Aspiration alone is not adequate: Breast screening task force missing the mark

Canada has been an innovator in evidence-based medicine through the pioneering contributions of David Sackett and others who drove the creation of The Canadian Task Force on the Periodic Health Examination in 1976.

Its mandate was to provide objective, scientifically justified guidance to physicians on matters that affect the health of Canadians, particularly the prevention of advanced and life-threatening disease. The Canadian Task Force on Preventive Health Care (CTF) was its successor. We fully support the contentions of the July 16 article in Healthy Debate that an institution in Canada that fulfils this mandate is valuable and essential.

But aspiration alone is not adequate. The article does a disservice by describing former Minister of Health Mark Holland as having been “angry” with the CTF, implying that his response in pausing CTF guideline activities and initiating a review was emotional. It is more likely that the minister recognized the CTF had deviated significantly – both procedurally and scientifically – with no effective governance mechanism in place to realign its direction. Three examples illustrate this:

First, before the evidence synthesis process began for the latest breast screening guidelines, the CTF chair publicly stated there was no need for changes to the guidelines, effectively prejudging the process.

Secondly, the draft recommendations were released by the CTF months before the modelling results (which actually support screening younger women) were received. While the CTF takes every opportunity to emphasize the potential harms associated with screening, it did not comment on this positive observation nor on the downward stageshift associated with screening resulting in decreased morbidity.

Finally, as volunteer expert consultants to one of the three evidence synthesis groups working under contract to the CTF to inform breast screening recommendations, two of us observed multiple examples of micromanagement and interference by the CTF, limiting what evidence was to be (and not to be) included and the methods for analysis.

Overall, these interventions tended to reduce the perceptions of benefit associated with screening and amplify perceptions of harm. Concerns over such interference led to one member of the Evidence Synthesis Group tendering his  resignation, though he eventually rejoined the group, and the publication of a report by the Evidence Group in which the limitations of the analysis imposed by the CTF were documented.

The CTF is funded by, and reports to, the Public Health Agency of Canada (PHAC) under the authority of the Minister of Health. It is logical that the minister would act to ensure its accountability. This is not political interference with the scientific process; it is good governance in service of the health of Canadians.

We write now because we are among the “key leaders in the area” mentioned in the previous article. Its suggestion that seeking advice from subject matter experts is inappropriate is misguided. As frontline clinicians diagnosing breast cancer across all stages, we see firsthand how flawed policies harm the patients we are committed to protecting. Serious errors in past guidelines have arisen from misinterpretations of data by those who were inadequately conversant with the subject.

Communication of our concerns to the minister occurred only after multiple attempts to engage the CTF regarding problems with the scientific methods. Subsequently, personnel at the PHAC were contacted to address issues regarding dysfunctional operational behaviour and governance of the CTF. The response from PHAC was that the CTF was at arm’s length from government, thereby precluding its intervention. Though the arm’s length relationship is intended to protect scientific independence, it certainly does not imply that the government should ignore its role in ensuring accountability.

While an effective, evidence-based objective task force would be an enormous asset to Canadians, that is not the task force that currently exists.

While we fully agree that an effective, evidence-based objective task force would be an enormous asset to Canadians, that is not the task force that currently exists. While the initial wave of concern came from the CTF’s rigid and unscientific approach, the Coalition for Responsible Healthcare Guidelines was formed because many internationally recognized experts in multiple fields observed similar behaviour in guidelines pertaining to their own areas. These are not paid lobbyists; they are researchers and clinicians who found glaring errors, gaps and delays in the current guidelines, and poor alignment with the current body of scientific knowledge. Further, when these experts attempted to convey these disconnects to the CTF, their volunteer efforts were curtly dismissed.

The July 16 article mischaracterizes efforts to restore balance and objectivity to the CTF as creating “manufactured ignorance;” however, the relevance of this term is not explained. Concerns about CTF behaviour relate to its failure to incorporate modern data and a systematic tendency to overestimate harms and undervalue benefits. How is this “manufactured ignorance”? The U.S. and Canadian task forces independently commissioned sophisticated computer modelling studies, and both showed screening benefits exceed the harms by a substantial margin. The modelling results are consistent with empirical findings. This information was not used to inform the CTF draft breast screening recommendations, and the recent Canadian modeling report is still not available on the CTF website.

To be clear, there is no “big money” supporting our efforts seeking a better CTF. We are all volunteers. Our positions are informed by our knowledge and experience and the desire for a better preventive health-care environment that will reduce death and suffering.

Health advocacy is an integral role for any medical professional. There is no desire to generate more “business.” Those of us who are physicians are pressed to meet the current workload that we already experience. Dense Breasts Canada has never received any funds from industry. It is volunteer run and donations from Canadians support its efforts. Donors are publicly listed on its website.

In reply to charges that we are conflicted in our efforts to reform the Task Force governance, operating procedures and behaviour, we would ask for some introspection and less cynicism; we all have conflicts of different types – professional, emotional, financial – in our activities. As professionals, we submit to measures to mitigate their effects. To suggest that such conflicts are the major motivator for individuals’ actions is naïve. It should be recognized that these individuals have valuable expertise and experience, and they care about their patients. They lend important context to guideline development and help bridge the gap between evidence and clinical practice.

Task Force members with strong ideological positions may have no financial conflicts, but often come into the role with rigid preconceived positions, working from intellectually conflicted positions that in all cases should be disclosed.

Our disclosures of real or perceived conflicts of interest:

 Martin J. Yaffe:

• 45 years as a researcher in breast cancer, radiation and breast cancer detection
• his lab at Sunnybrook Research Institute has a collaborative research agreement with GE Healthcare on topics related to breast cancer imaging managed through his institution. He receives no remuneration, other financial benefits or perquisites from this work (or for any other interactions with industry), but does benefit academically from the scientific and technical collaboration.
• a 43-year-old daughter and other female relatives who are concerned about breast cancer.
• based on earlier research, he helped found a company that produced software for assessing breast density. This was used both for research and for the provision of clinical information. He played no role in the operation of this company but held shares. In 2024, he divested his equity holdings in this company.
• he holds some shares in a small start-up company that is attempting to develop a dedicated breast CT scanner. Policy decisions on screening made in Canada are unlikely to have any effect on his income.

P.B. Gordon:

42 years of experience as a breast radiologist, now working part-time doing image-guided breast biopsies, both on screen-detected cancers and those detected as palpable lumps.

Shushiela Appavoo:

31 years of experience as a general radiologist. A portion of her income is derived from breast imaging, including screening.

Jean M. Seely:

36 years of experience as a physician, 32 years as a radiologist subspecialized in breast imaging and radiology, diagnosing breast cancer at all stages, including early with screening. Received speaker fee from BD Inc. for educational talk.