Dr Jean Seely

Dear members of the committee, thank you for the opportunity to comment on the draft CTF breast cancer screening guidelines

As a breast imaging specialist, I diagnose women along their entire cancer journey; I detect breast cancer with screening, or I diagnose it after a woman presents with a palpable lump. I perform breast biopsies and localize breast cancers for the surgeons. I interpret the imaging of women diagnosed with late-stage or recurrent breast cancer. I speak to women at all stages of breast cancer and screen detected cancers found before symptoms occur is a very different diagnosis than one found because of symptoms at stage 2, 3 or 4 metastatic. The CTF falsely states that an additional imaging test is a harm comparable to a delayed diagnosis of late-stage breast cancer- my patients attest that the severity of the harm of a delayed diagnosis vastly exceeds any stress associated with any additional imaging test. Equating these harms is a false equivalency.

The recent draft guidelines released by the Task Force for breast cancer screening have sparked significant concern within the medical community, and as an expert included on the evidence review panel, I find these recommendations profoundly disappointing. These guidelines ignore robust, recent evidence supporting the initiation of screening at age 40, a standard adopted by the US Task Force and numerous other countries worldwide.

The CTFPHC?s recommendations are anchored in studies dating back 40 to 60 years, utilizing antiquated technologies like film-screen mammography, which is obsolete in today?s medical practice. As experts, we recommended against including these outdated data which overlook monumental advances in breast cancer treatment, including hormone receptor-positive treatments like tamoxifen, less invasive surgical options like lumpectomy, sentinel lymph node biopsy, and modern immunological and chemotherapeutic agents that have revolutionized breast cancer management. The CTF working group interfered with our expert recommendations and insisted on using them. The CTFPHC approach diminished the importance of recent observational studies involving millions of women comparing screening to no screening with updated diagnosis and treatment. These studies include one Canadian study of 2.7 million women screened over 20 years demonstrated a 44% reduction in breast cancer mortality in women who began screening in their 40s. Similar studies in Sweden show even greater benefits, with reductions in mortality between 50 to 60% for women aged 40-74 years detected via screening compared to those diagnosed symptomatically. Further, the TF used the old trials to evaluate cancer stage at detection, and therefore missed the benefits of early-stage detection with up-to-date screening technology. The improvements in screening technology in the past 15 years improve breast cancer detection by 20% to 40%.

Breast cancer is a devastating diagnosis, yet the harms are mostly preventable when it is detected early. The survival rates are starkly different across stages: nearly 100% five-year survival for stage one detected through screening, compared to only 22% five-year survival for stage four, where the disease has spread and become incurable. Further, the treatments are much less intensive and costly when treated early, where stage 1 cancer costs an average 30,000$CDN to treat as compared to up to 500,000$ for stage 4. Systematic screening programs in Canada find that 86% breast cancers are diagnosed at stage 1.

The CTFPHC disregarded data that showed that women of race/ethnicity other than White are more likely to be diagnosed with breast cancer in their 40s. A one-size fits all approach to recommending screening only starting at age 50 discriminates against these women and contributes to their twice higher rates of advanced stage breast cancer, due to delays in diagnosis and lack of access to screening mammography programs.

The CTFPHC acknowledged that women with dense breasts were twice as likely to develop breast cancer as women with non dense breasts. However, it failed to recognise the reduced sensitivity of mammography in these women, which drops from 90% in women with non dense breasts to 60% in those with the densest breasts. The CTFPHC ignored high quality randomized studies that showed that adding screening with MRI reduced interval cancers (those cancers found by symptoms after a normal mammogram) by 80% and by 50% in women screened with supplemental breast ultrasound. These interval cancers have been shown in evidence-based medicine as acceptable surrogates for breast cancer mortality, which takes 10 years or more to demonstrate.

We must demand that our health policies be reflective of the latest scientific evidence and best practices in medicine. As a medical community, we owe it to every woman in Canada to advocate for guidelines that are not only scientifically sound but also reflective of modern medical technology and treatment advances.

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Dr Martin Yaffe

I thank the committee for this opportunity to discuss this important issue.
The decision to participate or not in breast cancer screening should be up to individuals. BUT, to inform that decision they need accurate, unbiased and accessible information regarding benefits, limitations and potential harms associated with screening.
The Canadian Task Force on Preventive Health Care provides advice to primary care physicians and the public, but disturbingly the information has been distorted to discourage participation in breast cancer screening.

I am a senior breast cancer research scientist who leads a group of 20 researchers at Sunnybrook Research Institute in Toronto. I also co-lead the Imaging Research Program at The Ontario Institute for Cancer Research. Much of my work over the past 44 years has focussed on breast cancer screening. My group helped develop and validate the technique of digital mammography and establish breast density as a risk-factor for breast cancer. In 2015 I helped write the IARC/WHO handbook on breast cancer screening.

Some if the things I have learned since 1978:
Multiple randomized trials conducted in the 1960s to 1990s proved the principle that mammography -screening can detect breast cancers earlier and can help reduce breast cancer deaths.
With modern developments in both screening and breast cancer therapy, more recent large studies, including one in Canada with 2.7M women demonstrated that participating in screening from age 40 onward is associated with at least 44% reduction in deaths, much larger benefit that seen in the randomized trials conducted 40 -60 years ago. Screen detection of their cancers could give some women back 20 additional years of life. Earlier stage cancers often require less arduous types of therapy (avoiding mastectomy, chemotherapy or axillary surgery) and incidentally cost much less to treat.

A decision on screening involves weighing the benefits of averting premature death against limitations and possible harms. The Task Force has not done this. Instead it has made blanket statements about harms, suggesting without evidence that they may approach or outweigh the level of benefit for younger women.

The Task Force did commission a project to model screening outcomes. A Table in their Guideline suggested very low benefit from screening younger women, however details are not yet publicly available for scrutiny. I published modeling results in 2015 and 2022 (some using the same model as the Canadian Task Force) The US Preventive Services Task Force has also commissioned such modelling to inform its update. Results coming from 5 NCI-funded groups agree well with those from my lab. They show continuously increasing absolute and relative benefits as the starting age for screening is reduced to 40, the stopping age is increased to 79 and screening performed annually rather than every 2 years. The worst results are obtained when screening is at 3 years, a strategy suggested by the Canadian Task Force, with no evidence to support it.

Modelling allows weighing screening benefits versus harms. I?d be happy to describe this further in the questions. It showed that the net Quality Adjusted Years of Life gained by screening increases when screening starts at 40, continues beyond age 74 and is annual. The benefits consistently dwarf the harms.

The Task Force takes a ?Less is more? position toward screening. This comes at the cost of thousands of lost lives accompanied by increased morbidity due to later treatment of disease.
I participated as an invited volunteer expert to the Ottawa Evidence Review and Synthesis Centre along with three colleagues, an oncologist, a breast radiologist and a breast cancer survivor. We noted interference by the Task Force in the work of the Centre. Against the advice of the invited experts the Task Force insisted that the Centre include and analyze the very old randomized control data which had already been included in 2018. In 2018 it refused to consider observational data, even from large well conducted studies or modelling. In 2024, such data were allowed, however, the Task Force set arbitrary thresholds to assess its validity and used too short an observation time to allow the full impact of benefit to be measured.

The Task Force insists on specifying outcomes only in absolute quantities minimizing the perceived level of benefit ? 2 lives saved per thousand seems like a small benefit even if it represents 40% mortality reduction and 470 deaths avoided each year in Canada. Based on public comments and guidance to the evidence groups and emphasis on the data used to inform the guidelines, it is apparent that the Task Force has a strong bias against screening/ preventive medicine of any kind. )

Of course, nobody should be coerced to be screened. It is a personal decision. But impediments to access must be removed to provide equity in saving lives. And no woman should ever be put in a position of having to debate with her doctor to be able to access screening.

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Supriya Kulkarni, DMRD, DNB, FRCP(C), FSBI

Honourable Health Committee Members,

I am grateful to have this opportunity to talk to you all today about breast cancer screening, a topic close to my heart. I am an academic breast imaging radiologist working at the Princess Margaret Cancer Centre in Toronto and currently serve as the president of the Canadian Society of Breast Imaging. I am greatly invested in improving patient care and experience through the health care system.

The recently issued Canadian Task Force recommendations that excluded screening of eligible women between 40-49 yrs. came as a huge disappointment to many of us. The recommendations conflict with those of other reputable organizations, leading to confusion among healthcare providers and patients.

Canada?s evolving ethno-racial landscape has been systematically excluded by the Task Force recommendations which are still predominantly based on older studies involving white women. The data is not fully representative of our population, leading to recommendations that might not be applicable, beneficial, or safe for everyone. For example: Black women experience poor breast cancer survival rates, are more likely diagnosed with advanced-stage breast cancer, and more likely to have biologically aggressive tumors all of which occur at an earlier age than white women.

Data shows significantly higher proportions of stages 2, 3 and 4 breast cancers occurring in women in Canadian jurisdictions that do NOT include women in the 40s in screening programs as opposed to those that do. Lower stage means less aggressive treatments, less side effects and increased disease-free survival.? Stage Matters?

Modelling shows that by not screening women in the 40-49 age group we would see an additional 470 avoidable deaths every year. This is equivalent to allowing a passenger jet full of young Canadian women crash every year because we refused to screen them at the right time. This is the chilling reality of the situation.
Mammography is a compression technique, there is tissue overlap and up to 16% of women who come for their first mammogram a likely to be recalled for additional pictures and ultrasound and sometimes end up with a biopsy with benign diagnosis. (This percentage drops over the subsequent years.) Recalls are not harms. This is like sending your bag through the airport screening, most of the times it goes through but sometimes it gets pulled out, opened, checked, and given back and occasionally a forgotten nail clipper gets thrown out. Most women are grateful that they went through the one extra step for safety.
The Task Force recommends ?shared decision making? to allow women discuss with their primary care providers the age at which they should have a mammogram. In a country grappling with severe shortage of family doctors this is only a distant dream. The power differential between the physician following the task force guideline and patient is a barrier in shared decision making. The current tools provided by the task force are biased towards not having a mammogram.
Among other recommendations, the Task Force recommended against supplemental screening for women with dense breasts. We know dense breast tissue precludes finding breast cancers at an earlier stage akin to finding a snowball in a snow storm. This often leads to delayed diagnosis, greater stage and spread of cancer, more extensive and expensive drugs which may lack funding. These drugs can have devastating side effects significantly diminishing quality of life and function.
The task force stated that there was insufficient evidence to support supplementary screening and selectively chose to follow the US task force on dense breasts recommendations meanwhile there are decades of data that demonstrated the benefit of supplementary screening. More recently Ontario Health conducted a health technology assessment (OHTAC) and drafted a recommendation to publicly fund supplemental screening.
To conclude we want guidelines based on new and inclusive science that are aligned with other international guidelines and that consider the changing landscape of diversity and ethnicity in Canada. Early detection with novel personalized therapies is the best we can give women in their cancer journey. No woman should be denied a mammogram, self-referral should be allowed, and those women who prefer not to have a mammogram should be free to opt out.
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Patient Advocate Shira Farber’s Testimony

My name is Shira Farber. I am here today to share my own story but represent a sisterhood of breast cancer patients across Canada who give of their own limited time and energy to improve breast screening guidelines for all Canadians.

Today is an important anniversary for me. Three years ago, to this exact date, I was at Princess Margaret Hospital in Toronto undergoing a biopsy confirming my cancer diagnosis. I can recall the visceral sensation of hearing the words ?breast cancer? and believing in my heart of hearts that everything would be OK because I thought I caught it early. However, diagnostic testing revealed three large tumors in my right breast and stage 3 breast cancer. What my surgical oncologist described as a cancer found ?not too late? but one that she wished had been found earlier.

What I have learned and what the task force has not paid enough attention to in these guidelines, is that stage does matter when it comes to quality of life and in reducing some of the side effects associated with more aggressive treatments.

The chemotherapy I received was an aggressive dose dense treatment which made me so ill I could not work and spent most of my days in bed. I could not care for myself let alone my children or mother. My mouth was full of sores, I lost all of my hair and my joints were severely impacted. I developed iron deficient anemia and tachycardia, I became extremely ill and was hospitalized with acute constrictive pericarditis. I almost required emergency open heart surgery. I couldn?t walk short distances without being winded and was forced to use a wheelchair.40 of my lymph nodes were removed resulting in permanent lymphedema. The mobility in my arm is severely restricted, I get run down and tired easily. I do what I can with physiotherapy but am living with chronic pain. The treatment protocol for a more advanced staged cancer, also limited my options for reconstruction and required multiple surgeries.. My body image was shattered and my mental health was severely impacted. I live with PTSD and fear of recurrence.

The Task Force guidelines refer frequently to shared decision making between patients and doctors. When I turned 40, I recall asking my former family doctor, who was a wonderful family doctor, if I needed to have a mammogram. I was advised that women with average risk didn?t need them according to the new Canadian Breast Screening Guidelines. I recall asking again closer to the age of 45 and receiving a similar response. I was not aware that most women with breast cancer do not have a family history. I did not understand that risk factors like breast density which can only be discovered with your initial mammogram placed me at higher risk. I didn?t push back or self-advocate because I trusted my doctor implicitly and was fearful of the pain I had erroneously associated with mammograms. I had faith that these guidelines, if they were Canada?s recommendation and those of my medical practitioner, were the gold standard and would keep me safe.
Women’s voices are simply not reflected sufficiently in the Canadian Task Force on Preventive Health Care guidelines. There is a major disconnect between what they are recommending and what actually occurs in family doctors offices. They fail to take into account the power imbalance between doctors and patients. I speak to women with later staged diagnoses all the time. Some describe having to advocate for themselves to get a screening referral and being denied because their doctor believes they know best or are not up to date on the latest research and evidence, Some are fearful of pushing back too hard and being labeled a difficult patient and potentially losing the privilege of having a family doctor.

The Task Force also infers one of the harms associated with screening as anxiety associated with call backs. I would give anything in the world to experience the transient anxiety of a call back over the physical pain I have experienced and the fear I have of leaving my children without a mother or my husband without a partner. Women are resilient. We can handle anxiety with the right tools.
Over the past year, I watched as the task force, while in the process of conducting an evidence review, made numerous public statements to the press, on social media and lectured about what they refer to as the harms of screening. I have no faith in a process where members who claim to be objective have publicly declared and maintained their bias.

When I was diagnosed with cancer, I did the same thing I did for family and friends in similar situations. I researched my doctors, found a cancer care hospital I trusted and I spoke to others with similar experiences. Isn’t this what every Canadian woman deserves? Then why are family doctors and Canadians taking directives from non-specialists in the field of detection? Why aren’t we listening to the screening experts and surgical oncologists who are at the front lines of this disease? Why aren’t we learning from patients’ lived experiences? Where are our voices?

Canada has the ability to make this change now. We have an opportunity to give women evidenced based modern guidelines that could protect some from later staged cancers. We can’t undo the past harms but we can prevent future unnecessary suffering and deaths.
Thank you.

Watch Video here

https://parlvu.parl.gc.ca/Harmony/en/PowerBrowser/PowerBrowserV2/20240611/-1/41890

Witnes

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June 10 WATCH THE TESTIMONY OF DR PAULA GORDON AND DR SHIELA APPAVOO HERE

https://parlvu.parl.gc.ca/Harmony/en/PowerBrowser/PowerBrowserV2/00010101/-1/41871?Embedded=true&globalstreamId=20&viewMode=3

STATEMENTS BY DR SHIELA APPAVOO AND DR PAULA GORDON TO THE STANDING COMMITTEE ON HEALTH JUNE 10 RE ISSUES WITH THE 2024 DRAFT GUIDELINES

1. STATEMENT BY DR SHIELA APPAVOO TO THE STANDING COMMITTEE ON HEALTH

Honorable members of the Health Committee, Thank you to this committee for convening this important study with such urgency.
I?m Shiela Appavoo, a general radiologist with an interest in breast imaging. I chair the Canadian Society of Breast Imaging Patient Engagement Working Group and I also founded and chair the Coalition for Responsible Healthcare Guidelines.
I speak today about my serious concerns about the recent draft guideline issued by the Canadian Task Force on Preventive Health Care regarding breast cancer screening, recommending AGAINST screening women 40-49. This guideline stands in stark contrast to those provided by the US Task Force, the Canadian Cancer Society, and the majority of Canadian provinces, all of which have recognized the need to lower the screening age to 40. The Nurse Practitioners Association of Canada has also recently withdrawn their endorsement of the 2018 Task Force guideline, which also recommended against screening below 50.
The Task Force decision not to screen women 40-49 is biased. It is troubling that this stance was seemingly predetermined. The Task Force leadership indicated in the media in early May 2023 that there was no need to change the Canadian guidelines. This was before the evidence review began. Lo and behold, this prophecy was fulfilled almost exactly a year later.

How does the Task Force come to such different conclusions than the rest of the modern world? Without the context provided by the fulsome guidance of experienced content experts, they amplify harms, such as overdiagnosis and callbacks for additional imaging and they minimize the benefits of early detection. One rarely hears Task Force discussions mentioning the lives saved or mastectomies prevented by screening.

The US Task Force has acknowledged and acted on the increasing incidence of breast cancer as well as racial disparities. Canadian research has found similar trends here at home and the Task Force guideline even acknowledges higher mortality in black women in their 40s, but fails them in its guideline, begging off on a lack of evidence, abandoning common sense and the precautionary principle. In every racial group except white women, breast cancer starts to peak in the 40s and yet the Task Force makes little attempt to accommodate these groups. While acknowledging the influence of race, ethnicity, family history and breast density, the Task Force has minimized these important individualizing issues.
One of the misconceptions of the Task Force is that improved life expectancy is attributable to better treatment with an implication that treatment is a substitute for early detection. This is problematic. Women with early-stage diagnosis are far more likely to live out their full lifespan with less of the aggressive treatment, existential dread and generational trauma of a woman and her family dealing with a late stage cancer diagnosis. Simply put, women with smaller less advanced tumours tend to live longer and better-quality lives and screened women tend to have smaller tumours than non-screened women.

It has been mentioned by Task Force members that screening should be limited to control costs. This is a false economy. Screening is an investment, considering the costs of modern treatment. Work done by researchers in Ottawa has demonstrated that by screening from age 40 to 74, Canada would save around $440 million annually. The costs of treatment far outweigh the costs of screening. We cannot afford not to screen.

If instituted, the consequences of these new Task Force guidelines will be dire. Many young women will potentially pay with their lives. Most provinces and territories have recognized this and have allowed self-referral for women aged 40-49. However, the recommendation of a primary care provider is still the strongest predictor of whether a woman will actually go for screening. As long as doctors are being given the Task Force message that women in their 40s don?t need screening, many of those women won?t get access.

By continuing to make the same recommendation that the Task Force has made dating back to 2011, Canada?s national guideline is falling farther and farther behind the provinces, other countries, and expert recommendations. This has led to patchwork access for women across the provinces. Unfortunately, these guideline problems are not isolated to breast screening and are a pattern seen in multiple other guidelines during the past 15 years of the Task Force?s existence.

We must not allow these guidelines to stand as they are. We must have a guideline that is informed by the latest evidence, one that truly serves the best interests of Canadians and with respect, looking at its record, we must dismantle and rebuild this Task Force. Thank you for your attention to this critical issue.

2.STATEMENT BY DR. PAULA GORDON TO THE STANDING COMMITTEE ON HEALTH

Honourable Health Committee Members:
The Canadian Task Force understates the benefits of screening, but they are obsessed with what they call ?the harms?. They recommend against screening women in the 40s, even though women aged 40 to 49 are 44% less likely to die of breast cancer if they have mammograms. Andthey recommend against supplemental screening for women with dense breasts, even though many more invasive cancers would be found earlier if it was used.

I?ll explain what they think the harms are. Even that term is misleading. They really are risks or limitations.

The first is the anxiety women experience if they are recalled for additional tests after a screening mammogram, and are not found to have cancer. Only about 5% of recalled women are diagnosed with cancer. That anxiety is real, but it?s transient, and it pales in comparison to the anxiety a woman feels if she learns that she has an advanced cancer, and that she faces the possibility of death or at least months of surgery, radiation, and chemotherapy, which might have been avoided, had her cancer been found earlier. The Task Force gives false equivalence of this anxiety, to delayed diagnosis and advanced cancer.

The Task Force also disproportionately focusses on overdiagnosis. That?s the theoretical possibility where a woman is diagnosed with cancer, is treated for it, but dies of another cause sooner than her breast cancer would have killed her. For example: She might die sooner of a heart attack.

Overdiagnosis is much less common in younger women. They are less likely to die of other causes, and their cancers are more aggressive than in older women, so they grow and spread faster if left untreated. In women in the 40s who get breast cancer, breast cancer accounts for ~91% of the deaths, but in women in their 70s, it accounts for only 48%.

Cancer doesn?t regress if left untreated. They may grow fast or slow, but if given time they will spread and kill. Drs. Wilkinson and Seely, working with Statistics Canada, showed that after screening of women in their 40s was stopped in response to Task Force recommendations in 2011, the rate of metastatic cancer went up by 10% for women both in their 40s and 50s.

Overdiagnosis is only important if it leads to over-treatment. With current testing and rapidly advancing research on predicting how a given cancer will behave, oncologists can offer less treatment for some breast cancers. But if women choose to not be screened because of the Task Force?s emphasis of overdiagnosis, they lose the opportunity to find their cancers early and save lives.

In their 2018 review, the Task Force said that the rate of overdiagnoses was 48%, based mainly on an old flawed Canadian study that has been discredited. For the current review, overdiagnosis was 11% when the discredited study was included, but only 6% when it was excluded. The 48% rate, incorporated into the decision tool created by the Task Force and used in shared decision-making may well have been responsible for countless deaths.

Screening is not perfect. Women should be told about the risks of being recalled, and overdiagnosis, but should not be discouraged from screening.

Some members of the Task Force say that screening is less important because treatment is getting better. It?s not a contest. Screening and treatment are synergistic. Cancer can be treated more effectively and less aggressively when it?s found earlier. Of course, there are anecdotal stories about women with early cancer, who didn?t do well, and women with Stage three who did. But it?s like hearing stories about people who smoked all their lives and died at age 95 without developing lung cancer. Reliable data trumps those outlier stories.

Some members of the Task Force claim that screening can?t save lives of women with rapidly growing cancers. Not true: Statistics Canada has shown that when triple negative cancer is detected at Stage one, the 5-year survival is 96% but at Stage 4, it?s only 7%. Stage at diagnosis does matter.

And it?s more than about just saving lives. Chemotherapy can often be avoided when cancer is found early. Most patients with Stage one cancer don?t need chemo. Most patients with Stage two and higher do need it.
Stage at diagnosis does matter!

Early detection also allows for less aggressive surgery: lumpectomy vs mastectomy, and sentinel node biopsy vs axillary dissection. The traditional armpit surgery to sample lymph nodes leads to permanent swelling of the hand and arm in about a third of women.
Stage at diagnosis does matter!

So to sum up, the science is clear. Screening finds cancer at lower stage, improves the quality of life for women with cancer, and saves more lives.The alleged harms are not reason enough to deny or to discourage women from the opportunity for early detection.
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Dr. Ify McKerlie

Good morning,

I would like to thank the members of the Standing Committee for the Status of Women for this incredible opportunity to speak about the current Canadian breast screening guidelines.

My name is Dr. Ify McKerlie. I have been a general radiologist with a focus on breast imaging for over 20 years. I co-chair the patient engagement group of the Canadian Society of Breast Imaging. In my practice over the years, it has become increasingly obvious that patients who are affected by breast cancer are getting younger and younger. In addition, the increased incidence of breast cancer has also been shown in recent Canadian research [1]. My daily practice includes diagnosing and performing biopsies on these patients, and as such, I am often the first point of contact and the deliverer of bad news. Breast cancer in younger women tends to grow faster and is more aggressive.

The Task Force has recently released their recommendations for breast cancer screening. It is important to acknowledge that the Task Force members do not specialize in the field of medicine- breast cancer screening- for which they have set the guidelines. They have mistakenly placed higher emphasis on the potential harm that early screening may cause, rather than the life-saving benefits.

Breast cancer is a disease that has a far-reaching impact. The brutal harm of a late-stage diagnosis is significantly more severe than the potential harm of undergoing additional imaging.

The outdated study from the 1980s which the Task Force continues to use to make their guidelines was comprised of a population of 98% white women [2]. Forty years later, however, Canada is a much more racially diverse country. Over 9.5 million Canadians were identified as a member of a visible minority group in the 2021 Canadian census [3] making up 26.5% of the total population.

In the US, it was noted that in Black, Hispanic, and Asian women, breast cancer peaks at an earlier age of 40 when compared to white women. [4] The Task force was aware of a recent yet to be published paper from Statistics Canada showing similar findings of an earlier peak of breast cancer in minority populations in Canada.

In the recently released guidelines, the Task Force notes that the lifetime risk of breast cancer in these populations is lower than the risk in white populations. They go on further to note that non-white populations in the 40-49 age group, are diagnosed more with breast cancer, have a higher proportion of aggressive subtypes of cancer, are less likely to have hormonally sensitive cancers and less likely to have Stage I.

Black women have an even more sobering outlook with a 42% higher mortality than white women, more aggressive cancers, and stage for stage worse outcomes [5]. For the 40-49 age group, the Task Force notes, ?There are data showing variability in incidence, mortality, subtype and stage at diagnosis (e.g., higher mortality in Black women.? Higher mortality was also noted at age 60-69 for First Nations and Metis women.

Despite listing all the disadvantages facing racialized women, they put a strong emphasis on informed patient choice, which would require an educated discussion with a family physician. The Task Force promotes a ?one size fits all? approach that counters the observed variability in values and preferences. If a woman chooses to be screened, they still recommend screening every 2-3 years.

When the US guidelines were announced, the US Task Force stated that ?new and more inclusive science had led it to call for screening at 40 [6]. In Canada, where is the use of new and inclusive science?

With knowledge comes responsibility and so knowing the above, acknowledging higher mortality in Black women in the 40-49 age group and not acting on it, is simply unethical and discriminatory.

The Task Force also discriminated against women with dense breasts by not recommending supplemental screening. Breast density is highest in Asian, Black and Hispanic women [7].

It?s 2024. We must include the 40-49 age group in the screening population, particularly given the incidence in racialized women and higher mortality in Black women, as well as the higher risk to women with dense breasts. Lives depend on it.

In the absence of proper governance and an accountability structure for the Task Force, and indeed for any organization, there is chaos. Women in their 40s are not acceptable losses.