Consultation on the Government of Quebec's health policy on prevention

For a comprehensive approach to health literacy and breast cancer prevention:

Recommendations submitted by Breast Cancer Action Quebec to Lucie Charlebois, Minister of Rehabilitation, Youth Protection and Public Health

17 November 2015

Who are we?

Breast Cancer Action Quebec (BCAQc) is a nonprofit organization whose mission is to advocate for breast cancer prevention through education and to empower women to take control of their health. We work to empower people to make the societal changes needed to stop this disease before it starts. We work to improve the lives of women affected by this disease and reduce its impact on future generations.

Since heredity and lifestyle account for only 50% of breast cancers, we focus on the causes of the disease that can be tackled through primary prevention. We offer capacity-building activities to citizens, with a particular focus on women, in order to give them the tools they need to assert their right to health and to a healthy environment. Through our actions, we seek to inform, sensitize and mobilize women so that they can help fight against harmful substances found in their homes, their places of work, and in the general environment.  

A large part of our work involves informing women and the general population about ways to reduce the risk factors associated with this disease. Through our programs, we fulfill our mission of sensitization, advocacy and support. In addition, Breast Cancer Action Quebec organizes various public events, including workshops, conferences, discussions and outreach events. To carry out these activities, BCA-Qc often joins forces with other women's groups as well as environmental and academic groups in Quebec and throughout English-speaking Canada.

We have paid special attention to health literacy among women and girls, with particular focus on those from immigrant or ethnocultural communities or from socioeconomically marginalized backgrounds because these parameters add to the factors that exclude them from discussions about or involvement in health advocacy. Using plain language to explain scientific information about toxic substances and their health impacts, and introducing accessible strategies for action, are some of the ways we help women and communities exercise their own and their families' rights to health.

 

Orientation 1: Developing capacity at an early age

For over ten years, Breast Cancer Action Quebec has had a very dynamic youth program. We firmly believe that environmental health education and awareness should begin as early as possible in a young person's life. This is why we work with girls and young women from various and often marginalized communities, to whom we teach the basics for a healthy approach to taking control of their own health. We always emphasize the importance of a collective approach in order to improve the circumstances and lifestyle habits of individuals, thereby encouraging young women to take part in activities aimed at sensitizing their communities. These activities focus on the importance of a healthy environment and the need for community involvement in bringing about lasting changes.

Our recommendations:

  • Support community organizations working to educate young people about their own health and the health of the environment;

  • Support initiatives that enable adolescent boys and girls to take part in collective actions to improve their environment and to experience bringing about sustainable changes in their communities and in society.
 

Orientation 2: Designing safe and healthy communities and territories

This orientation is the very core of Beast Cancer Action Quebec's mission. We work constantly to promote environmental health justice, which must necessarily involve better regulation of toxic substances used in the manufacture of a wide range of products that are discharged into our air and water. Economically marginalized communities often experience the greatest impact of environmental injustice and thus suffer greater health impacts as well. The following are some of the issues that are of particular concern to us.

Research on environmental factors linked to breast cancer is neglected

Many breast cancer researchers agree that direct exposure to carcinogens and toxic substances accounts for at least 20% of such cancers. Only 5-10% of cases can be linked to a genetic cause. Yet barely 2% of breast cancer research funding is earmarked for the study of environmental factors, and only 3% to 4% is used for prevention studies.[1] Moreover, researchers currently recognize that it is very likely that the causes of breast cancer are multi-factorial, in other words, that most cases of breast cancer are caused by various genetic predispositions interacting with environmental and lifestyle-related factors. In view of this complexity, we must examine the following issues, even if they are difficult:

Breast cancer and endocrine disruptors

Because of the problems caused by endocrine disruptors (EDs), a broad range of chemicals that disrupt the body’s delicate hormone balance, we must completely rethink current definitions of what constitutes toxicity and exposure. Many EDs are estrogenic (i.e. they act on our bodies as does estrogen); any increase in exposure to estrogen, in any form, is a significant risk factor for breast cancer. Despite this, while the search for a cure is well funded, there is minimal funding for the study of endocrine disruptors.

Breast cancer and pesticides

Researcher Luc Gaudreault, a professor in the Department of Biology of the Université de Sherbrooke, studies the link between pesticides that are known endocrine disruptors and certain cancers, particularly breast cancer and prostate cancer. It has been hard to obtain funding for this research.[2]

Breast cancer and traffic-related air pollution

Another aspect of the link between toxic substances found in the enviroment and breast cancer was examined in a study conducted by the Research Institute of the McGill University Health Centre. The results of this study showed that postmenopausal women living in Montreal neighbourhoods most heavily polluted by traffic fumes were twice as likely to develop breast cancer as those living in the least polluted neighbourhoods.[3] Researchers in California went a step further and identifed mammary gland carcinogens found in traffic-related air pollutants.[4] Yet very few groups, even among the major breast cancer foundations, study this issue or fund its research.

Our recommendations:

  • Support and promote research on the links between environmental factors like  endocrine disruptors and breast cancer, with a view to better understanding and taking action regarding  the causes of this disease;
  • Tighten regulations governing the use of pesticides and herbicides containing known carcinogens such as glyphosate during the next revision of the Quebec Pesticides Act;
  • Recognize that a reduction in traffic levels and a corresponding reduction in air pollution will reduce the incidence of a broad range of diseases, including breast cancer, and will support all actions in pursuit of this goal.

Orientation 3: Improving living conditions that foster health

Social inequalities in health and breast cancer

According to a study conducted in Quebec by the Public Health Board of Montreal, there is a persistent gap in life expectancy between residents of wealthy neighbourhoods and those  living in underprivileged neighbourhoods. Social and behavioural factors that are harmful to health have a cumulative impact throughout a lifetime. Moreover, in the vast majority of breast cancer cases, tumours develop over the course of 10 to 20 years before being detected. The researchers involved in this study actually use breast cancer as an example of the impact of social inequalities on health. In the section dealing with breast cancer, the authors state the following:

Cancer rates are a clear illustration of social inequalities in health (SIH) and confirm beyond any doubt that SIHs kill. Individuals' socioeconomic status determines a number of physical and social factors that can cause disease, determine its frequency and influence access to care. The impact of socioeconomic factors can cause variations in access to health care among social groups, especially when the concept of access to health care goes beyond diagnosis and treatment to include medical information, early screening, appropriate and timely treatment, as well as, naturally, the quality of care. (...) Breast cancer is a particularly telling example of this issue.[5]

There are also other forms of inequality when it comes to breast cancer. For example, regardless of their socio-economic status, women of African descent are at greater risk of suffering from more virulent breast cancer or contracting the disease at an earlier age as well as having a higher mortality rate than white women.[6] It is therefore crucial that we become involved early in the lives of young women, particularly those who are marginalized and/or belong to groups with low socio-economic status, by empowering them to lead the lives they want in the way they choose. We want them to acquire the tools they need to act on the factors that have a significant impact on their health.

Breast cancer and occupational exposure

Researchers Jim Brophy and Margaret Keith published a very innovative study highlighting a significant rise in cancer rates among women employed in agriculture, the plastics industry, food canneries and metalworking as well as those working in bars and gaming establishments[7]; most of these cancers occurred following occupational exposure to endocrine disruptors. Brophy and Keith were refused a grant to continue their research. Yet in a recent policy statement, the American Public Health Association called for a focus on the environmental causes of breast cancer, including occupational causes.[8]

Our recommendations:

  • Endorse the creation and promotion of health literacy programs for girls and women from marginalized communities;
  • Ensure that such programs are offered on an ongoing basis, not just once;
  • Support the creation of public awareness programs on breast cancer risks linked to certain occupations and ensure that such programs are implemented;
  • Promote programs that enable occupational health and safety committees in workplaces where some women are at greater risk of developing breast cancer in order to improve working processes and conditions, and to eliminate exposure to toxic substances.

Orientation 4: Stepping up prevention in the health and social services system

A new breast cancer paradigm that calls for a new approach to prevention

There has been no progress in the reduction of the incidence rate of breast cancer for over ten years. A breast cancer prevention program based largely on mammography screening is far from an adequate approach to this disease. Faced with a new paradigm pointing toward the complexity of this cancer, its causes, biology and treatments, the time has come to rethink our approach to breast cancer prevention. Moreover, population-wide mammography screening programs lead to overdiagnosis and overtreatment, which we must also avoid.

The above-mentioned studies, dealing with the social inequalities of health and breast cancer, show that comprehensive health literacy programs are crucial in order to enable all women to recognize changes and symptoms about which they should consult a health professional. A comprehensive approach would make it possible to take action regarding a range of diseases instead of just breast cancer, regardless of the seriousness of the latter.

Population-wide screening programs are based on the hypothesis that cancer progresses steadily and gradually to a fatal stage if left untreated. Breast cancer, however, is not a uniform disease; it may require a different treatment for each case. Also, tumours do not necessarily progress at a constant pace. Indolent (or lazy) tumours can stop growing, grow more slowly or even shrink. This all leads to a new paradigm centered on the complexity of cancers and their treatments.

The belief that the early screening of breast cancer saves lives has therefore become problematic. It leads to medical interventions for women whose tumours would have remained harmless but who are nevertheless subjected to unnecessary surgery, radiation, chemotherapy and hormone therapy. In addition, these women must suffer the medical, financial and social consequences of breast cancer for the rest of their lives, all of which could have been avoided.

There has not been a definitive estimate of the full scale of overdiagnosis and overtreatment. To date, statistics from the scientific literature concerning the number of breast cancer cases affected range between less than 10% and more than 50%, a significant range.[9] The Quebec breast cancer screening program itself recognizes that ten of the 77 women diagnosed over a ten year period under this screening program were cases of overdiagnosis.

Moreover, very few women understand the concept of overdiagnosis or overtreatment. The completely inadequate education provided on breast cancer, regardless of the simplistic message about early screening, does not encourage women to deepen their understanding of the disease and to ask questions, which would enable them to give truly informed consent for treatments.

In 2012, the U.S. National Cancer Institute convened a panel of cancer specialists and patient advocates to examine the need for a deeper investigation of cancer overdiagnosis. The panel issued the following consensus regarding overdiagnosis and overtreatment[10]: It proposed that we must recognize that overdiagnosis occurs and is common, and develop new terminology to replace the word "cancer" with the classification of “low risk lesion” and to adapt  detection methods that avoid identifying unimportant lesions. Finally, the report also suggests that we need new strategies on how to approach the progression and prevention of breast cancer.

To enable women to better understand the issue of overdiagnosis, we must change the breast cancer discourse. We must move from an alarmist approach to a more nuanced one based on an understanding of the complexity of cancers and the need for differentiated treatments, which, in some cases, may be limited to close monitoring. We must re-examine screening programs and the treatment of DCIS, develop less aggressive treatments, and establish registers that would facilitate better understanding of how cases evolve. We also need to coordinate studies so that basic research into tumour biology is given priority.

In addition, all women must be empowered and encouraged to discuss these issues with their doctors when they are diagnosed with breast cancer. Last, it is vital that all women are informed and empowered in order to deal with all issues surrounding this disease, regardless of  complexity.

Our recommendations:

  • Health literacy programs should be developed that focus on breast cancer—its prevention, detection and  overdiagnosis—and available treatments in addition to the possible option of an active monitoring approach in some cases, rather than intervention;

  • Protocols should be developed that limit overtreatment caused by mammography screening programs through switching to active monitoring, among other approaches, and women should be informed of these options.
 

Final questions and conclusion:

To ensure that the Government of Quebec's health policy on prevention does not become mere words on paper, it is imperative that we answer a number of questions. Who will be in charge of implementing the policy? Who is in charge of funding initiatives aimed at improving the health of Quebecers by means of a strong health policy on prevention? And who will be accountable for the outcomes of such a policy?

Despite the significant prevalence of breast cancer in its female population, Quebec lacks a true breast cancer prevention program. Mammography screening is not a prevention program. A true prevention program starts with health literacy and active outreach, particularly with respect to marginalized girls and women, as well as increased research into cancer-causing environmental factors and better regulation of toxic substances harmful to human health. These are all priority public health concerns.

 

[1] International Cancer Research Partnership (2012). Cancer Research Funding from an International Perspective: Report from the International Cancer Research Partnership, 2012.

[2] Radio-Canada (2015). « Un chercheur de l’Université de Sherbrooke s’intéresse à l’impact des pesticides sur les cancers. » 29 juin 2015.

[3] Crouse, Dan L., Mark S. Goldberg, Nancy A. Ross, Hong Chen and France Labrèche (2010). Postmenopausal Breast Cancer Is Associated with Exposure to Traffic-Related Air Pollution in Montreal, Canada: A Case–Control Study. Environmental Health Perspective. 118 (11) 1578-1583. 

[4] Garcia, Erika, Susan Hurley, David O. Nelson, Andrew Hertz and Peggy Reynolds (2015). Hazardous air pollutants and breast cancer in California teachers: a cohort study. Environmental Health. 14:14.

[5] Direction de la santé publique, Agence de la santé et des services sociaux de Montréal (2012) Les inégalités sociales de santé à Montréal, le chemin parcouru. p.80.

[6] Iqbad, Javaid et al. (2015). Journal of the American Medical Association, 313(2):165-173.

[7] Brophy, James, Margaret Keith, et al. (2012). Breast Cancer risk in relation to occupations with exposure to carcinogens and endocrine disrupters: A Canadian case-control study. Environmental Health. 11:87.

[8] American Public Health Association (2014). Breast Cancer and Occupation: The Need for Action. Policy Number: 20146.

[9] Elmore, Joann G. and Ruth Etzioni (2015). Effect of Screening Mammography on Cancer Incidence and Mortality. Invited Commentary. JAMA Internal Medecine. Published online July 6, 2015. Downloaded from http://archinte.jamanetwork.com/ on 07/072015.

[10] Esserman, Laura, J. and colleagues (2014). Addressing overdiagnosis and overtreatment in cancer: a prescription for change. Lancet Oncology. May 2014. 15(6): e234-242.