HANSARD
NOVA SCOTIA HOUSE OF ASSEMBLY
STANDING COMMITTEE
ON
HEALTH
Tuesday, July 9, 2024
COMMITTEE ROOM
Cancer Screening Programs
Printed and Published by Nova Scotia Hansard Reporting Services
HEALTH COMMITTEE
John A. MacDonald (Chair)
Danielle Barkhouse (Vice Chair)
Chris Palmer
John White
Nolan Young
Hon. Kelly Regan
Rafah DiCostanzo
Gary Burrill
Susan Leblanc
[Gary Burrill was replaced by Lisa Lachance.]
In Attendance:
Judy Kavanagh
Legislative Committee Clerk
Gordon Hebb
Chief Legislative Counsel
WITNESSES
Nova Scotia Health Authority Cancer Care Program
Dr. Helmut Hollenhorst, Senior Medical Director
Dr. Robert Grimshaw, Medical Director, Cervical Cancer Screening
Krista Rigby, Director, Population Oncology
Eileen Kilfoil, Manager, Cancer Screening Programs (Cervical, Colon, Lung)
Dr. Michael Stewart, Medical Director, Colon Cancer Screening Program
Nova Scotia Breast Screening Program
Dr. Siân Iles, Medical Advisor
Trena Metcalfe, Program Manager
Anne Yuill, Director, Healthy Populations and Provincial Initiatives, IWK Health Centre
HALIFAX, TUESDAY, JULY 9, 2024
STANDING COMMITTEE ON HEALTH
1:00 P.M.
CHAIR
John A. MacDonald
VICE CHAIR
Danielle Barkhouse
THE CHAIR: Order. I call this meeting to order. This is the Standing Committee on Health. I’m John A. MacDonald, MLA for Hants East and Chair of the committee. Today we will hear from the Nova Scotia Health Authority Cancer Care Program and the Nova Scotia Breast Screening Program regarding Cancer Screening Programs.
Just a reminder to put your phones on silent. I’ll now ask the committee members to introduce themselves by stating their name and constituency. I will start with MLA Leblanc.
[The committee members introduced themselves.]
THE CHAIR: For the purposes of Hansard, I’ll also recognize the presence of Chief Legislative Counsel Gordon Hebb to my left and Legislative Committee Clerk Judy Kavanagh to my right.
What we’ll do first is allow everybody to introduce themselves and their position, and then we’ll go to opening remarks. I will start with my far left. Mr. Stewart.
[The witnesses introduced themselves.]
THE CHAIR: I apologize, Dr. Stewart. It was fuzzy because I’m wearing reading glasses. The next is opening comments. How many people have opening comments? Okay. I will start with Dr. Hollenhorst.
DR. HELMUT HOLLENHORST: Good afternoon and thank you for the invitation to meet with members of the Standing Committee for Health. As senior medical director of the provincial Cancer Care Program, I have the honour to co-lead an incredibly dedicated and talented multidisciplinary team of cancer health professionals and administrators with my colleague, Jill Flinn, who wasn’t able to make it to today’s meeting.
Together with our leadership team, we are responsible for developing and delivering adult cancer programs and services across the province. This includes cancer prevention and early detection, treatment, follow-up, supportive care, palliative care, and end-of-life care. We are working closely with our partners at the IWK Health Centre who have responsibility for pediatric cancers and the Nova Scotia Breast Screening Program.
Our work is guided by our cancer control strategy, which was informed by cancer care teams, patients, families, and communities. We are currently in the fourth year out of five executing the strategy that was mainly focused on cancer care stabilization and optimization. It is also aligned with Action for Health.
Since today’s discussion is about cancer screening, I’ll provide you with a brief overview of cancer screening in Nova Scotia. Cancer screening is not for people who have possible symptoms of cancer. These individuals need to see a health care provider. Cancer screening is about looking for cancer or a pre-cancer before there are warning signs or symptoms. Screening must be done regularly, at the interval recommended by the specific cancer screening program in order to be effective.
Nova Scotians are fortunate to have four organized cancer screening programs: cervical, colon, breast, and our newest program, lung cancer screening. Of these, cervical, colon, and breast are population-based screening programs, targeting individuals within a certain age group who are at average risk for the specific cancer. Lung screening, by contrast, targets individuals who are at high risk for the disease because of evidence indicating that lung screening is only beneficial for those at high risk.
In fact, all cancer screening programs in Nova Scotia are based on the latest scientific evidence and leading practice. The development of clinical screening guidelines includes literature review and discussion with subject matter experts, a review of leading clinical practice and guidelines from across the country and beyond, and a review of the Canadian Task Force on Preventive Health Care guidelines. The evidence is monitored, and as new evidence becomes available, guidelines are reviewed, discussed, and updated as appropriate.
The goal of cancer screening is to prevent cancer when possible or find it early when treatment is more effective and a cure is more likely. Cervical and colon screening programs can prevent cancer, whereas lung and breast screening can find cancer at an earlier stage.
Our screening programs are designed to lift the administrative burden of cancer screening from primary care providers to provide equitable access to cancer screening for all. This includes not needing a primary care provider to access our screening programs.
Colon cancer home screening kits are mailed to all Nova Scotians every two years beginning at age 50 until they are 75. Those who have an abnormal test result get a letter in the mail, copied to their family care provider if they have one. A screening nurse navigator also reaches out to answer questions about the recommended follow-up screening colonoscopy, and if the person agrees, books the test. Those with a normal test receive a letter indicating the test is normal, and that they should do the test again two years later when it comes back in the mail.
Pap tests for cervical cancer screening are available at well woman clinics across the province. A move to HPV testing is next. In a couple of years, it’s likely Nova Scotians will have access to at-home tests for cervical cancer screening. We’re already starting the work on this.
Our lung screening program targets Nova Scotians between 50 and 74 with 20 or more years of current or former daily smoking history. These people can self-refer by phoning the Lung Screening Program to book an appointment. During the telephone appointment, a screening navigator provides information about lung health, offers tobacco cessation supports for current smokers who are interested in quitting, and conducts a clinical assessment to determine if they would benefit from a chest CT.
Those determined to benefit from the chest CT are offered one. If they agree, they are booked for the test. Their test result is mailed back to them, along with when they should have another scan. Those with an abnormal test result receive a phone call from the nurse navigator who answers questions and provides information on next steps. The Lung Screening Program was introduced in Central Zone in January of this year. It will be expanded to Eastern Zone in the Fall, and to the rest of the province in 2025.
People can also self-refer to the Nova Scotia Breast Screening Program. I’ll leave it to Dr. Iles to share the details of how her program works.
You may wonder if cancer screening programs work. The answer is a resounding yes. Our cancer screening programs are saving lives. Incidence of cervical cancer has plummeted as the result of screening, and with vaccination, we can eliminate cervical cancer altogether.
In 2023, over 1,000 Nova Scotians had colon cancer prevented. They had no warning signs. They did the home screening test. Pre-cancers were found and removed because of the colon cancer home screening test. In the few short months since the Lung Screening Program has been operational, three individuals have had early lung cancers identified and are recovering from the surgery, four are in the middle of workup, two of them did in fact not have cancer, and one patient unfortunately passed away for other reasons unrelated to cancer.
Cancer screening programs are an excellent use of health care resources. We are saving lives and we could save many more if more people were regularly screened. We know we have more work to do. We are moving toward having nurse navigators for all people who have abnormal screening tests to ensure they get the information and follow-up care they need. We are working with diverse communities to co-design information and ensure a culturally sensitive approach and experience to cancer screening and all cancer programs and services.
On the horizon: cancer screening Nova Scotia, a one-stop shop for cancer screening and accelerated workup of suspected cancers will be a priority for our renewed and next phase of cancer control strategy. More to come. Stay tuned.
THE CHAIR: Dr. Iles.
DR. SIÂN ILES: I’m Dr. Siân Iles, as I’ve said, and I’m the medical advisor for the Nova Scotia Breast Screening Program. I’m a radiologist, which means I specialized in imaging, and I subspecialized in breast imaging.
I’ve been part of the Nova Scotia Breast Screening Program since 1991. I think I’m the only one left who was with the program from the very beginning, and it’s been a privilege and a lifelong joy to really be part of this.
I’m joined today by my colleagues: Anne Yuill, who is the director for Healthy Populations and Provincial Initiatives for the IWK Health Centre. Her portfolio includes our program; and Trena Metcalfe, who’s our manager for the Nova Scotia Breast Screening Program.
I want to begin my remarks by emphasizing the importance of screening mammography. Breast cancer is the most common cancer in women in Nova Scotia. Early detection by screening mammography, which can find cancers much smaller than those detected by clinical symptoms, leads to reduction in breast cancer mortality, fewer years of life lost due to breast cancer, and decreased morbidity of breast cancer treatment. Screening mammography is the only test to date that has been shown to decrease mortality from breast cancer.
I’m pleased to share that Nova Scotia has one of the most robust and successful breast screening programs in the country, with unique features and capabilities. Nova Scotia launched its organized breast screening program in 1991, starting with one single clinic in the Halifax Shopping Centre. I used to drive up there and read the images. We had to go in person. Since then, it has expanded to 11 fully accredited fixed sites throughout the province. A mobile screening program began in 1994 to better reach rural communities and priority populations to ensure equitable access to screening across the province. Today, the mobile screening program services 30 communities across Nova Scotia.
In 2022, 56,951 screening mammograms were performed; 3,986 were abnormal and required further testing; 1,305 went on to have a needle core biopsy; and 366 cancers were diagnosed as a result of screening.
Self-referral for screening mammography begins at age 40 in Nova Scotia. We’re fortunate in that regard. No primary care provider is required to refer or to be moved through the clinical pathway if additional testing is required. Self-referrals can be made by calling one central toll-free number.
As Helmut said, screening is for individuals who do not have signs or symptoms of breast cancer and who have not had a previous diagnosis of breast cancer. Individuals with symptoms are not eligible for screening. They should be evaluated by a health care professional and referred for diagnostic breast imaging for further evaluation. Screening mammography is a standardized set of four breast images performed at a screening site and interpreted later by screening breast radiologists. Diagnostic breast imaging is performed at a diagnostic site and targeted and tailored to evaluate a clinical sign or symptom, or to evaluate an abnormality already seen on a screening mammogram. Maintaining capacity in the diagnostic sector is crucial to an effective program.
Nova Scotia is the only province to have central intake and booking of breast imaging appointments. That’s all appointments, not just screening. Our unique provincial Breast Information System supports real-time monitoring and evaluation of wait times, maximizes use of available diagnostic breast imaging appointments, and allows for appropriate booking of procedures. Province-wide standardized synoptic reporting in the Breast Information System allows proactive booking based on radiologist recommendations, which takes the burden off primary care, and supports access for patients not attached to a primary care provider.
[1:15 p.m.]
The Breast Information System also tracks the entire journey of a person through breast imaging, whether screening or diagnostic, up to the point of definitive surgery for breast cancer, with safety checks in place to ensure that people are not lost to follow-up, and that they get care in a timely manner.
I would now like to highlight some of the unique features and strengths of our program. The Nova Scotia Breast Screening Program was the first program to have a patient navigator. The patient navigator tracks a person’s journey to ensure follow-up occurs, as well as being a resource for patients, primary care providers, and the public with any questions they may have about breast screening.
Nova Scotia does not have opportunistic screening. Opportunistic screening is a screening test performed outside of an organized program. Examples include mammography, breast ultrasound, or MRI done at private clinics as may occur in other provinces. These test results and patient outcomes are not tracked or monitored by a screening program. This core function ensures that a program is meeting quality indicators and will achieve the desired results of decreased mortality. We have no private clinics that provide breast imaging in Nova Scotia.
All screening and diagnostic breast imaging services are provided within the public system and are overseen by the Nova Scotia Breast Screening Program. All data from these services are captured and monitored. Our program is truly population-based.
Nova Scotia was the second province to implement density notification in all screening results letters in October 2019. It was the first province to use automated software for standardized calculation of breast density using software developed here in Nova Scotia. This company developed because of initiatives by the Nova Scotia Breast Screening Program to try to standardize assessment of breast density, and their software is now used worldwide. We have now implemented automatic annual recall of all women who have a screening mammogram with Category D density through our Breast Information System.
We are nearing the completion of province-wide implementation of quality software also developed by this company that provides standardized image quality evaluation, which will be used to monitor and improve image quality, a crucial factor for high-quality screening. Nova Scotia has evidence-based average risk clinical practice guidelines that include eligibility for trans and gender-diverse individuals. Anyone who meets these criteria may self-refer for screening from the age of 40.
Nova Scotia is one of only two provinces that has an organized high-risk screening program, following the model in Ontario. Anyone who has a breast cancer risk assessment using a recognized clinical model and has a lifetime risk of greater than 25 per cent is eligible for this program, which includes annual screening MRI, as well as mammography, starting at age 30.
The Nova Scotia Breast Screening Program provides quality monitoring for the entire system, including wait time reports, annual reports, national reporting on quality indicators, and indicator reports for Mi’kmaw communities in the province. We are connected with our sister breast screening programs across Canada through the Canadian Partnership Against Cancer Corporation, which allows provinces and territories to share evidence and practice, and reports on mammography screening programs nationally.
In closing, I want to emphasize the importance for individuals to self-refer for screening beginning at age 40, and to continue receiving regular screening. Screening programs will only make a substantial difference to population health if enough of the eligible population uses them.
I look forward to answering any questions that the committee may have.
THE CHAIR: We’ll start with the question-and-answer period. It will be 20 minutes for each caucus, and then we’ll divvy it up after that. It will be about six or seven minutes. The first will be 20 minutes to the Liberals.
MLA DiCostanzo.
RAFAH DICOSTANZO: Thank you all for being here. I’ve been looking forward to this. I hope I can do it justice. I want to thank you, and especially thank Dr. Iles for being here. I have wanted to meet with her personally since my diagnosis of cancer and what I’ve learned over the year and a half. I haven’t had the opportunity, so I’m grateful that she is here.
I’m also really grateful to see the support from so many women who have reached out to me since my diagnosis, since I’ve been speaking about my story and what has happened to me and learned about what dense breasts actually means. They are here. Honestly, you’re going to hear my story. My story is very small compared to a lot of them. There are many much worse situations. I was the lucky one.
My story is: My mother had breast cancer at age 72. She lives in Ontario. All I remember, actually, is it was not a big deal because she had a lumpectomy and radiation. It was bad, but I was living in Halifax, so my sister and brother took her, but it wasn’t as big a deal as it has been for me. I’ve had it 10 years later, and things should have improved for me instead of gotten worse for me.
Because of my mother having cancer, at age 50, I started having regular mammograms, yearly mammograms, at the Halifax Shopping Centre. Every year, regular, always negative - until 2022, when I had just turned 60. I was the most active 60-year-old, in my opinion, cycling 67 kilometres and doing everything, working 150 per cent, loving every minute of it. I had all the energy in the world.
There was a little lump. I go see the doctor. I actually took it easy because it was small. She says, I’ll send you. I was sent to the IWK Health Centre for the 3D mammogram and ultrasound, and I was given the clear. Everything was great. My husband surprised me with a lovely trip to Greece that year to celebrate my 60th birthday. I had cancer, but nobody told me.
Six months later, I have another lump on the same breast, a little above and a little harder this time. I took my time: It’s the same breast, I’m sure it’s negative. It took me three months. By the time I got my next one, I was getting dressed, putting my boots to go speak on March 6, 2023, to go speak at International Women’s Day. My family doctor calls me and says: Rafah, we need to send you to a biopsy because you have a 95 per cent change of malignancy, from the mammogram that I’d just had only six months or eight months earlier.
I was shocked. I joked with him and said: I need to go speak, this is not a good time, I’ll think about it. I went, I did my speech, came home, and life has changed night and day since that day. My story is nothing compared to a lot of the women who are here today.
My life was one appointment after another, one delay after the other, whether it was the biopsy, whether it was the other. I was lucky that my mastectomy was brought forward because somebody cancelled. I had my mastectomy, then I didn’t even know that now my tissue was being sent to California, which is a good thing. I didn’t ask for it.
Now I scored 30 in an Oncotype DX test. I had no clue what these are, what the test stands for. Now I have a high risk, and I was told a week before I’m supposed to start my chemotherapy that I need at least four rounds of chemo to be sure. That was the worst day of my life. Chemo has been - I have had a fear of chemo, and rightfully so. Chemo has done so much damage to me, to my life, to my work, to my family, and to everybody. Many of the women here have suffered the same.
My cancer should have been found. They tell me cancer takes three to four years to develop. I’ve had my mammograms in 2020, 2021, 2022 - and in 2022 I had not only a mammogram but an ultrasound, and it wasn’t found. Then I heard about dense breasts and started to be educated. I wish in 2022 I knew the high risk that I was under. I found out that it was us, when we were in government, we brought in this amazing software that Dr. Siân Iles just talked about. We tell women: You have a high risk of developing cancer. You have a much lower - 50 per cent or 43 per cent chance your mammogram will miss your cancer. But if I wanted - and many women here have gone to their family doctor and asked for extra screening, and the doctor tells them: You will be denied any extra screening to see if we can find the cancer early.
This is just beyond anyone’s imagination, that women want to find it early and we’re telling them, No, you can’t. Let’s wait until you’re Stage 2, 3, 4, then we can give you chemotherapy that costs money.
I went from probably just a lumpectomy and radiation - $40,000 or $50,000 - to a minimum $200,000 cost to the taxpayer, and I have another surgery maybe coming as well. All this cost could have been saved, but most importantly, my life, my quality of life has changed for I don’t know how long. It’s been over six months since my chemo. I’m still not back, and a lot of side effects that I’ve had to deal with.
What’s important to me? I know Dr. Siân Iles just in her speech said that we have the most robust and successful breast screening program in the country. So how did I go for 10 years of mammograms, and in 2022 an ultrasound and a mammogram, and it was missed and then I ended up with severe treatments? Explain, and honestly, there are at least 20 women here listening to you today who have gone through this, and some of them are in Stage 4 and 5.
How can this robust, amazing treatment fail women with dense breasts? Do you agree that dense breasts are a high risk as you’re sending in the envelopes with our screening, telling us: You have high risk, but you’re not allowed to have any extra screening? How do you explain that to the others and to me?
THE CHAIR: Dr. Iles, I forgot to mention, wait until I get your microphone, so it’s on the record. Dr. Iles.
SIÂN ILES: Thank you, Rafah, for telling your story. I am so sorry for what you’ve been through. It is really terrible to hear this story. I’m very sorry to hear the stories of all the women here as well. This is what I’ve spent my life doing, trying to prevent that kind of story. Unfortunately, screening is not perfect. As we’ve pointed out, in the denser breasts, we’re not as sensitive.
Breast density, as far as being high-risk in and of itself, Rafah, it doesn’t confer high-risk in the sense of the genetic kind of high-risk that we talk about with the BRCA mutations. The risk is higher in women with dense breasts, but the problem is, as you have pointed out, we can’t always see the cancers well with a mammogram. If you’re looking at a regular woman with a fatty breast, our sensitivity is about 80 to 90 per cent. In someone with more dense breasts, as you’ve pointed out, the sensitivity is about 60 to 70 per cent.
What we’re doing, however, is a population-based program. We have to be able to provide a test that is readily available, that is accessible, that is equitable, and that has proven benefits. That’s where screening mammography comes in. As you’ve pointed out, the benefits may not be equal for everybody, and some people with dense breasts, we’re not as sensitive, but we may miss cancers in any other breast as well. Unfortunately, it’s not a perfect test.
RAFAH DICOSTANZO: Unfortunately, that is just not good enough, when you are telling me that you know dense breasts are higher risk and you’re missing it, and you can do, and other provinces have. B.C. has trained their mammogram technologists on an advanced computer software that’s called contrast-enhanced. Both abbreviated MRI and contrast-enhanced mammography - abbreviated is used in Ontario, contrast-enhanced is used in B.C. - find four times what we’re finding here. These 15 per cent, we’re finding five in 1,000. The other 15 are these women who have gone through hell and back, and we know we can catch it early. We do, and we can, because they are doing it. Your colleagues at the same level have found ways.
I would love for you to tell me what you are doing to reach that same standard. I have a sister in Ontario who got an abbreviated MRI because her sister - me - had cancer, and I cannot get it for my healthy breast, but my sister in Ontario gets it because I had cancer. Explain that to me.
SIÂN ILES: Rafah, I want to explain something. Our high-risk program . . .
THE CHAIR: Order. A point of order. MLA Regan.
HON. KELLY REGAN: Dr. Iles, her name is MLA DiCostanzo . . . (interruption) This is a formal proceeding. I appreciate you probably do that when you’re dealing with patients, but this is a formal proceeding, and her name is MLA DiCostanzo. Thank you. (Interruption)
[1:30 p.m.]
THE CHAIR: Just a second. What happens is the microphone goes off because only one person is allowed to speak. Thank you, MLA Regan. I should have caught that.
SIÂN ILES: We do have a high-risk program, Rafah, and what I encourage anybody to do is to have a risk assessment. If you go to our website, there is actually some guidance on how to have a risk assessment done. If you have had a previous diagnosis of breast cancer and you meet our high-risk criteria, you are eligible for high-risk MRI screening. That’s the important component to know. If you’ve had the diagnosis of breast cancer, or even if you have not, make sure you get a risk assessment, because we do have a high-risk program.
RAFAH DICOSTANZO: Please explain to all of us what high-risk is, because my mother had cancer, I have had cancer, and I’m refused to have it. What is considered high-risk?
THE CHAIR: Sorry. MLA DiCostanzo, I’ll let you finish so it’s on the record.
RAFAH DICOSTANZO: There are three things, and I know I can’t have it. Many women - I will reach another point that you said in your things after you answer that one, please.
SIÂN ILES: Well, there are recognized risk models that are used to estimate breast cancer risk. Some of the things we know contribute to high-risk are, for example, genetic mutations, women who have had mediastinal radiation when they were younger. Those are also considered to be at high risk, and they would be included in our high-risk program.
The risk models that we recommend are the IBIS and the CanRisk models, and both of those include breast density as one of the risk factors. That is where we go, is using the recognized risk models, which do establish pretty accurately who is at highest risk. That’s who we can offer the high-risk screening program to.
RAFAH DICOSTANZO: I didn’t hear that my having cancer puts me at a higher risk. We know that many women who have had cancer in one breast, it reoccurs in the second. You’re telling me: No, wait until you have another lump, until you’re in Stage 2 to 4, until I feel the lump - either myself or through a doctor - before I will be qualified for an MRI. Is this even conceivable to most women who are sitting here? Wait until you’re Stage 3 and 4 before you’re allowed to have an MRI? You’ve had breast cancer, and you’re not allowed to have an abbreviated MRI.
SIÂN ILES: I’d just like to point out that we’re really beyond the screening discussion here. We're really now in a discussion about something called surveillance. Once you’ve had the diagnosis of breast cancer, then we’re talking about surveillance, not primary screening for asymptomatic women. As I said, we do have accommodation for high-risk women to be continued in the high-risk surveillance program, and we do have to depend on the risk models.
Average risk is about 13 per cent. Intermediate risk is 13 to, say, 20 per cent, and high risk is 20 per cent and above. We say 25 per cent in our guidelines. We actually do accept 20 per cent. There has to be a point at which we can make people eligible and people not eligible; otherwise, we would be overwhelmed with the needs.
RAFAH DICOSTANZO: I will come back about the overwhelmed and the need and something in your speech, but there’s also another word that you spoke about in your opening remarks. It’s called, Nova Scotia does not have opportunistic screening. I learned about dense breasts because one of the patients who are here spoke on the radio back in October. I was going through chemotherapy. I didn’t even know about my risk of dense breasts and that after cancer I will not be allowed to have an MRI as a regular. She went on the radio to say: I go to Ontario to get an extra ultrasound. I thought: What? That doesn’t make sense. She’s had a mastectomy, she’s had a story like mine if not worse, and she’s still denied an MRI here.
You’re calling her and me - I wish in 2022, when my husband took me to Greece, I had spent $200 to get an MRI and save this government and these taxpayers $200,000 of treatment and the hell that I went through. It was wrong. It is wrong what we’re doing here. We’re waiting until people need chemotherapy before we treat them. These women need a voice. Other provinces have seen this, and they’re not waiting for us to die to base it on mortality. That’s what we’re doing. We’re basing everything on mortality. You want me to die to be a statistic, and then it will increase the numbers for you so you can give me an MRI. No. No, this is wrong. I don’t want my daughters, their daughters, to go through what I went through. I will speak until I die or until this is changed, Dr. Iles.
And I love you, because I’ve heard - truly - my family doctor knows you and thinks the world of you. The radiologist who did my mammogram loves you. You are a wonderful woman. You are stuck on something that doesn’t make sense, and this policy that we’re doing is causing a lot of harm to women. We can do something about it, just like Dr. Gordon did. Just like Ontario did. My sister should not be allowed to have the MRI above me. It’s wrong. (Interruptions)
THE CHAIR: Order. Just to be clear, one person is speaking. If the gallery interrupts, the gallery will be asked to leave.
I understand what we’re at, but - no, MLA DiCostanzo, you’re fine. I just wanted to let everybody know that no commenting from the gallery.
RAFAH DICOSTANZO: The word “opportunistic” - it is wrong. To call me opportunistic - I wish I were smart enough to have the MRI for the $200 in Greece. I will go to Toronto until the policy of Nova Scotia changes. I’m not waiting for it to be Stage 2 or 4 before I catch it. That’s what you’re offering me in Nova Scotia under our policies.
These policies have to change before more women and more younger women - I had it in my sixties. I can’t imagine what it does to a 40-year-old, losing your breast, losing your hair, losing your identity as a woman, literally. I can handle it at age 60. It’s much harder. It breaks families. It breaks so much. You’re wrong - we are doing it wrong, and it doesn’t even make economic sense, what we’re doing. We can save money and we can help women. It’s wrong, what we’re doing to us.
“Opportunistic” - please take that word away. They are lucky to have opportunities to go and pay for it. We need - if you don’t want us to have the private, offer it to us. Nobody will go. Why would I go and have it somewhere else if it’s offered to me here? Why would I? Why would Elizabeth, who spoke on the radio, who does a trip every year at her own cost? We can’t do this to women. We are discriminating.
And talk about discrimination - I also heard that it’s much higher in Black women and multicultural women. I’ve never even spoken about this. Most of the women who are here are white. So imagine how high, how much higher, it is in the other population - but they don’t speak up. I am their voice. Let’s help them.
THE CHAIR: MLA DiCostanzo with 32 seconds.
RAFAH DICOSTANZO: All right. What’s the question that - I would go back and just ask one thing later.
Elizabeth, do you have anything? How much time do I have?
THE CHAIR: Well, now you have 19 seconds.
RAFAH DICOSTANZO: I thank you - all of you - truly. Please do right by women. It is your daughters who I am speaking for. I have two daughters. I’m not going to let them go through this. Never. Hopefully never. We are lucky, as women, to have organs on the outside that can be tested easily.
THE CHAIR: Next it will be the NDP for 20 minutes.
MLA Leblanc.
SUSAN LEBLANC: I’m just going to ask a couple more questions about breast cancer screening and dense breasts. Dr. Iles, in the Fall you mentioned in an interview, and you’ve sort of talked about it here today, that we need to collect more evidence to gauge the value of the supplementary screening for individuals with dense breasts before we can put public money toward it.
Can you elaborate on the type of evidence that would be needed? What would indicate, for you, a change in policy? What would prompt a change in policy?
I want to encourage people to come to screening. Don’t worry if you have dense breasts. We’re not as good, but please come to screening anyway, because the vast majority of people do not have Category D dense breasts. The Category D dense breasts - there is some evolving evidence, published here in Canada by Dr. Jean Seely, who is a colleague of mine. I know you all know Jean. She’s a wonderful human and very interested in dense breast advocacy. What she was able to show is that in provinces that provided annual screening for breasts - they didn’t always have the breast density as part of the information, but it was basically looking at that particular issue - that we decreased something called interval cancers.
In a screening program, an interval cancer is a cancer that occurs between screens, something like Rafah was talking about here. You have a negative screen and then you’re diagnosed with a cancer later. Unfortunately, it’s a real problem in all screening programs, no matter how good they are. It’s one of the things we monitor as part of our program. We evaluate all interval cancers on an annual basis to see what happened: Was there something that could have been different, was this a true interval cancer - lots of information that we glean from that.
This study did show that there was a decreased rate of interval cancers with annual screening. We implemented our program, the annual recall, based on that data and other data that we have for Category D. When it comes to supplemental . . .
THE CHAIR: Just one second. I’m pausing your time for this one, by the way.
Dr. Iles, just a reminder, please refer to everyone as MLA and their last name. It’s the same reason as why it’s Dr. Iles.
SUSAN LEBLANC: I thought the Chair was going to explain that sometimes we might interrupt just to ask for clarification, and now I can’t quite remember what the clarification was. Oh yes, I think it was: In Nova Scotia, if you have Category D dense breasts, you can get a mammogram every year no matter how old you are. Great.
SIÂN ILES: When it comes to some of the other modalities for supplemental screening, the evidence is not as strong in the sense that we don’t have enough evidence. We have some evidence. We do know that, for example, supplementary ultrasound, contrast-enhanced mammography, and abbreviated MRI all find more cancers, but to establish a population-based program, there are other features and other factors that have to be taken into account.
If you look at the World Health Organization and the principles they use to establish a population-based intervention, then we’re not at that standard of evidence yet for supplemental screening for dense breasts.
SUSAN LEBLANC: That’s helpful. Yes or no question: Can you confirm whether that data is being collected in Nova Scotia right now - the data that you would need? Are you looking at larger population data, or are you looking at Nova Scotia data?
SIÂN ILES: We’re really looking at randomized - there will be no randomized control trials, most likely. What we’re looking at is more evidence that interval cancers are decreased. Screening is always a balance of benefits and harms. Harms are things like a false positive, having a biopsy you don’t need. There’s a concept called over-diagnosis - which is a real thing - which is that some of the cancers we find may never have become clinically evident during the woman’s lifetime, and we are now putting her through treatment that she may not have needed, but we diagnosed a breast cancer in a screening program.
That and a number of other factors, including the environment that you’re providing the screening program in, are very important in deciding whether to implement a population-based program. That really has not been a consensus yet anywhere in the world.
[1:45 p.m.]
SUSAN LEBLANC: One of the other things I’ve heard a lot about in this discussion is the idea that when we’re looking at whether to implement a program or not, we look at the result being life or death - like, do people die from it. It does seem to not make sense to not have a program because not enough people are dying, as opposed to a situation where people might not die, but they are going to be a lot sicker and they’re going to have a lot more treatment, they’re going to lose their hair, and all of the things that my colleague has pointed out.
One of our jobs as MLAs and government is to manage money. Can you speak in terms of when you’re looking at your end results, are you looking at numbers like lives saved, or are you looking at - what did you say (interruption) - how great your life is or how bad your life is, whatever that is called? Also, has there been a lot of work done on the examination of a budget? How much would it actually cost to provide extra screening for people, at least even with Category C and D breasts? Have those things been studied?
SIÂN ILES: We are really at the moment focused on our high-risk program. We want to ensure that those women at the highest risk of breast cancer are getting good care. That is, at the moment, our focus. That doesn’t mean we’re not monitoring and looking at the numbers of women who have Category D breasts.
Just to clarify, pretty much all of the evidence for supplemental screening is in Category D, rather than Category C. We have about 25 per cent of our population in Category C? (Interruption) Twenty-three per cent, and 2 per cent in Category D. So if you know that we do 56,000 screenings or more every year, you’re looking at a quarter of those women requiring supplemental screening if we include Category C and Category D. That will give you some idea of the scope of what would be needed if we were to implement a supplemental screening program.
SUSAN LEBLANC: Great. I’m sort of moving away a little bit now, and just in general, with the 30 mobile screening locations included in the Nova Scotia breast screening program, can you tell us how often screening appointments are offered? With the mobile ones, how often would someone in a community that gets a mobile clinic have the ability to book an appointment? How does that work? I’ll ask that first.
SIÂN ILES: When we designed the stops for the mobile unit, we used a principle called geomatics, where we looked at the geographic distribution of women by age and postal code across Nova Scotia. We then designed the stops so that ideally, each woman can have the screening mammogram at the appropriate interval.
The intervals we recommend are age 40 to 49, we recommend annual screenings. We’re one of the few programs that’s able to do that. At 50 to 74, if you’re average risk - if you don’t have a family history, or a history of a breast biopsy with atypical changes, then we recommend every two years. That’s how these stops are designed - to try to allow people to have access.
We also place priorities - as MLA DiCostanzo pointed out - on the Native population and other underserved populations. That is also a focus that we are quite interested in. We’re doing a lot of work in that area as well to try to ensure - as MLA DiCostanzo points out - that some of these other women who don’t have equitable access to screening have a better opportunity.
I would like to talk about the concept of equitable access.
SUSAN LEBLANC: I would like you to talk about equitable access, but I have a lot of questions. Obviously, I know how important it is.
In terms of the way you’ve described that - I get that. I have just had a mammogram. Basically, what happens with me - and I might talk about this, if I have time when we talk about the colon cancer screening - is that I go: Oh, I think maybe I’m due for a mammogram. Then I call, and they’re like: Yes, you should have one in six months. So I’m like, okay, and then I book it now. The fact is that if I called in six months, I wouldn’t be able to get one in six months. So this goes to how much we’re being served by the screening.
I guess my question is, especially in the mobile areas - and I don’t know why I’m pointing at my colleague across the way there. I guess because he represents a town near Digby. Are people able to get their appointments every year, or are people finding that they’re calling, and then they’re saying: We don’t have one for a year and a half? That’s A part, and B part is: Would you recommend that we have more breast screening available in general?
SIÂN ILES: That’s a great point. First of all, we only have about a 46 per cent participation rate in Nova Scotia. We would like to have 70 per cent minimum. First point I want to make for everybody is: Come for your mammogram screening. That is our first line of defence. The more people who come, the better. Population-based screening has been shown to decrease mortality in the screened population by 40 per cent. The other very important point is if you come, come regularly. You pointed that out. Don’t just come once and assume it’s good for five years. It’s not. You need to come regularly, you need to come at the appointed time, as Dr. Hollenhorst pointed out.
As far as the wait time, those are published, and Trena I think can talk about that.
SUSAN LEBLANC: That’s okay. With respect, I wonder quickly - this pen is hilarious by the way, and I enjoy this type of humour, “Woop woop, test your poop.” When I turned 50 last Fall, I got that kit in the mail, and I was like: This is amazing. It just gets mailed to you. It’s amazing. I was shocked to know that only 42 per cent uptake is in that program. Why wouldn’t you do that kit? They mail it right to your door. Same thing. Again, I wonder if there’s a way to send a letter when you turn 40 or whenever you do annual ones to say: Now you’re eligible, come on in for the fun.
It’s way more fun to get a test like that than it is to have cancer. I don’t mean to joke about it, but honestly. I’m shocked at the numbers you’ve just given me. I don’t know what we should do about it, but we should do something.
I did want to ask - I want to change my tack a little bit to HPV testing for exactly this reason that we’re talking about. Dr. Hollenhorst, you did speak about the fact that HPV testing is on the way, and I just wanted to get some clarification on some of what’s been happening with that. We put out a press release today calling for the government to make sure that this program is implemented as soon as possible because it will save lives. Can you talk about - you mentioned that it’s maybe a couple of years away, but what has been done so far and what are the barriers to making it happen tomorrow?
THE CHAIR: You want Dr. Grimshaw? Dr. Grimshaw.
DR. ROBERT GRIMSHAW: We’re actively planning for the transition to HPV. There are a lot of reasons to do that. The first and most pressing reason is it’s a better test to screen women who have been vaccinated through the school-age program against cervical cancer. We know that the vaccine through the school-age program will prevent - the one that was used - will prevent 75 per cent of cancers. The new one is probably closer to 98 per cent. As they age into screening, if they have an abnormal test, it’s more likely to be a false positive. They have to come in, see someone like me, have biopsies done, all sorts of things. The HPV test is a better test to keep them out, in theory.
The other reason is technologists who read pap smears are becoming thin on the ground. Schools have closed around Canada. There are only two that are still training people, and neither of them is in the Maritimes. The ability to attract people down here to sustain screening will pass.
HPV screening is a little better than regular pap testing. Much like breast testing and colon screening, the main problem is people not having the test regularly, not taking advantage of the test that’s available. Where we stand right now, we have an active planning process that’s looking at the transition. It involves all sorts of things needing to be done. Right now, pap smears are done at five or six labs around the province. Under HPV testing, what happens is you get an HPV test done. If it’s negative, you’re good to go. Unlike pap testing, where it’s every three years, HPV testing if you’re negative is every five years. That’s a big benefit.
If it’s positive, they then take the same specimen and do a pap test on the same specimen, and that determines whether you get a repeat test done in six months or a year, or if you come in for a colposcopy. The number of pap tests in the province will go from around 55,000 - 60,000 or whatever we’re doing a year now down to probably 3,000 or 4,000, which will only be in one centre. That has to be rationalized.
The machines that are used to do the HPV testing need to be decided upon where they’re going to be. The companies need to be chosen. The process we figure is going to be about two years from now before the HPV testing rolls out, but it’s coming.
SUSAN LEBLANC: Do you have any kind of ballpark price tag on a yearly cost for that program when it comes?
ROBERT GRIMSHAW: It’s been submitted. The nuts-and-bolts part has been submitted through the lab business case, and we’re just teasing that apart to see what pieces of that are covered and what are not. The other change for the program is we’ve talked about navigation, meaning having someone who contacts people with abnormal results and navigates them through the process of biopsies for breasts, colonoscopies for colon. We’re looking to transition cervical screening to the same standard as the rest of the programs in the province and navigate things. If you have a negative test, you’ll be able to see your negative test and you’ll know you’re good for five years. If you have a positive test, you’ll have a navigator contact you and tell you that the results are abnormal.
Overall, there’s a little extra cost with that. The overall pricing for HPV testing versus cytology is pretty much cost-neutral and will only probably get cheaper as time goes by, because lab tests tend to get cheaper, whereas humans reading cytology tend to get more expensive over time.
SUSAN LEBLANC: Other provinces use their cervical cancer screening programs to keep track of individuals who are due for a pap test, and letters are sent to patients to remind them. Again, I just refer to the colon cancer screening program that sends a thing in the mail. I mentioned: Wouldn’t it be great if the mammography program did or the breast screening program did? Is that something that you might look at in terms of HPV and breast cancer screening? I don’t know who wants to answer that.
ROBERT GRIMSHAW: For cervical screening, we have not done that. We’ve done some research projects on it. It does get a yield that’s small. Going forward though, I think we’re pretty excited about some of the opportunities with apps or YourHealthNS and things like that as a way to remind people that they’re due for a test. Certainly, part of the navigated process that we’re looking at is reminders. Again, the most important thing is getting the testing done.
We know we’re very good in the province if a woman has a pap test. The people in the province with cervixes are very good at following up - it’s the people who aren’t being tested regularly who are the problem.
SUSAN LEBLANC: That also speaks to the lack of primary care attachment probably, because you’re not going to go to a mobile clinic, for instance, to get a pap if you don’t have a primary care provider. Back in December, the executive director of the Halifax Sexual Health Centre noted that they’d seen a rise in the number of people coming in to get paps because also, when they do have a primary care provider, they’re being told that they don’t do paps anymore as part of their practice. I’m just wondering: Are any of you aware of the problem, and what actions are being taken to ensure that the care that primary care patients receive includes necessary cancer screenings?
ROBERT GRIMSHAW: Absolutely right. We know, and I commend the sexual health clinics around the province. They have stepped up for women who don’t have pap tests. I know that for me in the colposcopy clinic, 30 or 40 per cent of the women I see do not have a nominal family doctor who’s taking care of them. They get their services provided usually through sexual health clinics around the province or through well woman clinics around the province, and they make all the difference.
That’s one of the things that’s very appealing about the transition to HPV screening, is number one, we’ll change the number of tests that are being done from every three years to every five years, so there will be more time available to do that. The other advantage of HPV testing is that it does offer an opportunity for self-testing for some patients to have a self-test done that can work like the colon test. You get a kit in the mail, you test at home, you mail it in, and you get a result. That way, for women who do not have an attachment and have a hard time getting in to see someone through a sexual health clinic, it gives them that option. That’s partly why the navigated approach is . . .
THE CHAIR: Order. At 20 minutes, I say, Order, and I have to cut you off. I apologize for that. PC caucus. MLA Barkhouse.
[2:00 p.m.]
DANIELLE BARKHOUSE: Dr. Hollenhorst, during your opening statement, you said: Stay tuned. It’s now been almost an hour. Have I stayed tuned long enough? (Laughter)
Right now, we have four different - we have lung, breast, colon, and cervical cancer. I’m just wondering: Are there plans to expand the services for each of these programs in the future?
HELMUT HOLLENHORST: As I’ve briefly mentioned, our initial cancer controls were really focused on stabilizing and optimizing. We had challenges to continue providing accessible and timely care. We have been quite successful with this so far.
Looking forward into the next five years at what will be the priority, it became very clear that if we don’t go down to the root of the cause of cancer and early detection - and early detection does include screening of patients who are symptomatic, accelerating the workup of suspected cancer, so that the time from first symptom to cancer diagnosis can be shortened. That has been identified as the highest priority moving forward in the next few years.
Also, the time is right. We have implemented digital solutions in health care, being the OPOR, the Oncology Transformation Project, YourHealthNS, and C3 and others. These are all solutions that must integrate and must be available to all Nova Scotians. This does include access to new digital and innovative solutions to reach patients, Nova Scotians, families, and communities. We envision that we work together - all of our four screening programs: the three within Nova Scotia Health Authority, the breast cancer screening program, and the IWK Health Centre - and work toward one-entry screening and cancer prevention, so that essentially all the appointments can be made.
The follow-ups that are necessary can be sent to patients. We can combine this with health and wellness education. We can launch questionnaires and patient feedback in real time in response to this, and hope, as such, that the word spreads. Those who are participating are usually hearing. But if we stay in contact, this will be a theme. This will continue to be discussed - go out into the family, into the community - another way of engaging more people to get screened.
All of our screening programs will be continually evolving. As we have heard, the dense-breast and high-risk patients with breast cancer, the HPV testing within the cervical cancer program - we are also looking at innovations in lung cancer and colorectal cancer screening. We are also looking at new methods that are not standard of care yet - looking at breathing tests and genetic sequencing, circulating DNA, which can be tested with just a sample of blood that can be taken everywhere and anywhere.
We are involved in research and innovation, and have connected with industry partners, but this is work in progress. A lot of these are not ready yet for becoming standard in practice, but they will. We always try to stay on top of things and be happy to pilot some of these programs as they become available.
DANIELLE BARKHOUSE: I think maybe I heard that there will be additional screening programs for cancers not currently offered, like, I don’t know, melanoma. I’m not going to put words in your mouth.
HELMUT HOLLENHORST: Right now, we are working with the Canadian Task Force on Preventive Health Care, and looking at the best evidence and programs that are available and that are currently being implemented nationwide or beyond.
Melanoma certainly is increasing in Nova Scotia. We have high rates of melanoma diagnosis and other skin cancers. Still, there is no established skin cancer screening program currently available or recommended. CPAC has not made it a priority yet, and I am not aware of any active programs being under way right now.
The question is: Do we need a population-based screening program for melanoma and other cancers, or are there different ways of patients being able to access care?
We are in conversations with the division of dermatology. There are great strides made in new technology, AI-driven technology, that actually may be helpful to be utilized in these kinds of programs.
DANIELLE BARKHOUSE: I’m pretty sure - maybe I’m not sure, but a large percentage of the people in this room have been touched by cancer. My father passed away from not lung cancer but a sunburn on his lungs, and brain cancer as well. He was the world to me. It’s very important to all of us.
We are aware that there are certain types of cancer with unique challenges, if you will. When it comes to early detection, how are screening methods determined and implemented here in Nova Scotia?
HELMUT HOLLENHORST: All of our screening programs are based on best evidence. We have a close relationship with CPAC, which is helping provinces and jurisdictions along establishing screening programs. An example would be the recently implemented lung cancer screening program work that was done over several years, co-developed with First Nations and other equity-deserving populations, building the infrastructure necessary to implement such a program, the training, the teaching not only for patients and families but also primary care providers, implementing lab and additional capacity in diagnostic imaging, those who read those images, who report those images and training patient navigation.
There are a lot of steps that we need to follow to carefully implement such a program, and then decide how we’re going to roll it out. What we have lately used for this is research that is provided by one of our epidemiologists, Dr. Nathalie Saint-Jacques, who was looking at 300 distinct geographic areas within Nova Scotia and looking at determinants of health and cancer risk. We have data for over 20 different kinds of cancer to determine where cancer risk is the highest. This has usually helped us to decide where to start such a program, and then from there spread across the province.
There are a lot of learnings when we start a new program, and we integrate those learnings and have our programs periodically reviewed before we decide how to further expand to really make sure all providers are best trained and best prepared, family physicians and the public are informed, and the resources are in place to expand. It would be ethically not acceptable if we offer screening and then don’t have the resources in place to follow up with diagnostic tests and need to follow up for any suspicious finding.
DANIELLE BARKHOUSE: That leads me to ask: How does Nova Scotia compare to the rest of the country in terms of access to cancer screening? I know we heard a little bit about it in your opening statements, but . . .
HELMUT HOLLENHORST: We have the four screening programs, as we have outlined, and these programs are accessible to all who qualify and meet the criteria for a screening program. Also, all of our screening programs are navigated programs, which means that there is follow-up after being entered into the program, which can be done without a family doctor through self-referral. We try to minimize the barriers as much as possible.
What we still see is that the uptake is not very high. For the colorectal screening program, we have currently a 44, 46 per cent participation rate. We would like to have 60. For the cervical cancer screening, correct me if I’m wrong, I think we had, pre-COVID-19, 55 and now it’s 48.5. We’re not quite where we were before. Breast screening: you referred to that as well. Lung screening: there are no standards existing yet because we were the third or fourth province in Canada that implemented this program. There are no firm standards defined yet. It’s accessible, but the participation rates are still not optimal.
DANIELLE BARKHOUSE: Dr. Iles, I gave you a little bit of a break because you were asked so many questions.
As someone who has never gone through breast cancer, I was listening intently to the conversations, and I learned quite a bit. You had said - and I’m just kind of piggybacking off the question about screening - that once it’s detected, once you go through this, it goes through surveillance. Can you just tell me quickly how that is, for myself and anyone at home watching? I know that I’ve emailed a bunch of ladies to watch, because these committees are quite important and informative.
THE CHAIR: Dr. Iles.
SIÂN ILES: That’s a great point, and I think it’s very important. In breast cancer, after you’ve had the diagnosis, you’re no longer eligible for screening mammography. You would have to come to one of the diagnostic sites to have your mammogram done.
Where we’re unique, compared to all the other provinces, is that once you come for your first post-cancer mammogram - and those are recommended annually, as long as you’re in good enough health that you would be able to have treatment if you had a recurrence or a second breast cancer - then we actually will proactively book you for your next mammogram. You don’t need to worry about your family doctor or anybody sending you a reminder. Those are proactively booked, and the appointment will be sent to you. That’s unlike all the other provinces, where if you had a history of breast cancer, you have to depend on your primary care person, your oncologist, to ensure that you get annual surveillance mammography, which is what is recommended.
The difference really is that screening is for asymptomatic people who have not had a diagnosis of cancer. Surveillance is once they’ve had a diagnosis of cancer, looking to see if they have a recurrence, if they have a second malignancy. We do know - as MLA DiCostanzo has pointed out - that if you have a history of breast cancer, your risk is somewhat higher than the average risk. That risk is very difficult to quantitate, and it’s really the job of the oncologist and the breast surgeons to figure that out. That’s way past my level of expertise. But what we do have currently is annual mammography surveillance, which is what is recommended.
DANIELLE BARKHOUSE: How much time do we have left?
THE CHAIR: Seven minutes, 40 seconds.
DANIELLE BARKHOUSE: Okay, I have to share. There are four of us. I don’t want to, but I will. (Laughter)
THE CHAIR: Are you going to tell me who?
DANIELLE BARKHOUSE: I guess. MLA Palmer.
THE CHAIR: MLA Palmer.
CHRIS PALMER: Thank you, MLA Barkhouse. I appreciate that.
This is a very informative and educational meeting we’re having today. It’s an emotional meeting as well. I want to welcome our guests who are here visiting us today in our committee as well. There are not too many families, as my colleague has said, that aren’t touched by - whether it’s breast cancer, any type of cancer.
One thing I’m getting from this information today, and this education today, is that we all have a lot of work to do in getting more people to do screening and testing. I take that challenge on as an MLA, for sure, I can tell you.
Dr. Iles, you also said that screening is not 100 per cent accurate. I guess we can never get 100 per cent, but we all want to share the goal of improving outcomes and the negative effects that cancer can give people.
I have a couple of quick questions. The first one, I guess, is from a rural lens. I represent a rural constituency in the Annapolis Valley. For individuals across the country, I’m sure some of the barriers are early detection, and can often be local access to screening services in some rural areas. Can you discuss with us how some of these initiatives we’ve been discussing today are working to provide better access for people in rural areas who might not live close to a hospital or a clinic? I’m not sure who might want to touch on that.
SIÂN ILES: As we’ve pointed out - as MLA Leblanc pointed out - we do have a mobile screening service that is expressly designed to do that for breast cancer screening. So that’s my answer for breast cancer screening. The mobile service is designed to do that - to allow access to underserved communities, underserved populations, and it is designed with the information we have on where people are and their ages, et cetera, to try to make sure they have good access for breast screening. That was the reason we did the mobile.
[2:15 p.m.]
HELMUT HOLLENHORST: One example is the colorectal screening and prevention program - 186,000 kits are sent out every year. They come to people’s houses where they can take the tests in the privacy of their homes. They can send the test back and get the result and a call from the patient navigator, if and when they qualify or should have a colonoscopy. They will also make arrangements to receive such a colonoscopy, which usually is done within the particular zones or locations, closest hospital when possible. This only can be done by specially qualified and trained endoscopists who participate in the screening programs. This is a home kit. Hopefully with HPV testing similar, we want to reach people in their homes so that they’re not dependent on a family physician and hopefully reduce that barrier of going somewhere, making an appointment, and all this kind of thing. It’s just more accessible this way.
With lung cancer screening, the test that’s needed - it’s a self-referred program. Again, it’s a navigated program where there’s education about lung health given by phone, where there’s a risk assessment done and smoking cessation offered. We have the most advanced program in the country to give free nicotine replacement and the associated coaching and supports to patients and families. Again, that can be everywhere, regardless of where people are living.
If they do need to have a test, a screening CT scan can be done in any hospital where a CT scanner is available. The challenge we have is not the CT scanners; the question may be asked: Why don’t you put a CT scanner in a truck and drive around the province and get people their CT scan? The challenge we have is the technicians. We can’t get any technicians. Technicians are a rarity. We could run our units or our machines much longer and have plenty of access if there were adequate human resources available.
CHRIS PALMER: You’ve talked about the navigation part. I think it maybe leads into the surveillance part afterwards, too, that Dr. Iles had mentioned. I think, Dr. Hollenhorst, in your opening statement, you might have called them nurse navigators, and then I’ve heard cancer patient navigators. Are we talking about the same thing, number one? I think that’s an important role people need to know more about. If you could expand a little bit about that. I know you’ve just touched on it here, but maybe expand on that role. I think you might have mentioned there’s potential to expand that role going forward too.
HELMUT HOLLENHORST: Navigation has been a core principle for the Nova Scotia Cancer Care Program for many years. Where this was first introduced, I think, was in breast screening years ago when Dr. Iles started the program. We also introduced patient navigators in our community oncology science, which is a different function, a different role. At the end of the day, it’s the primary contact for our patients being diagnosed with cancer or suspicion of cancer to make an immediate contact with the patient and have them navigating the system, avoiding multiple conflicting appointments, providing information, and getting social work involved, any kind of health support, transportation support, and so on and so forth.
For the navigation for the screening programs, it’s again this person one-on-one who’s accessible to any Nova Scotian who is either entering a program or has an abnormal test to decide if they qualify for further diagnostic testing and how this would unfold. It’s again a direct contact with a health care professional within a short time window to help patients along that journey.
There are other models of navigation as well. When we talk about patient navigator or nurse navigator, it’s essentially that interface between the patient, the family, community, and the health care professionals and specialists in oncology.
CHRIS PALMER: We know that time is of the essence when it comes to maybe some kind of test that might be a little awry, and the role of those navigators. Do you feel that obviously we need more? We can always use more. Do you feel that we can move towards having more numbers that are going to be giving better service? Is that what you’re . . .
THE CHAIR: Dr. Hollenhorst with 20 seconds.
HELMUT HOLLENHORST: We have been very fortunate within our business case to stabilization of cancer care that funding was provided for various patient navigators who are actively already in their jobs or are being onboarded. We’re also looking at hiring liaison individuals who are situated within population groups of equity-deserving . . .
THE CHAIR: Order. We’ll be in the final round. It will be seven minutes.
I’ll start with MLA DiCostanzo.
RAFAH DICOSTANZO: Thank you to Dr. Hollenhorst. I think you just touched on my next question. That’s the shortage of technicians in the province.
I think if there’s anything I can deduce from what was said today, it makes incredible sense to do pre-screening and to catch things early, and we’re dying for - we’re saying, how come only a 43 per cent uptake, or this - we want people to take it. But when it comes to breast cancer, we’re denying them. To me, it does not make sense. However, it has to be a reason, and the reason is the shortage.
I think Dr. Iles’ hands are tied. She would love to offer more screening and more, but her hands are tied because of the shortage that we have.
I would like to ask specific questions of what we’re doing for the future. I was told from a mammogram, or somebody who gave me - we’re training, I believe, technologists. They’re all trained as an X-ray technologist - a four-year program, B.Sc. - and then they specialize, either in mammography or MRI, and this is extra training they take for so many months. The pay is low. Right now, a nurse who is doing just the same four years is making $20,000 to $30,000 more. Very few technicians are going into that field, because we don’t pay them enough, and the incentive to take those extra is only a couple of dollars. So there’s no incentive for them to specialize in new machines.
We are graduating, I was told - please correct me if I’m wrong - 10. We literally need 30 today, and we want to double the population, so we need 60.
What is the department doing to prepare for the future, and where are we? Dr. Iles, can you give us more? Who is responsible for making decisions on how many radiology technologists, as well as for our lab technicians? They are in the same boat. What used to take two weeks for the biopsy results now is taking six weeks. It’s inhumane and it’s wrong. My cancer, when I did the biopsy, was the size of my nail. By the time I got my - it was this big. I could feel it for the six weeks.
What are we doing to prevent the excess wait after biopsy? How are we hiring? How are we incentivizing? Are we going abroad to bring technicians from other countries like we’re doing with nurses and doctors? Who is responsible for that? If they could answer that, please.
THE CHAIR: Dr. Hollenhorst, who do you want for this? Is it you?
HELMUT HOLLENHORST: I can start and maybe then have others to add to it.
The health human resources crisis is not limited to Nova Scotia or Canada. It’s a worldwide crisis. Technologists - and not only technologists but also nurses, physicians, all of these health care professionals - are scarce. A lot are retiring. There’s a generational shift right now, and there’s more and more need for sub-specialization.
The models of care that are being implemented across the country also actually vary. You’re really looking at what is the right care for the right patient at the right time by the right provider, and how can we better define roles and responsibilities so that each provider can work to their full scope of practice and minimize and eliminate waste, where waste is present?
We have a number of different strategies that we try to employ. One of them is to buy seats at the Michener Institute of Education in Toronto, where technologists are trained and educated, and then be committed to a return of service while they get part or all of their tuition paid to do this work. Part of it is also to bring them in for some practice experience, to just get to learn and get to know Nova Scotia, get to know rural areas in Nova Scotia, and perhaps find a passion and a connection to start working here.
We’ve also implemented some sign-on bonuses. We not always, but more often, are more competitive with what other jurisdictions are offering and making available to these technicians.
It’s not only a matter of bringing them in but retaining them. We have to look at what makes it actually attractive for them to stay here in Nova Scotia. We have the ocean, we have nice people, we have all these kinds of things, but people have to make a living. They want to have a career and they want to have professional development. We’re really looking at what other supports we can wrap around these health care professionals to support them fully functioning in the role that they were given and that they were trained for.
These are some of the initiatives, some of the supports that we put in place. The Cancer Care Program typically has been quite successful in hiring, but we also have to be cautious, because we poach from other programs. We have to look at the health system at large. If we’re taking all the nurses, the acute care workers, the technicians, then other areas will run into trouble, so we are firmly integrating and collaborating with the rest of the health care system to try to meet that balance.
RAFAH DICOSTANZO: I didn’t hear what our numbers are now. What is your five-year plan or long-term plan? What are the numbers - what is the shortage? Are we literally just graduating 10 technicians a year for Nova Scotia? Are we graduating them here? I heard it’s Toronto, so you’re not graduating them here. How many seats do you see that we need right away, and how many in five years? What are you doing about increasing the numbers for both technicians and lab technicians?
HELMUT HOLLENHORST: I will not be able to answer that question because this is all part of the diagnostic networks that are outside of the governance of the Cancer Care Program. What I can speak to is technicians in radiation oncology. We have currently a number of positions open, and advertising and interviewing nationwide, and are able to give . . .
THE CHAIR: Order. MLA Lachance with seven minutes.
LISA LACHANCE: I’m actually going to continue on the discussion around workforce. I think it’s really important to note the important work being done by all health care professionals. I’m specifically thinking about the role of the NSGEU folks in this important work. The navigator positions you were speaking to - can you clarify how many of those positions are currently filled, or on the flip side, vacant, and who typically occupies those positions?
THE CHAIR: Dr. Hollenhorst.
HELMUT HOLLENHORST: That would be to one of our operation directors.
THE CHAIR: Ms. Rigby.
KRISTA RIGBY: As you’ve mentioned, the navigation role is an important role. It’s a role that has been successful across other areas of our Cancer Care Program and health system. As we launch the lung screening program, we wanted to ensure that - we know already that the folks who are coming in to the lung screening program are at the highest of risk. We wanted to ensure that they had the necessary supports around them to be able to navigate and to be able to refer them to cessation counselling, tobacco NRT, nicotine replacement therapy, if necessary.
We went with this model of a nurse navigator for lung screening, and we are going to be expanding this out further. We do have screening nurses within our colon cancer screening program as well, and we’re going to be basically putting in a business case to request additional resources. Right now, we have no vacancies. We have both positions that we have for lung screening filled, and it is possible that as we move forward, we will need more of these resources. As the programs grow or change, expand, we will likely need these positions in place. They are nurses that we are hiring.
To Helmut’s point, as we carefully try to recruit these folks, we also have to be conscious of where we’re pulling them from in the system. It’s a fine balance, but we typically don’t have issues with recruitment, or we haven’t so far.
[2:30 p.m.]
LISA LACHANCE: In that case, Dr. Hollenhorst had talked about sign-on bonuses and that sort of thing in the navigator roles. I guess that’s because they’re nurses, so they would qualify for the general nurse sign-on.
Going back to the lung cancer screening program, what is the timeline for expanding the cancer screening program province-wide, and based on that, what would your HR resources be?
KRISTA RIGBY: Another great question. As was mentioned earlier, our lung screening program was launched in January of this year, and we’ve initiated the program with two screening nurse navigators. We are currently working with our Eastern Zone partners to be able to roll out. We’re targeting late Fall this year. We’re also in early conversations with our Northern Zone and Western Zone partners, and looking at early in 2025, or Spring of 2025, I should say, for those two.
LISA LACHANCE: That’s good to hear, because I know too in the Eastern Zone, that’s where we have the highest rates of lung cancer. I’m wondering, in the almost six months since January, since the program was launched, have folks been coming from across the province to Central Zone for screening, or has it only been limited to folks in the Central Zone?
KRISTA RIGBY: To this point, it’s only been limited to the folks within Central Zone, and that’s for a couple of reasons. The first is that we definitely had to build a lot of infrastructure and create a lot of pathways and processes as we designed this program, certainly building those off best evidence and practice and other jurisdictions that have already rolled out lung screening. We wanted to do it on a smaller scale, recognizing that it obviously creates a little bit of an inequity across the province initially, but we wanted to make sure that we took our time, got it right, and rolled it out safely. Essentially, as the program is ready and as the zones are ready, we’ll gradually bring them on board.
Just to comment, our colon screening program has been in place for how many years? Fifteen? I was going to say 20 years, but it’s 15 years. That was rolled out in a similar fashion. It was rolled out by site. There weren’t zones back then, but by site and a very planned, phased implementation. That’s so we can build in an opportunity to evaluate and tweak things and change things as we go, as we find areas that didn’t quite work out the way we had hoped they would initially.
THE CHAIR: MLA Lachance with just over a minute.
LISA LACHANCE: I see someone else at the table who might want to hop in.
THE CHAIR: I assume that’s Ms. Kilfoil.
EILEEN KILFOIL: I just wanted to jump in on that because I think it’s a great question about if we opened up the lung screening program province-wide. One of the key things with lung screening is we recognize that it is such a devastating disease, and there was no pathway for the people who needed it most. If you weren’t attached or you had barriers, there was no way for people to get the CT scan. We deliberately have left it so that you have to live within the zone where it’s available, because travelling is a privilege that many don’t have. We wanted to make sure we knew what resources were available. We wanted to be as equitable and fair as possible.
We do get a lot of inquiries from people who are outside the zone. My team takes their name, lets them know it’s coming. We make referrals at that point to Tobacco Free Nova Scotia if it’s appropriate . . .
THE CHAIR: Order. Sorry.
MLA White, I believe.
JOHN WHITE: I have a couple small questions before I pass to MLA Young. I just want to say thank you to the eight of you and the hundreds, or I’m assuming maybe thousands of people you represent who are hardworking health care professionals who are helping us, as MLA DiCostanzo has explained - a very personal story. We were recently in Cape Breton and announced a PET-CT scanner, and I think the statistic he said was one in two will have cancer to deal with. He said it was higher in Cape Breton.
I don’t know what those numbers are, but I’m sitting here and I see the folks visiting in the gallery back there. I see you for who you are, but I see Leigh-Anne Cox back there. I see Cayla back there. I see my mom back there and my sisters-in-law back there. That’s what I see.
It’s a very personal and extremely emotional topic. I do thank MLA DiCostanzo. I really thank you for bringing a point to this as well. The story is heartbreaking. It’s wrenching, and it’s something we need to learn from, absolutely. But I do want to say that in recognizing as well all the work you are doing.
I remember when we were campaigning, we talked about following the health care professionals’ lead. I’m very happy that this is the calibre of professionals we have to follow because I’d be stumped. I have no idea where we were going to start. It shouldn’t be a political decision. I appreciate all you do.
My question - earlier we talked about an at-home screening test for cervical cancer within possibly two years? I was kind of wanting to know if you could follow up on that and tell us maybe who would be eligible for that, and how effective it would be. I think that’s what we talked about earlier. I see a stumped look, so I want to make sure I’m okay with that question.
ROBERT GRIMSHAW: We hope to roll out the self screening as part of the transition to HPV primary screening. It’ll come after the initial transition. In terms of who it’s best for, nobody knows that right now. That’s one of the things that we hope to learn. Some of that learning will come from places like B.C. where they’ve brought it out and have made it available. They’re trying to figure out how to use it best. Is it best to put out in drugstores and let people take it? Is it best to send letters to them saying: Hey, would you like to have a kit sent out to you? Or is it best to mail out a kit?
It’s a little different than colon screening. The kits are more expensive. The return rates I’ve seen in B.C. are around 30 per cent. Strangely enough, in B.C. initially, it’s lower in people who asked to have the kit sent to them than it was in people who had the kit sent out to them.
We hope to use it both by securing some funding through CPAC for research to look at it in special needs groups. We know that women - people with cervixes - who are visible minorities are under-screened. We hope to look at how to roll it out around the province.
We’ve had some initial discussions with the breast program. One of the ideas when breast and cervix were originally started by the late Bob Fraser, and I think the late Judy Caines, although I hope . . .
ROBERT GRIMSHAW: I hope I haven’t killed her unnecessarily (laughter), so apparently, I did. Judy Caines was to have a combined mammogram screening that had a little room in the back where you could get a pap test done. That proved to be prohibitive from a space point of view, but what we’d like to do moving forward is have a way of, if a woman’s coming in to have a mammogram done in a mobile clinic, to be able to have someone check her screening history for pap screening and say: Hey, you haven’t been screened. Would you like to have a test? Here, you can do it. There’s a washroom. Here’s what you do; let’s go - and take advantage of those opportunities.
Those are some of the things that we hope to do. We’re certainly excited about self testing. We know it can be potentially a solution for women who don’t have family doctors. It can be a solution for women who, sometimes in rural areas, know their family doctor really well and don’t particularly want to go in and have a pap test done by their next-door neighbour.
The little asterisk on self screening, though, is that if you’re abnormal, you’ll still need to have a pap test done. It’s not an answer for women who don’t want to be examined by physicians, because if it’s abnormal, that goes with the territory.
JOHN WHITE: The other question I wanted to ask is brief. I’m wondering, with the collaboration with the IWK Health Centre and the various cancer-screening treatments and programs, how that helps the youth in Nova Scotia.
HELMUT HOLLENHORST: We are one health care system. It just happens that we are in two different organizations, but we are all caring for Nova Scotians. Screening, as I said earlier, the same as accelerated workup of a suspected cancer, is of high priority to us. We always have been connected with the IWK, and more recently, more frequently and more often as we look at strategic directions of how to move forward. One of the big steps forward hopefully will be that one entry screening and prevention program using digital solutions that also help to teach, to educate, to advocate, but also to remind people when they are due for their next test and so on and so forth.
A number of business cases we have actually together put forward to serve our population, regardless of what institution is looking primarily at them, so we don’t want this to be a barrier. Just the opposite. I’m rather optimistic that we’re going to be successful with it.
I’m not sure if you want to add anything to it.
SIÂN ILES: Yes, I have to say that this vision for cancer care is very exciting for us. We’ve always been a little program on our own. This is our program. You’re looking at it right here. To be able to be part of a larger vision is really important, and we’re hoping that - as we’ve talked about - having a central intake, having a risk assessment - not just for breast cancer, for colon cancer, for lung cancer - having that central kind of point, and leveraging, as we’ve talked about, digital solutions for both encouraging people to come and reminding people to come back.
That’s where I really see this is going to be a huge advantage for us to be able to be collaborative with the cancer care system, which is Nova Scotia Health Authority. We’re in the IWK Health Centre, but as Helmut has said, we work shoulder to shoulder. Our vision is better care for Nova Scotians.
THE CHAIR: Thank you. That will be it.
There will be closing comments. I’ll allow Dr. Iles to go first, if you have any closing comments.
SIÂN ILES: I just want to thank everybody, particularly MLA DiCostanzo for sharing her story. It’s the kind of story that breaks my heart and I never want to hear. Running a screening program, those are the stories we don’t want to hear, but we know they happen, and we would like to be able to prevent that in the future.
What we need to do, as Dr. Hollenhorst has spoken about - we need to look at the evidence. We need to be able to develop a program that is properly done. We need to be able to make sure we have the infrastructure, we have the training, et cetera. When and if the evidence becomes available, that’s certainly going to be our planned approach, but it has to be done in an equitable manner as much as possible, and we do need the evidence, first of all, to start the process. Then also, we need to be able to set it up in a way that it is going to work. That’s what we were talking to with the lung cancer program. You heard how that’s starting in one site and then moving forward. That would be the kind of model we would follow, going forward, when the evidence becomes available.
HELMUT HOLLENHORST: I want to say a big thank you for inviting us today to speak to you, to listen to you. The way I see it, it’s another way of engagement. What we have done all along is not talking only internally but engaging our people, our patients, our families, our communities. That has made us so successful up to this point and guides us in the right direction. Everything and anything you’ve said today, you’ve asked today, is extremely important to us. You represent Nova Scotians.
We take it close to our heart to develop and advance our programs and hope we can continue having those conversations for better health care - in this case, for better cancer prevention for all Nova Scotians.
I also want to mention one other piece that has not been discussed at all today. That is the primary prevention piece - health and well-being. More than 50 per cent of all cancers can be prevented if we vaccinate our people, if we stop smoking and reduce drinking, if we test our dwellings for radon and for arsenic, if we provide better access to care, if we exercise more - healthy lifestyle choices - anything that belongs to it. But that requires accessibility of those measures, and that requires strong policy and support from government.
We just want to put forward a plea that you continue to advocate for healthier people and healthier community. It can prevent up to 50 per cent of all cancers, and the same measures will also prevent and reduce risk from many other health issues that all Nova Scotians have to fight.
THE CHAIR: I’d like to thank you all for being here. I’d like to thank the audience for being very patient and putting up with two hours of questions.
You’re excused. We are going to take a three-minute recess before we come back. We’re in recess for three minutes.
[2:45 p.m. The committee recessed.]
[2:49 p.m. The committee reconvened.]
THE CHAIR: Order. If I can get all the MLA committee members to be in their seats, please.
MLA Regan, I know you mentioned that you have a motion. That will be dealt with under any other business. Can you please send that to the clerk so she can share it? I assume it’s not a five-word motion. That way everybody will see it.
The first part of committee business is that July 2, 2024 letter from Derek Spinney, Nova Scotia Health Authority, in response to requests for information made at the May 14th meeting on Public-Private Partnerships in Health Care.
Is there any discussion on the correspondence? Seeing none.
At the last meeting there was a question regarding agenda-setting. I reached out to Mr. Hastings, and the response I got is once an item is put there, the majority votes. In the event that for example the PCs brought three forward and one of them did not get a majority vote, they would have two and they would be expected to bring another one at a later time. That would mean the NDP for one, the Liberals for two. Just because two come in does not mean the committee has to endorse all of them.
The other question was regarding putting motions together for them. The recommendation is based on the clerk’s recommendation to my right, and her preference, and any clerk’s, is that they are broken out. They really should not be grouped together in future. Each one will be dealt with separately. I asked the question because it was asked. Any discussion on that? Everybody good? MLA Regan.
HON. KELLY REGAN: I move that in consideration of the information received today from Nova Scotia Health Authority Cancer Care Program and the Nova Scotia Breast Screening Program, and in recognition of the significance and potential impacts of the Find it Early Act and Expanding HPV Testing Act, I move this committee write a letter - or the Chair on our behalf write a letter - to the Minister of Health and Wellness to pass this legislation.
THE CHAIR: That motion was sent to the clerk just now, I take it. It hasn’t been received yet, so I’d like to get that to the members before we deal with it. I don’t know if you want to wait to see how . . . (interruption).
KELLY REGAN: It is not a requirement that members of the committee have a hard copy of this or an electronic copy. It’s not a difficult motion. We heard about a couple of screening programs here today that are important for women’s health. We had previously talked in the Legislature about the Find it Early Act. We’ve talked about the Expanding HPV Testing Act. Folks know what this is. It’s not a complicated motion. It’s just to write a letter to the Minister of Health and Wellness saying that these two bills should be passed because these are important things for women’s health. I do believe that it’s not required that we all receive a copy of this.
It goes to our staffer - I’m not going to read it out loud here because I don’t want everybody . . .
THE CHAIR: Actually, the clerk’s email is public. It’s on the website.
KELLY REGAN: I call the question.
THE CHAIR: As you know, as being a previous Chair, calling the question has no actual merit here. I have a question.
I just asked the Legislative Counsel, and as the Chair, that’s why I asked for it. I have the ability to ask for it, so that’s why I asked for it to be sent out. Although the member may feel that the rules don’t require it, my interpretation of the rules would be totally different, as you know. For this one, that’s why I wanted it sent out. Although you say it’s a simple motion, it’s a lot of words. I believe it’s going out now. What we’ll do is I’m going to hold your motion, because I’m assuming MLA Leblanc is not asking for a motion. I’m going to see what she wants, and as soon as she’s done, they’ll have enough to discuss. MLA Leblanc.
SUSAN LEBLANC: This falls under other business, Chair. I just wanted to first of all thank the clerk for her excellent emails in advance of the meetings where we see the pronunciation of our witnesses’ names and the preferred pronouns of our witnesses. I wanted to ask if we could go one step further, and that is for people who don’t have an official title in front of their name like a doctor or an MLA, and where it’s just Trena Metcalfe, I’m wondering if we could find out what they prefer to be referred to as, like Mrs., Ms., Mr. I’m wondering if we could do that.
THE CHAIR: She’s nodding, so I’m going to allow the clerk to speak to it. The clerk.
JUDY KAVANAGH: It is in the excellent email I sent you last night.
SUSAN LEBLANC: The Mrs. and Mr.?
JUDY KAVANAGH: Yes.
SUSAN LEBLANC: Oh, it is.
JUDY KAVANAGH: Would you like me to start putting it on the agenda, like we have . . .
THE CHAIR: MLA Leblanc, and then I’m going to close this off and go back to MLA Regan’s motion.
SUSAN LEBLANC: Sure, the agenda would be helpful. Or even more helpful would be just on their name cards. That would be great. Thank you.
THE CHAIR: So the clerk can deal with that. I assume all agree? Okay.
MLA Regan, we’re back to your motion. Is there any discussion on the motion?
MLA Young.
NOLAN YOUNG: With the utmost respect, the Legislature is the place to debate bills and to pass bills and pass legislation. I don’t think it’s for committees, for nine people, to try to push bills forward. That’s the whole purpose of the Legislature - with the utmost respect.
THE CHAIR: Is there any other discussion on this?
SUSAN LEBLANC: I would just say that in certain jurisdictions - in many jurisdictions - across Canada and at the House of Commons, there is procedure that when a bill is in the process of being debated in the Legislature, it actually gets sent to committee, and the committee studies it, hears from witnesses, talks about it, and then sends it back with a recommendation.
For my money, I would support this motion. But I would just say, if our committee structure worked better, then perhaps we would have the mandate to recommend or not recommend certain bills. I wish that was the case, but it is the case in some jurisdictions.
THE CHAIR: MLA DiCostanzo.
RAFAH DICOSTANZO: We are not asking to pass the bill here. We will pass it in the Legislature. Just a recommendation from the committee that with what we heard today, they should look at those two bills and pass them when the time comes.
THE CHAIR: Any other discussion on this?
MLA White.
JOHN WHITE: When I read this motion, it ends with, “I move that this committee should write a letter to the department/government to pass this legislation.” That’s what it says, “to pass this legislation.”
RAFAH DICOSTANZO: Before we go further, could we extend it by five minutes or ten minutes, whatever you think it’s going to take us to get - we’re running the clock. If we could just take until . . .
THE CHAIR: Let’s find out. Is there any discussion on this? We’re going to call the question.
All those in favour? Contrary minded? Thank you.
The motion is defeated.
Any other new business?
The next meeting will be Tuesday, August 13, 2024, from 1:00 p.m. to 3:00 p.m. The topic is Links Between Health Outcomes and Lack of Safe Affordable Housing. Witnesses will be the Department of Municipal Affairs and Housing, the Department of Community Services, the Department of Health and Wellness, the North End Community Health Centre, and Adsum for Women and Children.
We are adjourned.
[The committee adjourned at 2:58 p.m.]
