Preventive healthcare in Canada

Leanne Kaufman:

As we look at our aging population in Canada, or even our own selves aging, there’s an opportunity to think of healthcare a little differently. What if we could shift the narrative when talking about healthcare as being primarily how we’re cared for when we’re sick to being focused on the measures that keep us out of the emergency room? That’s preventive healthcare. Most Canadians do their own preventive healthcare to some degree already, and advances in science, medicine, and technology have made this increasingly possible, but there’s a lot more to come. Canadians are already living longer, but are they living better? Could preventive healthcare be the key that may allow them to do so?

Hello, I’m Leanne Kaufman, and welcome to RBC Wealth Management Canada’s Matters Beyond Wealth. With me today is Dr. Khalil Sivjee, Medical Director of Cleveland Clinic Canada. In association with Cleveland Clinic, he also serves as Chief Medical Director here at RBC. Amongst his many prior accomplishments and roles, he served as a Staff Pulmonologist at Kaiser in Orange County, California, and as Division Head of Respirology at Sunnybrook Health Sciences Centre. He also holds a teaching appointment as Assistant Professor of Medicine at the University of Toronto Faculty of Medicine. Dr. K, thanks for being here with me today to talk about preventive healthcare and why this matters beyond wealth.

Dr. Khalil Sivjee:

Thank you, Leanne.

Leanne Kaufman:

So what does it mean to you when I ask about preventive or preventative medicine versus predictive? Are they all the same thing or is there a difference?

Dr. Khalil Sivjee:

I think the way to look at this is to look at primary care as an umbrella term. And below that umbrella of primary care, we have preventive care, which should include the traditional screenings that people go to their family doctors for, like cancer screenings, heart disease screenings, getting vaccinations, looking for things like high blood pressure, high cholesterol, sugar levels, prediabetes, and then detecting these early and keeping them under control to prevent the consequences of later events, like heart attacks and strokes. Also under that umbrella, besides preventive care, is predictive care. And what we’re looking at with predictive care is looking deeper than the traditional ways of screening for disease, trying to identify diseases that you may develop even before you start to develop them, and then intervening with other lifestyle management or medications to reduce the impact of these diseases or maybe to avoid them altogether. For example, if I detected a gene in someone’s DNA that predisposes them to breast cancer, I may suggest that we start screening for breast cancer much sooner than the traditional recommendations and maybe more frequently as well.

Leanne Kaufman:

So then what is preventive healthcare? Can you give us some more examples of what we mean by that?

Dr. Khalil Sivjee:

Yeah, so preventive health care, again, falls under the umbrella of primary care. And those are well-established tests that take patients that are at certain risk for diseases and using evidence-based guidelines that physicians follow and physicians help create, determine what’s best for that population. So if you fall into a certain risk group, then you have that screening done. The challenge, though, with purely preventive health care versus predictive health care is that in some individuals, they have additional risk factors that are not captured nicely and neatly into those guidelines. So they may be left out of certain screening tests. And the other problem is that as new modalities are being discovered, new tests, new screening modalities, the national guidelines that we all follow can take a long time to incorporate those new modalities. I’ll give you the classic example. When mammography first was discovered and came out for breast cancer screening, it took over a decade for breast cancer screening using mammography to make it to the guidelines. And so there’s a lag there that we need to address.

Leanne Kaufman:

So you’ve talked about some of these screenings, vaccinations, mammography, some of it might be lifestyle. What are the forms of preventative healthcare that we have today? And does the average Canadian need all of them?

Dr. Khalil Sivjee:

Yeah, I think when you say what are the forms, what you really mean are what are the traditional methods of screening for disease? And those are well-established, try and true. You get your blood pressure checked, you get your cholesterol checked, you find out what your blood sugars have been running. And then you try to screen for certain cancers, for instance, that we know we can screen for, and there are typically five. There’s colon cancer in both men and women, cervical and breast cancer in women, and prostate cancer in men. And if you’re lucky enough to have your skin looked at, head to tail screening for skin cancer as well. We’re starting to incorporate some screening for lung cancer and high-risk populations, mostly those that used to smoke or smoke currently. But that’s it, that’s where it ends. Those screening tests are all we have for cancers. But those will be considered the kind of the mainstay foundational screening for disease that we recommend for all Canadians.

Leanne Kaufman:

And it doesn’t sound like a whole lot when you think of all the various types of disease that are out there, that’s not a massive number of screens. But I think maybe I’ll ask you about that in a minute. What about, how comfortable should we be with the timelines around when we’re being asked to get these screenings? Like back to the question of, should every Canadian have them? I mean, obviously there’s gender issues in some of the screens, but are these things we need to be asking for or should they be brought to our attention by our primary caregivers?

Dr. Khalil Sivjee:

Yeah, so your primary caregiver is oftentimes using these evidence-based guidelines. These evidence-based guidelines are based on large population studies. And the challenge nowadays is that as we learn more and more about who you are as an individual, right down to your genetics and what you may be at risk for, more so than someone that looks very similar to you in a population study, but may be at a different risk for the same disease. The guidelines don’t lend themselves to individualizing recommendations. And sort of the classic example is when do you start screening for colon cancer? The traditional number was fifty. You turn fifty and go for your colonoscopy to make sure you don’t have early signs of colon cancer. But if you have a gene that predisposes you to being at a higher risk for colon cancer, maybe that should be in the forties. And we’ve seen and heard of unfortunate cases of people in their forties dying of colon cancer, never having been screened because the guidelines say you should be screened at forty. Now, we’re starting to slowly change that. You’ve heard about breast cancer screening ages starting to drop, colon cancer screening ages starting to drop. But we only do these at a population level and not at an individual level. Hopefully, as we become more sophisticated in our screening down the line, we’ll be able to adjust these so that each individual, based on their risk profile, gets screening at the appropriate time.

Leanne Kaufman:

Probably a lot of this is driven at least in part by economics and we are used to free healthcare in Canada paid for by our tax base. And we know that a lot of our tax dollars go to the healthcare portfolio, but at the same time, access to this preventative care through our primary care providers can be a real challenge for Canadians. Do you have any comments on that?

Dr. Khalil Sivjee:

Yeah, the healthcare system is fantastic when you’re very sick, if you have had a heart attack or a stroke or have cancer. But that’s what it was designed to do. So when we created our healthcare system, sixty years ago through the Canada Health Act and the work of Tommy Douglas, it was meant to be a sick care system. If you were sick, we don’t want you to have undue financial pressures because of that. And you get the care you need. It was never really meant to be a primary and preventive healthcare system. So unfortunately, here we are, sixty years later, where, as you said, a large proportion of our annual budget in some provinces, fifty percent or more, is going to sick care and paying for this expensive, great care in hospitals, but not leaving much else for preventive care and primary.

Leanne Kaufman:

So I kicked some of this off by talking about advancements that are coming and in some cases already here that’ll help with all of these preventive measures. And one of them that I was made aware of at a US-based conference over a year ago was a test called Gallery, which I understand from you is now actually available in Canada. Can you tell us a little bit about what the Gallery test is?

Dr. Khalil Sivjee:

Yeah, sure. The unfortunate fact is that a third of us will develop cancer during our lifetimes. And as we age, that risk of cancer, developing cancer, goes up. As I mentioned, we only screen for five cancers and we screen for them when we see them, either on a scope or a scan or with our eyes. We’re not screening for them in the early phases of the development of that cancer because until now, we never had a way of doing that. Gallery is a revolutionary way of looking for DNA from the cancer cells that can be detected very close to the time that the cancer cell forms. So for instance, when a cancer cell is doubling, which is how cancer grows, it doubles itself and copies itself, bits and pieces of its DNA that it has to copy are fragmented and start to circulate in your bloodstream. We can pick that up with this gallery test. So now, instead of screening for five cancers later in the development of those cancers, we can now screen for up to fifty cancers very, very early as these cells are duplicating in their early phases. So that’s what the gallery test is. You’re right, it is now available in Canada. It’s been available in the US for some time. And I have to say, while that sounds really exciting and like it’s all good news, it’s actually not all good news because like with every test, not every test is perfect. There’s gonna be false positives, which means your test comes out positive that you have this DNA from a cancer cell floating in your bloodstream, but you actually don’t have cancer. And there’s false negatives. So we have to make sure that we understand that no test is perfect. And unfortunately, if you’re told that you might have cancer, that may lead to downstream testing that would be unnecessary for you. But it’s a pretty good test and it’s getting better as we learn more and more about it and gather more and more data.

Leanne Kaufman:

So to your point, if you do get this test done and it does come back with a positive, what’s the next step? Is the Canadian healthcare system prepared now to respond?

Dr. Khalil Sivjee:

So that’s the good question. That’s a really good question. And the answer is, and this is not gonna be a satisfying answer, but it’s too early to know. If I detect the DNA from a pancreatic cell that might be cancerous floating in your bloodstream, what do I do with that information? I can’t do a CAT scan on your abdomen every day. That’s way too much radiation. That would cause more harm than good. So this is an area of active research as more and more people are getting these tests done. And frankly, people are kind of personalizing the follow-up for each case. And that’s the way it should be. That’s why getting these tests really is not simply a matter of going to the doctor, rolling up your sleeve and getting blood tests done. It really needs to come with some pre-test counseling and then the test with the results. And then some close post-test counseling. You do really need an advocate and a health partner if you decide to get this test done.

Leanne Kaufman:

Yeah, I can see that. It’s like the dangerousness of me having access to my own test results before having someone to translate what it means for me. It’s a double-edged sword as far as I’m concerned, but I can’t help it. I have to sign up for it. So are there any other kind of tests or diagnostics out there or that you know of in development that are similar to Gallery and that they’re going to have this very early detection or they’re going to aid in that preventative, maybe it’s not preventative if you’ve already got the DNA, but whatever that early detection and prevention, what else is happening?

Dr. Khalil Sivjee:

Yeah, so as I mentioned earlier, one of the things a cancer cell has to do is copy itself, and copy itself over and over and over and over. And in doing that, not only does it have to copy its DNA, but it has to make its proteins. It has to make the shell or the cell membrane around it. It has to make the organelles, all the bits and pieces of the cell that are required to make the cell work. So besides copying the DNA, it makes another substance called RNA. And so the DNA becomes RNA, and then the RNA is translated into proteins. And there’s a new test that literally was just discovered a few months ago. In fact, the discoverers of this test, two gentlemen named Victor Ambrose and Gary Ruvkin won the Nobel Prize in Medicine in the year of this discovery. But they found bits and pieces of RNA, which they called microRNA. And they can tell what type of cell this microRNA has come from. And so if you have a spike in microRNA, and we can detect that and detect what type of cell it comes from, that’s another potential way to detect cancer at its very, very earliest stage. In fact, there’s a Canadian company called CanScan that’s going to commercialize this test probably later in 2025.

Leanne Kaufman:

So lots to look forward to and reasons to be optimistic about our ability to get in front of this and not just treat sickness, but be preventative.

Dr. Khalil Sivjee:

And detect disease early, yeah. 

Leanne Kaufman:

Yeah, and I know because I’ve heard you speak in other forums that there’s all sorts of other things that we can be doing without having to speak to a primary care physician to be preventatively healthy, like the good old adages of eat whole foods and move your body, right?

Dr. Khalil Sivjee:

Yeah, you know, it’s interesting. Those old age old adages, we sort of just took on faith before, but we’re actually now learning more and more about the science behind them. So eating right and exercising and managing your stress, we’re actually figuring out what proteins are created, what genes are upregulated and downregulated from those lifestyle activities that then impact on disease. So not only are they age old adages that make sense, but they’re actually now proven with a biologic background.

Leanne Kaufman:

Well, it’s all fascinating stuff and I watch it all with great interest. Dr. K, if you hope that our listeners today just remember one thing from our conversation, what would that one thing be?

Dr. Khalil Sivjee:

Well, I’ll piggyback on what we just said, which is live a healthy lifestyle. So eat right, exercise, and certainly manage the stress that all of us face in life. But I would also say have a reliable health partner, someone that can help you measure your risks for disease, and then help you navigate the best plan for managing disease if you develop disease, and manage your best plan for screening for diseases as well. So hard to do it alone. You know, Google can only take you so far. You do need a reliable health partner.

Leanne Kaufman:

Thank you so much, Dr. K, for joining me today to explore how preventative healthcare may change the way Canadians experience their own longevity and why this matters beyond wealth.

Dr. Khalil Sivjee:

Thank you.

Leanne Kaufman:

You can find out more about Dr. K on the Cleveland Clinic Canada website or on LinkedIn. If you enjoyed this episode and you’d like to help support the podcast, please share it with others, post about it on social media, or leave a rating and review. Until next time, I’m Leanne Kaufman. Thank you for joining us.

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