Quebec doesn’t have the resources for breast cancer screening at 40

A radiologist uses a magnifying glass to check mammograms for breast cancer. (AP-Damian Dovarganes/The Canadian Press)

Health Minister Christian Dubé mandated the Institut national d'excellence en santé et en services sociaux (INESSS) to study the potential expansion of breast cancer screening starting at age 40.

“It's not just a question of widening access,” stresses a CIRANO researcher, ”but also of ensuring better follow-up. How can this be achieved in the context of a shortage of healthcare personnel?”

A new study by the Centre interuniversitaire de recherche en analyse des organisations (CIRANO) highlights the delays in breast cancer screening in Quebec. It ranks among the worst in Canada for delays in diagnosis following an abnormal screening result. There are also no guidelines for women with high-risk factors such as family history or breast density.

One in eight women will be diagnosed with breast cancer in her lifetime. In Canada, it is the second leading cause of cancer death among women of all ages, but the leading cause among women aged 30 to 49.

In Quebec, when women turn 50, they receive a letter from the government informing them of their eligibility for the Quebec Breast Cancer Screening Program (PQDCS) and inviting them to book an appointment.

Earlier this year, the program was extended to women aged 70 to 74. Quebec thus followed in the footsteps of other provinces, which for many years have offered screening up to the age of 74.

CIRANO's study highlights Quebec's poor record when it comes to following up an abnormal mammogram result. According to the research centre, “an outdated cancer registry and a lack of standardization of care contribute to Quebec's delays”.

“Opening up the program is one step, but appointments for mammograms also need to be accessible. So, it's not just about expanding the program, it's also about making sure that women can get the test, that specialists are able to read the results, and that there's follow-up care that's available enough,” said Erin Strumpf, co-author of the CIRANO study.

“With more mammograms, we're going to have more abnormal tests, which will increase the need for follow-up. That could mean even longer delays. We need to find a way to better organize [follow-ups], not just open access to mammography,” she added.

Delays in diagnosis have tangible consequences for women's health. They increase the risk of diagnosing cancer at an advanced stage, leading to more extensive treatment and a poorer prognosis, according to the study. Canadian Cancer Society data shows the five-year survival rate is 99.8 per cent for stage I cancers; 92 per cent for stage II; 74 per cent for stage III; and 23.2 per cent for cancers diagnosed at stage IV.

Strumpf believes it is possible for Quebec to do better, despite the labour shortage. For example, as soon as a mammogram is done, an electronic file can be shared from remote regions to major urban centers where there are more staff to analyze the results.

“There are certainly ways of making the system more efficient,” she said. “But it's true that if we want to offer more services, we normally need more resources.”

Data access problem

“Quebec data on organized screening programs are not available to researchers and journalists,” said Strumpf.

Quebec's cancer registry data are not updated. The most recent data from this registry shared with the rest of Canada dates from 2017.

“This data is not just for the researchers' pleasure, it's to be able to understand: with the interventions we do, do we get better or not? The request to INESSS is to predict whether [the intervention is] a good idea or not, but we also want to know whether it was effective,” Strumpf said.

The Ministry of Health publishes some data on various health issues on its dashboard. However, according to the researcher, these are only fragments that are insufficient to understand, for example, the impact of expanded breast cancer screening.

“It's better than nothing, I suppose, but sometimes putting a few figures on a website allows the ministry or government to say: 'we've given out information, we can't be more transparent than that,'” said Strumpf, who is also a professor in McGill University's Department of Epidemiology, Biostatistics and Occupational Health.

Physician shortage an obstacle

The idea of screening at 40 would not be to screen all women at that age, but rather to make screening more accessible to women who feel it will benefit them. To do this, the government would also have to share and popularize information, said Strumpf.

“In my opinion, it's important that education doesn't just come from the doctor, because we know that in Quebec, many people don't have a family doctor,” she said.

“If we move in this direction, it's going to be important that the information women need to measure the advantages and disadvantages is available and popularized, so that people can better understand their situation,” she added.

The CIRANO study maintains that the shortage of family doctors in Quebec “undoubtedly constitutes a serious obstacle to diagnosis.” In some cases, women with symptoms try to find information online, pay at private clinics or go to the emergency room.

Strumpf points out that even if the Ministry expands the screening program, there won't be “an obvious lead” for a 40-year-old woman to get tested. She suggests not putting everything in the arms of oncologists by making better use of the skills of specialist nurses, for example.

INESSS is expected to announce its recommendations on screening at age 40 by 2025. Elsewhere in Canada, New Brunswick and Ontario have recently followed the lead of British Columbia, Nova Scotia and Prince Edward Island, which have been offering screening at age 40 for several years. Manitoba announced this fall that by the end of 2025, the age of eligibility will be reduced from 50 to 45, with the goal of eventually lowering it to 40.

This report was first published in French by The Canadian Press on Oct. 18, 2024