Canada News
Quebec should make breast cancer screening accessible from age 40
These new provisions aim to better meet the needs of an aging population, but leave out many Quebec women at risk of developing breast cancer, as highlighted by a recent CIRANO study. (File Photo By Marc-Lautenbacher/Wikimedia Commons, CC BY-SA 4.0)
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Quebec is the only province to exclude women under 50 from its breast cancer screening program. Perhaps it’s a distinction we could do without.
After 15 years without revision, the Quebec breast cancer screening program was recently changed. The maximum age of eligibility for screening was expanded from 69 to 74, enabling older women to benefit from extended follow-up. These new provisions aim to better meet the needs of an aging population, but leave out many Quebec women at risk of developing breast cancer, as highlighted by a recent CIRANO study.
There is a growing consensus across the country on the need for earlier screening. The Canadian Cancer Society is calling on the provinces and territories to lower the age of eligibility to 40 for average-risk women. This request is in line with recent research, based on Canadian data, which shows that women who do not have access to screening in their forties go on to develop breast cancers at more advanced stages.
Provinces such as New Brunswick and Ontario have followed the lead of British Columbia, Nova Scotia and Prince Edward Island, which have been offering screening as early as age 40 for several years. Manitoba also plans to lower the age to 45 by the end of 2025, then to 40 in 2026. Saskatchewan and Newfoundland are also preparing to follow suit. In Alberta, women aged 45 to 74 are eligible for the provincial screening program.
In other OECD countries, recommendations are following the same trend. In the U.S., the American Cancer Society suggests that women aged 40 to 44 start voluntary annual screening, those aged 45 to 54 annual screening, and those aged 55 and over screening every two years or annually, depending on their health. In Europe, screening is recommended for women aged 50 to 69, and suggested for those aged 45 to 74.
Think ahead to better protect
Breast cancer screening saves lives. By making it possible to diagnose the disease at an early stage, the chances of survival are considerably increased. According to the Canadian Cancer Society, the five-year survival rate is 99.8 per cent for Stage I cancers, compared with 92 per cent for Stage II, 74 per cent for Stage III and only 23 per cent for cancers diagnosed at Stage IV. By broadening the age criteria to include more women, particularly those aged 40 to 49, screening programs can identify tumors before they develop, thereby reducing mortality.
According to the most recent statistics on the subject, 20 per cent of new cases of breast cancer in Canada in 2021 will be found in women under 50. Nearly two-thirds of these cases occur in women aged between 40 and 49. Recent research also suggests an increase in the incidence of breast cancer in younger Canadian women. Cancers diagnosed in women under 50 are generally more aggressive than those diagnosed in older women, which also argues in favor of early detection.
In addition to increasing the chances of survival, early detection improves patients’ quality of life. Cancers diagnosed at less advanced stages often require less invasive treatment. As a result, patients can avoid major procedures such as chemotherapy or major surgery, which affect their physical and psychological well-being. Detecting the disease early in its progression makes it easier to maintain an active life and reduce stress, while easing the burden on caregivers and the financial impact on families.
Investing to guarantee access
Expanding screening raises a trade-off between quantity and quality. Increasing the number of eligible women requires additional resources (health-care staff, imaging equipment, infrastructure) to ensure equitable and rapid access to testing. Including younger women in screening could lengthen waiting times, further delaying diagnosis and reducing the expected benefits.
In a context where certain groups of women, notably immigrant women and other vulnerable populations, already have relatively low screening rates, it is essential to ensure that lowering the age of accessibility does not create increased pressure on resources or further disadvantage these groups. Careful planning and investment in the logistical capacity of programs are therefore essential to ensure that the extension of screening combines efficiency, accessibility and quality of care.
This means perfecting the knowledge and imaging techniques used for screening, to limit the number of false-positive cases. False results – when an abnormality is detected but is not actually cancerous – can cause significant anxiety and psychological stress. Such patients are often subjected to invasive, often painful, complementary examinations. This adds to the emotional burden and, in some cases, leads to a loss of confidence in the health-care system. The costs associated with false positives are even more relevant for younger patients, whose higher breast density increases the risk of errors in mammography interpretation.
Adapting methods to individual characteristics, such as breast density or risk level, would improve diagnostic accuracy and enable screening to be better tailored to each patient’s needs. Fortunately, solutions do exist.
Reinventing screening: the made-to-measure approach
Recent studies on genetic factors, in particular the presence of mutations in certain genes, have highlighted the importance of personalized screening guidelines. For example, magnetic resonance imaging and ultrasound offer better visualization of dense breast tissue, enabling the detection of cancers that would have escaped traditional mammography. Three-dimensional radiography could also prove more effective for some patients. Integrating these more effective imaging techniques into breast cancer screening is likely to require significant investment. Canada – and Quebec, for that matter – is relatively under-equipped in terms of imaging equipment compared to other OECD countries.
Advances in information technology and artificial intelligence are also helping to improve the interpretation of results, notably by reducing false positives in complex cases. Tailor-made screening can be modulated according to each patient’s family history, genetic mutations and lifestyle, for more appropriate follow-up. Ontario and Alberta have set up programs for high-risk individuals to improve access to care, optimize targeting and imaging, and to establish dedicated access points. This approach, however, has been neglected in Quebec.
Beyond the age of eligibility, it is important to move towards personalized breast cancer screening to optimize resources and focus their use on patients most likely to benefit, while avoiding unnecessary interventions. Such an approach would encourage more efficient management of health-care budgets and promote sustainable medical follow-up, better adapted to individual needs. It would also align very well with the Quebec government’s recently announced strategy, which will focus on prevention to reduce the demand for health care and services.
The Institut national d’excellence en santé et services sociaux (INESSS) is preparing its recommendation regarding whether or not the recommended age for breast cancer screening should be lowered below 50. It is due to be submitted to Health Minister Christian Dubé by the end of the month. Relaunching the debate will hopefully lead to resolutions in the New Year to better protect the health of Quebec women.
This article first appeared on Policy Options and is republished here under a Creative Commons license.
