Future of Canadian Guidelines, Task Force in Doubt

Canada’s minister of health ordered a temporary pause in the work of the Canadian Task Force on Preventive Health Care (CTFPHC) on March 4, potentially jeopardizing five guidelines nearing submission for publication, as well as those in various stages of development.

The CTFPHC is an independent panel of primary care and prevention experts funded by the Public Health Agency of Canada (PHAC). Its mandate is to develop clinical practice guidelines to support primary care providers in the delivery of preventive care.

“This pause could negate years of work on the many guidelines in active development which are supported by scientific experts in evidence review and guideline development,” the CTFPHC warned. 

But organizations such as Breast Cancer Canada (BCC) that disagree with the task force’s process (and its position on breast cancer screening) are welcoming the pause. BCC called it “a defining moment to improve breast cancer screening.”

Guidelines at Risk

In addition to breast cancer screening, topics of guidelines in late-stage development include tobacco cessation, screening for depression in adults and youth, and cervical cancer, according to CTFPHC Chair Guylène Thériault, MD. Lung cancer screening, prostate cancer screening, and falls prevention in older adults are among the topics of guidelines in varying stages of development. The future of these guidelines is now in doubt.

“If the pause continues, contracts will expire, because now is when they are renewed,” Thériault told Medscape Medical News. “We will lose a lot of expertise from the Evidence Review and Synthesis Centres from a lot of people of science. 

“The task force will also lose all the work that has been done up to now,” she added. “It’s as though you’re building a house and you start losing the walls and parts of the ceiling, and the work stops there. Well, this house has been 2 or 3 years in the making. That’s hundreds of working hours and a lot of money.”

‘Unacceptable Decision’

René Wittmer, MD, a practicing family physician who also teaches evidence-based healthcare, is leading efforts to respond to the pause. That response includes a letter supporting the task force and condemning Health Minister Mark Holland’s decision to shut it down. The letter has been signed by more than 1700 individuals to date. Its headline conveys its message: “Pause of the Canadian Task Force on Preventive Health Care: An Unacceptable Decision That Weakens the Health of Canadians.”

“We launched the letter very simply, through email, and the number of signatures shows that the silent majority is extremely satisfied and thankful to have a credible resource like the task force,” Wittmer said.

The letter states that “suspending the CTFPHC paves the way for increased commercialization of healthcare and a surge in direct-to-consumer marketing of low-value — sometimes even harmful — tests and treatments. 

“The minister’s decision is welcomed by some critics of the CTFPHC who advocate for guidelines based on expert opinion rather than rigorous and impartial analysis of scientific data,” the letter continues.

“Disagreements among professional societies on the interpretation of science are one thing — scientific debate is both healthy and necessary. But suspending an organization whose mission is to ensure knowledge translation free from external pressures is entirely different.”

Breast Cancer Guideline

Holland’s disappointment with CTFPHC seems to have begun after the US guideline on breast cancer screening was published. Holland, who Thériault said should not be involved in the task force’s work, requested an update of Canada’s breast cancer screening guideline. That guideline was in early development, Thériault noted, “but we said we would speed up the process. We started the work, and the pressure was like we never had before. He wanted the result very, very quickly, so we dropped many of the things we were doing and came up with draft recommendations.”

On May 30, 2024, the day that the task force published the draft recommendations, Holland announced that he was “disappointed” in the recommendations and essentially “disavowed” the task force’s work, Thériault said. 

The recommendations state that clinicians and patients should use shared decision-making across the board and that women ages 50-74 years should be screened regularly. Unlike the US task force, however, the Canadian task force did not recommend regular screening for women ages 40-49 years. “But we did specify that if a woman in her 40s is aware of the benefits and harms, she should have access to screening,” Thériault said.

Experts have varying opinions about when to start breast cancer screening. Indeed, the same day that the health minister called for a task force pause, BCC released its statement supporting the pause, noting, “The Task Force’s past recommendations, including its decision to keep the screening age at 50, have raised significant concerns among experts, advocates, and Canadians affected by breast cancer.” 

Jennie Dale, cofounder of Dense Breasts Canada, also spoke against the draft guidelines, alleging that they are doing “damage.” 

Wittmer commented on how quickly Holland responded to the draft recommendations. “The speed at which the minister was appalled by what was published, heard back from experts who were concerned, and decided on a course of action, without due process, was unprecedented,” he said. 

One result is that PHAC set up an External Expert Review (EER) panel in October 2024 “to study the governance, mandate, and scientific review processes” of the CTFPHC. Its findings are due by March 31.

PHAC Responds

Speaking on behalf of PHAC, Kori Ghergari, director of media relations and ministerial services for Health Canada, explained part of the rationale for the pause and the expert review. “Feedback directly from Canadians and key leaders in the area who raised concerns on the existing guidance and process of the task force has touched on various issues,” she told Medscape Medical News. These issues include these questions:

• The timeliness of some guidelines and the task force’s ability to reflect the latest evidence or best practices
• The role and involvement of subject matter experts in the development of preventive healthcare guidelines
• The methodology used by the task force and the scientific evidence considered for guideline development (eg, exclusion of evidence that is not from randomized controlled trials)

Regarding the need to “modernize” the work of the task force — another point in the statement announcing the pause — Ghergari said, “The minister of health asked the EER panel for actionable recommendations to address changes and improvements to the task force’s structure, governance, and methodology to develop guidelines. 

“The minister also requested an international comparison as part of its evidence-gathering phase,” she noted. “This allowed the EER panel to look at best practices from around the world. Modernizing the task force could include recommendations pertaining to anything from membership to engagement to topic selection and methodology.”

The task force has been “a trusted source of evidence-based recommendations, guiding healthcare providers in the delivery of preventive care,” Ghergari added. “However, as primary care and the preventive care landscape have evolved, the need to modernize the task force’s mandate has also grown.

“This modernization is essential for the task force to remain effective, inclusive, and responsive to the full continuum of primary care providers, other sources of preventive care at the provincial and territorial levels, and the needs of patients and the public,” Ghergari concluded.

New Elections

Meanwhile, Wittmer and colleagues are assembling a coalition of clinicians and others committed to “the safeguarding of evidence-based healthcare in Canada,” said Wittmer. Coalition members “are extremely concerned and feel like we need to get together and speak in a united way to show that this is very concerning,” he added.

“After many months of thorough analysis by the EER, it is difficult to justify why the minister would preemptively act [by ordering a task force pause] without first considering the evidence the EER gathered and their final recommendations,” Wittmer said. “If the goal is to strengthen institutions and promote transparency, it would be both prudent and reasonable for the minister to allow the external reviewers’ conclusions to be made public before requesting an institution to halt its scientific work.”

In the US, Amir Qaseem, MD, PhD, chief science officer and senior vice president of clinical policy for the American College of Physicians (ACP), has taken notice. Qaseem, who oversees ACP’s clinical guidelines and scientific medical policy programs, which develop evidence-based recommendations and clinical policies for the organization, told Medscape Medical News, “ACP is aware of the situation unfolding with the CTFPHC. 

“While we cannot speculate on potential future situations in the US,” he said, “we are actively monitoring what’s happening in Canada and how that might impact evidence-based science, which ACP vigorously supports.”

“If the pause continues,” Wittmer added, “I think that’s the end of the task force. The task force will shut down.” The work to date has been part of an ongoing process under several contracts, he explained. “You can’t shut down such a big machine for a prolonged period and hope that it will just restart when you’re ready. And what I am so concerned about is that the shutdown comes at a time when family medicine and primary care are facing an unprecedented crisis.” 

Thériault said the task force is “very responsive” and is looking forward to the EER recommendations. However, she noted, if an election for a new prime minister is held before March 31, it’s possible that the recommendations will not be published or made public under the new government. “I don’t know what will happen with those recommendations,” she acknowledged.

Mark Carney became Canada’s new prime minister on March 14 and subsequently appointed Kamal Khera minister of health. Carney “has hinted he will call a federal election before March 24,” Politico recently reported.

Thériault reported that she reviewed a document on cervical cancer for the Institut national d’excellence en santé et en services sociaux. Wittmer reported being chair of Choosing Wisely Quebec. 

Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.