promoting HRT was that the formulation that was tested by the Women's Health Initiative was one particular formulation, the Wyeth-Ayerst's Prempro, and it's true, they chose that particular formulation because it was the most widely prescribed in the United States. It's not actually the most widely prescribed one in Canada, but there's an equivalent that's prescribed here.
MADAM CHAIRMAN: Which one was it?
MS. BATT: Prempro in Canada is called PremPLUS and it's a Wyeth-Ayerst's drug. The point made by the researchers of the Women's Health Perspective is that you can't assume that other formulations are any safer without clinical data, and here this is the precautionary principle at work. There's no reason to think that other formulations wouldn't have the same effect. I mean there might be some slight difference with dose level and so on in the numbers, but estrogen is estrogen. It's not as though the other drug companies are using something different, and it's also the case that it's very unlikely that there will be other clinical trials testing other formulations. It's partly because of the cost. A prevention study is enormously expensive. You need a lot of people, you need to follow them for a long time, and also the risk to participants, it just would not be ethical knowing what we know from the Women's Health Initiative to do another study with another formulation. So really the issue is a dead issue. We have the answer, as good an answer as we're ever going to get.
Well, this also could be applied to drugs as well as to - I framed it in terms of the chemicals in the environment, but barriers to linking exposures of environmental chemicals to breast cancer, it has been very difficult. In the last 10 years there has actually been a fair
amount of research looking at environmental chemicals and breast cancer. It has been very difficult to prove any kind of link. There have been supportive studies and there have been contradictory studies. There's a very good analysis in a book called When Smoke Ran Like Water, that just came out recently by a woman named Devra Davis, Ph.D., an epidemiologist in the States. She says that she doesn't think in our lifetimes that we're going to get an absolutely clear answer to this question of environmental chemicals and breast cancer, and she analyzes the reasons as follows: she says breast cancer has a long latency, it takes 20 to 30 years for the drug to go from the initial precipitating cause to the actual diagnosis.
[10:00 a.m.]
There are these critical windows, these times of sensitivity in exposure where the exposure is more likely to be damaging; for example, if it's an adolescent girl whose breasts are just developing. Some chemicals don't leave any trace in the body, and you have a mix of chemicals that we're all exposed to and questionnaires, which are the standard epidemiological tool, just simply can't be expected to identify exposures that have taken place 20 or 30 years ago.
Breast cancer is also a common disease and it's multi-causal so it's clearly not like smoking where you can say cigarettes are bad, get rid of cigarettes and we will essentially have solved most of the problem. You have drugs that are having an impact, radiation, chemicals possibly, plus these so-called lifestyle causes, so any one cause is having a relatively small effect and when you have a common disease that is multi-causal you get some clusters that occur by chance and then others that are related to the chemical and it is very hard to tease those out using epidemiological methods.
Over the course of a woman's life you would have interactions with genes and environmental causes, and you would have some environmental effects that were reducing your risk and others that are increasing your risk, and to tease all of that out is just extremely difficult. So this is where the emphasis on the precautionary principle again is that we should be looking for highly suspicious environmental causes and trying to reduce them without expecting to have absolute evidence or proof.
Just a few words about lifestyle and environment. They are often talked about as if they are two very different things. There's an awful lot of emphasis, and I find this in breast cancer prevention programs, on the lifestyle issues and much less on environment, and you can't really separate the two. I've just given a few examples. If you look at smoking, which is often referred to as a lifestyle disease, we know that tobacco companies have added chemicals to the product to make them more addictive, and we know that they deliberately target young people. So can we really say that people are making a choice when there are these kinds of tactics being used? In the same way, HRT, is it really a choice, when drug companies have been giving misleading information and women have been making a choice but not making it on the basis of valid information?
Early child-bearing is a very interesting factor in breast cancer, and there's been a lot of work trying to figure out why early child-bearing seems to have some protective effect. One of the most compelling analyses is there seems to be something in the way the breast development isn't fully complete until a woman has actually gone through a full-term pregnancy, and once a woman has had a full-term pregnancy her breasts are less susceptible to carcinogens. This has been shown in animals, so there's an interaction there. The reason, then, that having a child early is that that narrows the window in which you are highly vulnerable to carcinogens, whereas if you have a child later in life, or don't have a child, your breasts remain more vulnerable up until the time you have a child; so there is this interaction.
If you look at why a lot of women today postpone child-bearing, it's because of economic issues - they want to get their careers started, they want to go to school. Those are choices that we could effect with public policies that would make it easier for women who wanted to have children in their 20s, say, do it. Those are subject to public policies, it's not entirely a question of choice.
One of the drugs - getting back to drugs and drug issues - that really caught my attention was the drug Herceptin for breast cancer. I'm sure most of you know something about Herceptin, it's a very costly drug. Certainly, in terms of breast cancer drugs it was just off the chart compared to what other drugs were costing at the time it was introduced in Canada; it was in August 1999. It's a front-runner in what I see as a wave of very costly last-chance therapies. It's given to women who have advanced breast cancer and it has been shown to extend life for some women, in that the median extension is 5.1 months. So, it's not a cure, it's not even extending life for years, it's extending life at the end point of the woman's life for a number of months, if she's one of the lucky ones.
When Herceptin came on the market it was heavily promoted in the States, as they're allowed, and this is an ad that appears in this magazine out of New York called, MAMM, which is directed at women who have cancer. Each of the ads had a best-case scenario example of a woman testifying of how successful she had been on Herceptin. This was a woman who was still alive three years after taking the drug, so that's a fairly unusual case. The promotion has exaggerated the benefits, downplayed the risks and one of the things I became aware of - as somebody who is very involved in patient groups - is that the manufacturer very astutely partnered with patient groups to gain fast-track approval for the drug, and to promote it in the patient community.
So I think Herceptin is a case example of the kind of drug that is coming on the market now that just cries out for a review of drug pricing policies, a rationing of these costly, end-of-life therapies. I know that's a very touchy topic; people don't want to deny anything to someone who is dying. Maybe if this drug wasn't so expensive, I would say, I could agree with that but it seems to me it's a policy or a tactic of extortion on the part of the drug companies to be charging so much for a drug that really, if you can step out of the patient's role, the cost benefit is just not there. This emphasizes the need for controls on
promotion such as direct consumer advertising and promotion to physicians. It also demands an examination of the role of patient groups and how they're being used in these partnerships with drug companies.
Just two more slides on the drug issue - one on the drug issue and one on the question of patient groups. I have mentioned the Romanow Report and they had a chapter that a lot of you may be familiar with on prescription drugs. The Working Group on Women and Health Protection did an analysis of that chapter, which I've summarized very briefly here. It's in the packet that you've been given, it has a more detailed analysis. Our response to this chapter was we were very impressed by the report's commitment to public health care. We very much support that. We had cautious praise for the proposal of a national drug agency. We felt it really had potential. We had some concerns about accountability. The idea is to have a national drug agency that's at arm's-length from government.
Our concern was that there needs to be some accountability. If you have a government department, there is an accountability through the politicians. If you remove it and make it an arm's-length agency, you have to build in some other form of accountability. We believe such an agency must be independent of industry. International collaborations which are recommended in the Romanow report for this hypothetical industry do run the risk of being industry-driven because other agencies that deal with drugs in other countries are very much in collaboration with industry.
The structure should give opportunities for true public input in decision making, and this has been a real bone of contention that Women and Health Protection has had with the Health Protection Branch that makes decisions on drugs in the federal government, that there's so much secrecy and there is no real way that the public can make presentations on issues of concern to them.
We like the idea of a national formulary. We felt that this was a way of increasing the safety and effectiveness of approved medications and ensuring equitable access. We felt that equalization payments would be needed for poorer provinces. In terms of Nova Scotia, I think this would be an issue, and our group would be very much behind that concept. We felt that the catastrophic drug transfer plan that was proposed was lacking, particularly from a woman's perspective, and this would also apply to other groups that are disadvantaged in various ways. You're not going to have equitable access under the plan laid out, it needs to be modified.
Women are less likely to have supplemental health insurance. Women live longer and use more prescription drugs. They earn less. The threshold of $1,500 proposed would discriminate against women. We felt the designation of catastrophic drug coverage was too narrow. For example, it doesn't cover birth control, which is very often a woman's responsibility or ends up being on her tab. We endorse the idea of mandating the agency to
negotiate and monitor drug prices, a national agency could be very effective in this, more so than individual provinces trying to do it.
We endorse the proposal that the agency would address the evergreening of drug patent protection. There's a very current example in women's health of this evergreening process, where the drug companies basically repackage a drug so that they can extend their patent beyond the 20-year limit. The drug Serafem, which is really just Prozac repackaged for premenstrual syndrome and given another name, is taken less frequently, so it's supposedly a new drug. We endorse the stance that the Romanow report takes against direct consumer advertising.
[10:15 a.m.]
I think I will skip this last one. This is from Prevention First, the coalition I work with in the States. We made a representation a couple of years ago to the FDA. The FDA does have a system where members of the public, or public interest groups, can make representations on drug issues. We feel it needs to be tightened up a lot, particularly because there are a lot of groups that are highly funded by industry that are coming in under the guise of being public interest groups and they're really promoting industry interests rather than public interests. So that's my presentation.
I have some examples of a project that I did a couple years ago at the Mount with the Women and Health Protection. It was something I did with the Art Gallery to raise awareness of the issue of direct consumer advertising and it was particularly a promotion of some women's drugs. There's a pill called Diane that you may have heard of that's actually supposed to be prescribed only for severe acne, but it's also prescribed as a birth control drug and had a particularly obnoxious direct consumer advertising campaign which our organization - this was in the washrooms at Dal, an ad, and this was in a bus shelter. I mean we just felt this ad campaign was so awful, but we managed to actually raise a lot of awareness about it with our campaign, and this project at the Art Gallery got all kinds of press coverage. I can give you copies of some of the press coverage. We've got it here if you're interested.
So that's more of the advocacy work that I do - raising public awareness of issues and trying to get the public engaged in these issues that sometimes the implications aren't necessarily immediate on this.
MADAM CHAIRMAN: Maureen.
MS. MAUREEN MACDONALD: Where do I start? I want to thank you for coming and I think we're so fortunate to have someone of your calibre in the province doing this research, it's great. There are a number of things that I would like to follow up on and ask you about. You've touched on so many themes. The whole theme of public health, and
especially now with SARS in the news in Ontario I think has really made us understand the importance of public health infrastructure and public health infrastructure has gotten a very low priority probably in the last 10 years and, if anything, our resources have somewhat eroded in that area. We don't have the numbers of public health nurses and inspectors have been split up into all kinds of different departments. They're no longer under the Department of Health and even our Public Health Act in Nova Scotia is quite antiquated, I guess it hasn't been updated for a number of years.
So I guess one of the things I'm quite interested in is, you know, whether or not you've looked at, or your groups are looking at, public health infrastructure as a way to respond. I have sort of this idea that one of our greatest hopes in terms of taking on the insidious nature of the pharmaceutical industry is an educated and informed public, but that's where I think you have to have this public health infrastructure that's very proactive and I'm concerned that we don't have that. So that's one thing.
The other thing that I want to ask you about is with respect to the pharmaceutical industry, you know, I think they've become very, very sophisticated in that they're increasingly using advocacy groups to front their information. We've seen a number of programs on CBC and public television that would indicate that.
You know Barry's experience, I've had the experience of being lobbied once directly by a pharmaceutical company when I was first elected in the minority government. But my perception is that's shifted a bit now and the lobbying is being done more by groups of individuals that have particular health care issues and I'm never sure when those groups have funding from the pharmaceutical industry to promote their issues and to ask for support for particular drugs or treatments. Certainly these companies now have set up Web sites, they have magazines, they're doing that kind of stuff. How can we know who is being fronted by whom? Is there any work being done around that to help sort that out? Those are two questions.
I guess the last one is whether or not groups like yours get access to public support from federal or provincial governments. There is an opportunity to have a voice that's not funded by the industry and it may allow for more independence of thought analysis and those kinds of things. Those are three issues I'll throw out.
MS. BATT: I like those questions. I agree that the public health infrastructure seems to have been eroded a lot. I don't know a lot of details about things like the Public Health Act and specifically the infrastructure problems. I think it's something that happened when the cutbacks started in the 1980s and through the 1990s, because public health is basically invisible when it's doing its job well and it doesn't have the same kind of profile and oomph that treatment has when you have these individual faces of people who are sick.
Maybe this is going to be one positive outcome of the SARS outbreak. Certainly I think Walkerton also raised awareness of the problems of a poorly funded public health system. I think it's always going to need to be promoted, it's always going to need advocates, and I think we have to keep working on educating the public as to its importance and keep lobbying internally for government support.
I think another thing that I think is unfortunate with public health is that it's very long-term and it's very hard for governments to think in the long-term. You don't usually see the payoffs right away. I agree that's a real problem but maybe this is a moment where we have the opportunity to really promote public health.
I agree that the pharmaceutical industry has become very sophisticated in working with patient groups. When I finish my chair, which ends in June, I'm planning to do a Ph.D. at Dal and this is the issue that I want to look at. There have been media articles and TV shows touching on it, it has sort of come to the fore just in the last couple of years. The groups that are taking the money, they claim that they're doing important educational work. They frame it as educational work. I think when you look carefully at the agendas they have that there's a group that promotes direct consumer advertising. In the binder here there's an article by a woman named Durhane Wong-Reiger who's promoting direct consumer advertising and it's a counter to an article that I wrote opposing direct consumer advertising. She works with an anemia organization that's heavily funded by the pharmaceutical industry.
So there are these groups that people who work in the area are aware of, but you wouldn't know, typically, by looking at their materials. Their names are chosen to sound like they are grassroots organizations. The Cancer Advocacy Coalition of Canada is another one. It has a slick magazine that's actually called the Grassroots Action for Cancer Care.
I think part of the problem is that it is very hard for groups who are promoting the public interest agenda to raise money. The advocacy group that I started in Montreal, because we weren't oriented to doing support - the federal and provincial governments to some extent have been quite willing to support groups that do support, service work, and that's sort of a cheap way of getting service work done, sort of picking up some of the slack from the cutbacks in the professional sector. Groups that are doing advocacy, it's quite difficult to raise money. There's a tax law that works against you too. If you spend more than 10 per cent of your funding on advocacy, under federal tax laws you cannot call yourself a charity.
There are a number of ways that I think that the groups have sort of been set up that they are desperate for the money. Some of it may be naïveté or some of it may be opportunism or some of it may be simply believing that the source of your money doesn't matter. I am sure there are different reasons that people would give for finding it not a problem, but certainly all of the groups that I work with have decided that we cannot do the kind of work we do credibly if we're taking money from the industry.
As far as public support, as I mentioned, we've been fortunate to have money from the Women's Health Program, that's part of Health Canada. We've been very critical of a lot of their policies, but they seem to respect us as a group that knows the issues and is able to give them important feedback. There are groups like DES Action Canada, which was started about 20 years ago when the DES issue became apparent, they had regular funding from the federal government for years, and they've been totally cut out. There's no real policy in place that would allow groups that want to do this kind of work to apply for funds and get it. The group I work with in the States, Prevention First, got quite a nice grant from a foundation called the Goldman Fund.
In the States, they're just staggered that we would ever get money from the government to do the kind of work that we do, but they did get some money from the Goldman Fund, which is based in San Francisco. That was a two-year grant. It's now run out, and we're not going to get more funds. We're really having a hard time raising funds to keep that organization funded, and that's partly because, I think, of the way the foundations have been hit post-September 11th. There's the financial decline and so on, and many foundations are just being a lot choosier about where they put their funds. The funding is a problem.
MADAM CHAIRMAN: Mr. Hendsbee.
MR. DAVID HENDSBEE: I have a few questions. First of all, a clarification on the acronyms. I want to make sure we have this for the purposes of the records of Hansard, so that we know what all these acronyms stand for. WHI, Women's Health Initiative; WHP, Women and Health Protection; DTCA, direct-to-consumer advertising; FDA, Food and Drug Agency in the U.S.; HRT, hormone replacement therapy; and PMS, premenstrual syndrome.
MS. BATT: Yes.
MR. HENDSBEE: Now, the other two I couldn't decipher were AT under the gene carrier.
MS. BATT: It's a particular gene, it's a syndrome something like ataxia telangiectasia or something like that. It's a medical term.
MR. HENDSBEE: And the other one was NAPBC.
[10:30 a.m.]
MS. BATT: National Action Plan on Breast Cancer. Sorry about that, I wasn't actually planning to hand these out.
MR. HENDSBEE: I have three or maybe four quick questions and I'll ask them all at once and I'll let you answer them. First of all you told us about the negativity of HRT, hormone replacement therapy, and trying to relieve the symptoms of menopause and stuff. Could you clarify for me in regard to the homeopathic therapies or the herbal remedies such as black cohosh and red clover supplements that people are now taking, instead of hormone replacements, any comments on that?
Early detection, they talk about self-examination and mammograms. There have been various released reports about the controversy on the various findings. Some say, yes it's good to have it earlier or take mammograms, others say no, others are inconclusive. Could you tell us the benefits of early detection through self-examination and mammograms? My third question would be, the breast screening clinics and the mobile units we have in the province, do you believe we have enough of these facilities available for women in our province?
My last question would be, in the correlation of the proximity of hazardous waste sites, you had some literature, and you talk about advocacy of environmental issues. In the information you provided it talked about Love Canal in New York State, Perry in Ohio, and the Hudson River in New Jersey. Have there been any local studies about the Sydney Tar Ponds, in regard to the women in the proximity of that area? You talked about lifestyles as a possible indicator and you talk about North America versus the Orient. Have there been any local studies in regard to our lifestyle and our diet, in regard to the various communities and perhaps to the African-Nova Scotian community as perhaps one of those particular areas that could be studied for any monitoring by the Elizabeth May chair at Dalhousie? Those are my questions.
MS. BATT: I'll try to be brief, this could be one hour per question but I know we don't have that time. In terms of the alternative therapies, I can send some good references on that. It's not something I have a whole lot of expertise in but I've certainly followed it. There are a number of alternative therapies, like black cohosh, that have been suggested, promoted, tested for alleviation of hot flashes. Generally, the research is not extensive and we just can't say enough. I mean there are some that look promising and I think that because of the Women's Health Initiative, there will be more research done on those. I can certainly send you information that would tell you what is known to this point but generally, it's inconclusive because there just hasn't been enough research.
Early detection, that's a big one. Both mammography and breast self-exam, as you've said, have been called into question; vehemently defended by defenders and called into question by others. This is something I have been following ever since my diagnosis. I happened to have had a lump that I could feel that didn't show up on the mammogram. I guess I was kind of set up from the beginning to be somewhat skeptical and I've always been very interested in the kind of skeptical critique that has existed of early detection, actually,
for decades. Most people have accepted the premise that early detection is advantageous in breast cancer.
I think we really don't know. I think that for sure, early detection has been over-promoted. It's clear that there are some tumours that grow quite slowly and might never kill the patient. Others grow very quickly and we just don't have treatments that will work in those cases. But there's probably a middle range of tumours that are sort of a medium aggressivity and those ones perhaps, early detection does make a difference.
I think that we have to keep re-evaluating mammography. I think it would, I mean there was an enormous outcry when the conclusion was arrived at that breast self-exam was not worth investing funds in and I think there was a lot of misunderstanding about that. I, personally, was happy to see that study come out because I think that women have been encouraged to think that this is a way that they can reduce their risk in the absence of evidence again. I mean it was something that was introduced in the 1950s because Pap smears had been so successful and, you know, the American Cancer Society and physicians thought, well, you know, we could do the same thing with breast cancer and they basically just kind of injected it into their programs and it's only recently that there have been clinical trials and clinical trials have shown that it doesn't seem to reduce mortality.
Now, there are people like Anthony Miller and Cornelia Baines, certainly respected a lot in their expertise, who say that, in fact, they think it is important and that if you look at some data, it does show support. So I think we're sort of in that grey zone where we really don't know for sure. I think, you know, given the outcry when breast self-exam was criticized, I think you would get an even more hysterical outcry if mammography screening was cut back. I believe that in Denmark - this is the Danish study that the overview of mammography screening was published - I believe that Denmark stopped its mammography screening program and I can check on that. I think that it's important to look at other countries that have made certain policy decisions.
I think we're spending an awful lot of money on mammography and if it is doing good, it's not doing nearly as much good as people think it is and it may not be doing any good. I mean I'm really not sure, but I think that it would be virtually impossible as a policy decision to stop mammography screening in Canada given the high rates that we have, what an emotional issue it is, the fact that we don't have good prevention programs and we don't have good treatments. I mean it's sort of makes people feel like we're doing something and I'm afraid that, at this point, it's kind of an argument in its favour even though I don't think it's a really good argument.
There's often been kind of a confusion where early detection has been lumped together with prevention and I think it's really important to make the distinction that early detection is not prevention. If we're going to have good preventive programs, we have to say, you know, we're going to look at what the causes are and not confound or conflate early
detection and prevention. So that's one thing I think we can do and I think we have to be, as I said before, putting a lot more effort into prevention and sort of monitoring whatever new information comes up on mammography screening. I think in terms of the mobile units, given that I'm not certain how useful the mammography screening is, I can't say that I think we should be putting a lot of money into mobile units, but I think they should certainly be available in communities on an equitable basis. I mean it is important for people in outlying areas to feel like they're getting access to services that other people have. I would have to look more at the actual situation in Nova Scotia to give a more detailed response than that.
MR. HENDSBEE: My last question is in regard to environmental sites, the Sydney tar ponds, or any local studies?
MS. BATT: Well, there have been a lot of studies at the Sydney tar ponds and I guess you know as well as I do that they've been quite controversial and I think what has happened is exactly what I talked about where I don't think we're going to get the kind of definitive answers that people who are looking for absolute answers are looking for. There isn't a big enough population to get definitive answers or at least that's my understanding and I'm not an epidemiologist, but my personal suspicion is that you can't have that level of toxic environment and not have health impacts. I think we should be looking at the whole range of diseases, not singling out any single one but trying to do this kind of global analysis of many different diseases if research is being done.
I think the answer is in the precautionary principle. I think we have to be looking at ways of reducing those kinds of toxic sites, reducing the toxicity in every way we can, and just assume that's going to have health benefits down the road.
MR. JERRY PYE: Thank you, Professor. MLA Hendsbee sort of touched on the area I wanted to ask you the question on, but I didn't quite hear your response. He talked about African Nova Scotians. I'm wondering if in fact there is some research that has been done with respect to the potential for breast cancer in racially-specific individuals, whether they're Black, Chinese, so on, in that particular area. Also, with respect to lifestyles, which I didn't hear you mention, is there more of a chance for women living in poverty to get breast cancer than other individuals? Is there a correlation between poverty and breast cancer, lifestyles that is?
MS. BATT: Those are interesting questions. There has been a lot of research on different racial or ethnic communities in the United States. There's been very little here. I know there have been some studies in Nova Scotia, in the Black community, with breast cancer, but I don't think there are figures showing whether the rates are higher or lower. What they found in the United States is that the rate of breast cancer among Black women is lower than for Caucasian women. Actually, you can sort of make a hierarchy, that Caucasian women have the highest rates, Asian women are lower, I think Black women are in the middle, and I'm not sure where Hispanics, the other group they look at, are.
There is that hierarchy, but it does tie in with the affluence/poverty question, which I will get to in a minute. So that's incidence, incidence is lower, but in the States they found that mortality is higher among Black women with breast cancer. That may have to do with their having less access to services, but I think there's more to it than that. Poverty, generally, is not a good state to be in, particularly when you're sick. You just don't have the same kind of community supports and services, not just health services, access to healthy foods and all of those kinds of things that are helpful when you're battling an illness. I am being somewhat speculative here, but we don't know the answers exactly. We do know that incidence is lower and mortality is higher among Black communities in the States.
I think it would be very interesting to look at the statistics in Nova Scotia, but I don't believe it's been done and I don't know of an ongoing study, though I could be wrong. I could try to check into that. I am on the board of the Canadian Breast Cancer Research Initiative, which has pretty good tally on breast cancer research that's going on across the country.
[10:45 a.m.]
The question about poverty is very interesting because breast cancer is one of the few cancers where there's an inverse relationship - affluent women are more likely to develop breast cancer than poor women, and there's no clear explanation for that. I think when you see hormone replacement therapy, I think that one part of it is that there are medical interventions that contribute to breast cancer that are more common among affluent women than poorer women. We really don't have all the answers. We know there's definitely a relationship, but it's the reverse of what you might expect with breast cancer. Some of it may also have to do with different child-bearing patterns.
MR. BARNET: First of all, I want to thank you for coming. This has been fascinating. I was particularly interested in your views with respect to drug promotion. It's something I think you're going to find Nova Scotians and Canadians grow more increasingly aware of that issue. We've all seen the TV ads and magazine ads that have come from the United States and elsewhere, and I've been absolutely dumbfounded by some of what has been said. If you listen to the ads, often you'll hear an ad that paints a very rosy picture for a person being treated for any number of ailments and at the very end of the ad, at lightening speed, you hear somebody, a voice-over that says what side effects there may be and they list a ream of things that in fact are often worse than what's being treated in the original ad.
I don't know if they think they're actually fooling or tricking people by this, but I do think you're going to see in the near future - it has started now - more and more Nova Scotians and Canadians becoming increasingly more aware and concerned about the type of tactics used by the drug companies, and I think that you'll see some action with respect to that.
A couple of things that you've highlighted which interest me is that Nova Scotia has the second highest incidence of breast cancer, only to Manitoba. I don't know what the spread is - is it a drastic spread from the highest to the lowest? Is that information actually in this binder, maybe?
MS. BATT: I don't know if I have it with me. It's on the Web site of the Canadian Cancer Society. It's not dramatic. I could get it for you, or direct you to it.
MR. BARNET: That's okay, if it's there I can find it. That's something that interested me. The second point that you had indicated was the use of X-rays. I know if there are others who are saying there's an overuse of X-rays and that you have to be very careful about how many X-rays you're exposed to. Recently I had the opportunity to visit a chiropractor and he actually had an X-ray machine in his office - I was absolutely surprised that a chiropractor was trained to use this X-ray machine. Part of his treatment was to use this machine to treat a back problem, and I wonder if there may not be at least, or should there be an attempt to try to educate the public on the overuse and over-diagnosis of ailments with X-ray, if that might not be something that we should be looking at as legislators, as people who are responsible for the health of Nova Scotians?
MS. BATT: I think that would be an excellent strategy. I think you've touched on a couple of things. One is that there is a danger associated with use of X-rays - the more you have, the more it raises your chance of cancer. They really should be used very sparingly and I think that there's a common perception among the public that the safe thing to do if you think there might be a problem is have an X-ray, get it checked out. It's just the opposite. Physicians, again, are caught in a kind of a liability situation, where they don't want to miss something that might be important. They're over-inclined to prescribe X-rays to protect themselves. That's a recognized problem that's discussed in the literature. I think that kind of education would just be an excellent thing to do.
I just wanted to go back, quickly, to the point you made about the direct-to-consumer advertising and the way these ads are structured. That sort of trail-off at the end of the risks is part of what they're required to do. The FDA has regulations that says if they're going to show an ad, they do have to say something about the adverse effects. So they've figured out ways of sort of making the whole ad seem very positive, but then they sort of stick the stuff in at the end that they have to have there, about risks.
MR. BARNET: It's a tactic that they've picked up from auto dealers, it's actually a tactic they picked up from auto sales. If you look at the auto sales ads, at the very bottom there's this little tiny print that you can barely read with little stars and things that help identify what that overall price actually means. They say it because they have to, but they don't waste a lot of time and space doing it.
My final point, if I can ask this question, and it might be unfair, but do you think we have the ability as a society to drastically reduce or even, should I say that word, eradicate breast cancer? I know it comes from so many different fronts, it's like fighting a war, different battle zones. Do you think we can really do something as a society to drastically reduce this disease?
MS. BATT: I don't think we should set it up as a goal to drastically reduce it, I'm sure we can reduce it. I think our goal should be to reduce it in every way we can. We spend all this money on treatments that make a pretty modest difference, and yet when people talk about prevention, they sort of think, well, we have to get rid of the disease altogether. This is a disease that's been on the books for thousands of years. There probably will always be some cases of breast cancer, but I think we should be cutting back as much as we can.
MADAM CHAIRMAN: I think we have to learn to differentiate between the use of prevention of the disease and prevention of death. Maybe that's what we need to get more to.
MRS. BAILLIE: A couple of points in your presentation really came as a shock to me. First, only 5 per cent to 10 per cent of breast cancers have a hereditary component. I have seven sisters, four of them had cancer. When I go to the doctor, of course that's the first thing they ask you, is there cancer in your family? Then you're sent for all these tests. This is the first time that I've read this or heard this, that only - I guess that's true, it's in your presentation.
MS. BATT: Yes, it is true. If there are four or five people who have had breast cancer in your family, you may be one in that 5 per cent to 7 per cent. Also, cancer is so common that most of us have some cancer in our family. Even among people who don't have a genetic tendency, you get these clusters within a family that are probably environmentally related.
MRS. BAILLIE: Well, one lives in Manitoba and one lives in Newfoundland, and the others in Nova Scotia. The other thing was the consumption of alcohol as a cause of breast cancer. That's the first time I've heard that.
MS. BATT: Oh, really. The alcohol contributes to estrogen levels. I can't describe, physiologically, the connection, but it's quite well accepted that that's a contributing factor. I think a lot of women don't know that. Again, it's not like it's a huge causal contributor, it's one of these that contributes. It's not like if you drink you're going to get breast cancer, and if you don't you won't.
MRS. BAILLIE: But it might help prevent . . .
MS. BATT: Yes, it certainly . . .
MRS. BAILLIE: Over excess anyway.
MS. BATT: Certainly after I was diagnosed, I still have the occasional wine but I'm much more particular about when and how much.
MRS. BAILLIE: The other thing, do you have any statistics on the success rate on whether you have the whole breast removed compared to a lumpectomy?
MS. BATT: It's pretty well established that it doesn't make a difference in most cases, that a lumpectomy is every bit as safe as surgery and often has fewer side effects and certainly cosmetically for the woman it's usually preferable. Some women still want to have the mastectomy, it sort of gives you the illusion that you're doing more and, again, I think that's the misconception people have that the more medical intervention you have, the safer it is when in fact often the reverse is true.
MADAM CHAIRMAN: I just have one that I would like to finish up with. One of the earlier comments you made was that we are second in incidence only to Manitoba, but yet we have a higher death rate. Are there differences in the diagnosis and treatment protocols that are followed in the two provinces that would explain why more people in Nova Scotia die since not quite as many are, you know, we don't have quite as high incidence of the disease, but yet we have a higher death rate? Is there any explanation for that?
MS. BATT: I'm sure this has been looked at because, I mean, there are people who study these provincial statistics and they tend to be quite consistent year after year. I know that B.C. does quite well, but I don't have the answers. I could certainly find out or direct you to people who have done that kind of research.
MADAM CHAIRMAN: The only two possibilities that come to mind being, you know, as one of the unwashed, uneducated few - many - is that maybe there are things Manitoba is doing more aggressively than we are or the types of cancers that are found here are different than the cancers in Manitoba and, therefore, wouldn't respond as well to diagnosis and treatment?
MS. BATT: Yes. Well, there are other factors that are less well-known, I mean those are certainly two things to look at, but there are things, like social supports, that can make a difference in a person's survival. I was talking to one epidemiologist about the fact that there's apparently a higher mortality rate for cancer in the Ottawa area and this physician was saying that the explanation that people were tending to was recognizing that a lot of people come to Ottawa because of jobs and they come from somewhere else and they don't necessarily have family and support and, you know, they're moving in and out and so you don't have the same kind of stable communities that would provide support. I mean I don't think that would be the case in Nova Scotia. (Interruptions) It would be the reverse, but there are sort of obvious factors and then there are other more subtle ones to be looked at.
There's an initiative now, which you're probably aware of, the cancer control strategy that has been in the works for a couple of years and there is a bit about it in the binder. That's an attempt to get a national strategy that would systematically look at ways to reduce breast cancer incidence and mortality for all cancers all across the country by sort of setting in place targets and making sure that we are using the knowledge that we have to do everything possible to reduce incidence and mortality. It has been a long time coming and it's still in the early stages and I'm not even sure whether it has got the funding that it needs to go ahead, but that's the kind of strategy that we need to really systematically address the kind of differences you're talking about.
MADAM CHAIRMAN: I guess if that's all the questions, then I want to thank you very much for coming. It has been a fascinating discussion. I think we've all learned quite a bit and there will be a couple of minutes afterward where people will probably want to ask individual questions and so on. So while you're gathering up your stuff, if we could just wrap up our meeting, and thank you very much.
MS. BATT: Thank you very much for having me, I really enjoyed it.
MADAM CHAIRMAN: The other committee business that we have on hand is the draft report. Has everybody had a chance to read the report?
MR. HENDSBEE: I so move.
MADAM CHAIRMAN: Do we have agreement to sign off on it? Okay, I will circulate that. Our next meeting is May 29th. We have tentatively booked the Children's Aid Society. That's meant to be the discussion on children in care who wrote the report, The System: It Doesn't Work For Us. So that's why it's billed as tentative because we want to make sure since that was the topic approved by committee, that that's what the Children's Aid Society is going to be bringing to the table and, hopefully, with representation from some of the people who were involved with that actual report. That's what we're waiting to find out. If that's going to come to fruition, we will have the report circulated ahead of meeting time so we have a chance to actually look at it. Any questions?
We stand adjourned.
[The committee adjourned at 11:00 a.m.]