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Dáil Éireann debate -
Tuesday, 12 Feb 2002

Vol. 548 No. 2

Cancer Research: Statements.

I thank Deputy Gormley and others for raising this issue. The work of the National Cancer Registry Board is vital in our continuing fight against cancer in that it provides a national data set critical for epidemiological and research purposes and valuable information on cancer rates. I welcome the publication of the fifth report of the National Cancer Registry Board which summarises the first five years of data collection by the board and presents comprehensive data on treatment and survival patterns nationally between 1994 and 1998.

Regarding the Deputy's concerns, the years covered by the report, 1994 to 1998, pre-date the significant investment made in cancer services, especially by the Government, since the implementation of the national cancer strategy in 1997. As Dr. Harry Comber, director of the National Cancer Registry Board pointed out at the launch of the report last week, it will obviously take time for this investment to be reflected in cancer treatment services, particularly in relation to such statistics as five year survival rates.

It is also worth noting that the report states there was no significant change in the risk of developing or dying from cancer between 1994 and 1998. Cancer incidence in Ireland was similar to that in neighbouring countries. Overall, and for most common cancers, cancer rates were lower than in Scotland, Wales and Northern Ireland, higher than in England and close to EU averages. Exceptions were breast cancer, where our risk was lower than that of the neighbouring countries, and lung cancer in women, for which our risk was well above the EU average.

From 1997 to date, more than €103 million has been invested in the development of appropriate treatment and care services for people with cancer. Among a range of other initiatives, this investment has enabled the funding of 62 additional consultant posts in key areas such as medical oncology, radiology, symptomatic breast disease, palliative care, histopathology and haematology, together with support staff throughout the country. This includes approval which has been given for eight new consultant surgeon posts with a special interest in breast surgery.

This level of funding far exceeds the £25 million which was initially envisaged in 1996 and is a clear indication of the Government's continued commitment to the development of co-ordinated and patient-focused cancer treatment in line with the recommendations of the national cancer strategy.

Under the national cancer strategy, the national cancer forum was established to advise on appropriate developments and structures in the area of cancer. The term of office of the first forum expired in 2000 and I subsequently appointed Professor Paul Redmond as chairman of the second national cancer forum. The forum is representative of the medical, the palliative and the voluntary organisations involved in cancer services and continues to play a very important role in the provision of quality services to people with cancer.

Regional directors of cancer services have also been appointed in each of the health boards to oversee and co-ordinate the development of cancer services in their respective areas in conjunction with the chief executive officers of the health boards. These posts are proving to be of great benefit in assisting in the development of appropriate future cancer services.

In 2000, national screening programmes for both breast and cervical cancer were initiated on a phased basis. BreastCheck, the national breast screening programme, commenced in March 2000 with phase one of the programme covering the Eastern Regional Health Authority, Midland Health Board and North Eastern Health Board areas. Screening is being offered free of charge to all women in those areas in the target age group, 50 to 64 years of age. BreastCheck, as with many other sectors of the health services has found it difficult to recruit specialised radiographers. This shortage of staff has meant the programme has been unable to screen women as quickly as anticipated. BreastCheck recognised this difficulty some time ago and took a number of initiatives to address this shortage, including running both national and international recruitment campaigns. This has resulted in the recruitment of additional radiographers to the programme, and of BreastCheck's total number of 18 radiographer posts, 15.5 are currently filled. BreastCheck continues to explore other recruitment possibilities and reports that the targets achieved in all other areas are exemplary in comparison with breast screening programmes in Holland, Sweden and the United Kingdom. It is expected that phase one of the programme will be completed by December 2002. To date, more than 50,000 women have been called for screening and more than 34,000 women have been screened. This represents a 70% uptake.

Phase one of the national cervical screening programme was launched in October 2000 covering the Mid-Western Health Board area. Under phase one, cervical screening is being offered free of charge, to approximately 67,000 women in the 25-60 age group at five yearly intervals.

The provision of screening programmes, underpinned by international quality assurance criteria and best practice, is a key objective and the experience gained in phase one will facilitate the process of planning and organising the roll-out of these programmes countrywide. Both BreastCheck, the national breast screening programme, and the national cervical screening programme are currently in discussion with health boards concerning expansion of the programmes nationwide.

The report identifies that incidence rates for prostate cancer in men in all age groups showed statistically significant increases. Incidence rates in men under 65 years increased by 8.2%. Mortality rates showed no evidence of an upward or downward trend. The evidence of a divergence between incidence and mortality rates may be due to better case-finding, more incidental diagnoses or a genuine increase in survival.

In December 2001, €320,000 was announced by my colleague the Minister for Finance, Deputy McCreevy, for the Irish Cancer Society to support a study of prostate cancer, including diagnosis. A sub-group of the national cancer forum has recently been established on generic screening. This group, which is chaired by Mr. Michael Lyons, chief executive officer, East Coast Area Health Board, will review all issues relating to screening, including looking at specific diseases such as colorectal and prostate cancer. Their recommendations will help to inform policy developments in this area on an ongoing basis.

The National Cancer Registry Board's report shows clear evidence of a divergence between female incidence and mortality rates in relation to breast cancer, with a statistically significant upward trend in breast cancer incidence in women under 65 years and downward trends in mortality rates in all age groups combined. This divergence in trends is expected to continue as a result of continuing improvements in treatments and as a result of the BreastCheck screening programme.

A sub-committee of the national cancer forum was established to report and make recommendations on the development of symptomatic breast disease services nationally. Its report, which was published in March 2000, provides a comprehensive plan for the co-ordination and best delivery of symptomatic breast disease services nationwide.

I set particular emphasis on the central recommendations of this report. As breast cancer remains a major public health issue, it is vitally important that quality services are developed for symptomatic breast disease. It is generally accepted that women with breast disease are best served by a team of specialists working together and that women experience better outcomes if their cancer is managed in centres developed along the lines recommended in the sub-group report.

I am glad to confirm that during the past year, there have been extensive consultations between my Department and the health boards on the best way forward for the development of symptomatic breast disease services in their functional areas. More than 12 months ago I gave financial approval to the boards on condition that they would operate to agreed protocols and standards of care in accordance with national guidelines and quality assurance arrangements to ensure compliance with best international practice and to achieve optimum outcomes. The boards deliberated for some time before coming forward with the best solutions for their particular areas.

As well as investing funding in the delivery of services to people with cancer and in developing

screening services for particular cancers, I have also complemented these actions by initiatives in the field of health promotion. The health promotion unit of my Department supports an extensive range of initiatives that have an impact on the levels of knowledge and awareness of the risk factors associated with many cancers. These include mass media campaigns on anti-smoking, alcohol awareness and healthy eating. The unit also provides funding to the Irish Cancer Society in support of cancer prevention initiatives including the yearly Europe against cancer campaign.

The statistics on lung cancer published in the report reaffirm the need for comprehensive, strengthened legislative measures to tackle tobacco use in this country. The Health (Miscellaneous Provisions) Act, 2001 raised the age limit at which tobacco products could legally be sold to young persons from 16 years to 18 years with effect from 1 August last year. The House will also be aware that I advised the tobacco industry here that no further advertising or sponsorship, other than limited retail and trade advertising, would be allowed after 1 July 2000. The Public Health (Tobacco) Bill will now be enacted and implemented as a matter of urgency and a reduction in smoking will continue to be targeted through Government fiscal policies. The Bill confers enabling powers on the Minister for Health and Children to extend environmental controls on smoking to a range of public areas and public facilities not already covered by existing legislation.

The main provisions of the Bill include the establishment of the Office of Tobacco Control on a statutory basis; a comprehensive ban on tobacco advertising and on all forms of sponsorship by the tobacco industry; a system of retail registration and fees to be administered by the Office of Tobacco Control; a ban on the sale of packets of less than 20 cigarettes and restrictions on self service; full disclosure to the public on all aspects of tobacco; improved protection for people against passive smoking; and much tougher enforcement.

Health information is fundamental to assessing and implementing quality programmes. It is also vital to the wider areas of value for money, information for management, information for the public, knowledge management systems and knowledge bases. The national health strategy provides for the establishment of an independent health information and quality authority to lead the development of health information to support these requirements. The soon to be published national health information strategy will provide the context for future development in this area.

In the context of the national health strategy, I will continue to be advised by the National Cancer Forum on the planning, development and implementation of cancer services for the country. It is currently examining a number of issues of tremendous importance to the effective progression of the development of cancer services in this country. Areas such as protocols for the care and treatment of cancer patients, information requirements, audit and evaluation of our services, genetics issues and further screening programmes are important component parts of the appropriate future development of cancer service and the forum, as the established expert advisory body will report to me on these issues.

The Government is constantly striving to provide the best and most appropriate cancer services for the country. In recognition of the need to further develop cancer services, the national health strategy has identified the need for the preparation by the end of 2002 of a revised implementation plan for the national cancer strategy. This plan will be prepared by my Department in conjunction with the National Cancer Forum and will set out the key areas to be targeted for the development of cancer services in the next seven years. This will have regard to existing policies in the areas of symptomatic breast disease and palliative care and the forthcoming recommendations of the expert group on radiotherapy services. The work of that group is ongoing and I am awaiting the final draft report.

The work of the National Cancer Registry Board provides a vital contribution to informing the ongoing implementation of the national cancer strategy in terms of directing the way in which investment takes place, ensuring integration of services and that the objectives of the national cancer strategy are realised. The health strategy provides a significant opportunity for the forum to shape its work. It is also intended that the National Cancer Forum will work with the National Hospitals Agency and the Health Information and Quality Authority to ensure service, quality, accessibility and responsiveness. Furthermore, under the Ireland-Northern Ireland National Cancer Institute Cancer Consortium initiative, a research programme has been launched. This will allow hospitals throughout Ireland to participate in high quality clinical trials of new therapies for cancer, helping to ensure new and effective treatments are made available more quickly.

The developments I have outlined here today describe an overall framework through which cancer services can be developed and provided in a co-ordinated and effective manner. The Government is committed to ensuring a cancer strategy will form an integral part of the implementation of the overall health strategy which is aimed at ensuring quality and fairness in the provision of services to all. I look forward to ongoing reports from the National Cancer Registry Board, particularly in the years ahead, which should reflect the success and impact of the level of investment which has taken place since 1997 in particular.

The Minister referred to committees, consortia, review groups, health boards and agencies. There are so many groups, agencies, health boards, committees, reviews and commissions that the Minister does not even know their number. He could not tell me their number in a parliamentary reply.

My family has been devastated by cancer. My father died from cancer before my sixth birthday. My brother died on Christmas Day, my sister who had just turned 43 died and my other brother had a transplant because of cancer. Unfortunately, this is not unusual. The statistics in the Minister's report give the figures as a percentage of the EU average, which is below the Canadian average. If one were to compare the average rate of cancer deaths in Ireland to Canada, it would be even worse than those in the report. For example, in the case of lung cancer among males, the percentage is in the region of 160% or 165% of the EU average. The one cancer which is well below the EU average is lung cancer among women. Given that we do not have a child cancer strategy, as recommended in the report of the Oireachtas Committee on Health and Tobacco written by myself, and the fact that young girls are smoking more, I predict, as sure as night follows day, those cancer statistics for females will not only not decline but they will increase. The incidence of melanoma among males is approximately 152% of the European average and for females it is approximately 120%. The incidence of prostate cancer is approximately 120% of the European average. The incidence of bladder cancer among males is approximately 110% of the European average. All cancers, apart from skin cancer among males, is approximately 120% of the European average, which is well below the Canadian average.

I estimate that if we took a similar population to Ireland in France, approximately 3.8 million people, they would live collectively 13 million years longer than Irish people. That is an extraordinary figure. Why is it that people in Canada live to be 78 years of age on average? In parts of Europe people live to be 75 and 76 on average. Why is the death rate among Irish people, not just from cancer but heart diseases and other illnesses, so high?

It is time to divorce public health from health. Would it not be a good idea to redesign the Department of Tourism, Sport and Recreation? Perhaps tourism could be included with transport and there could be a Minister for transport and tourism. This would take all the transport issues away from the environment and the other Departments. The Department of Tourism, Sport and Recreation could then become the Department of public health, recreation and sport, dealing with food safety and preventative measures in regard to the environment. There is a case to be made for divorcing public health issues from health issues. The Minister is only toying with a solution. There is no point trying to shore up everything by having 60 or 70 different consortia, committees, review groups and so on. We need to take this issue more seriously. The approach to TB taken by Noel Browne needs to be taken to cancer and other serious illnesses. There is no evidence of this in the Minister's proposals.

Of all those who die in Ireland under the age of 65, one third die from cancer. We have the third highest death rate from cancer in Europe and many of those who die are awaiting so-called elective treatment. The chief medical officer informed us in his 1999 annual report that one third of cancers are preventable and one third are potentially curable. He also stated that good palliative care can provide significant improvements in quality of life. The appalling reality is that in a society awash with money the Government has failed to give priority to cancer services which could see more people survive cancer and enjoy many more years with their loved ones.

At the launch of Daffodil Day 2000, a consultant radiotherapist at St. Luke's Hospital, Dublin, painted a very unacceptable picture on the availability of radiotherapy services in Ireland. On average only 16% of cancer patients receive radiotherapy, despite the fact that up to 50% of patients could benefit from it. It was pointed out that up to 1,000 people per annum people are dying because of inadequate treatment. While 16% of Irish cancer patients receive radiotherapy, an average of 66% of patients receive such treatment in the EU. Could this relate to the statistics I have just quoted?

An eminent oncologist, Dr. John Crown, writing in the Irish Medical News in February last stated:

The National Cancer Strategy which emerged . . . undoubtedly led to service improvements. However, by the time the civil servants were finished with it, it contained some awful clangers, principally its total failure to address the hopelessly fractioned Dublin set-up, and its determination that Galway would become the world's only radiotherapy-less comprehensive cancer centre.

In truth, what was the worst cancer treatment system in Europe is better, but is still the worst cancer treatment system in Europe.

It is unfair to blame civil servants because they cannot answer for themselves, but Ministers can. I ask the Minister to respond to this point when concluding the debate. The verdict of professionals such as these and the fact that two major hospitals in Dublin had to postpone potentially life-saving treatments for cancer patients to make way for non-cancer emergency admissions, at a time of unprecedented wealth, huge budget surpluses and unprecedented amounts of taxpayers' money being made available by the Dáil to the Minister for Health and Children, give rise to concern.

Last year, one mother who needed chemotherapy for a cancerous lump on her neck said she had her life-saving treatment cancelled each day for almost two weeks. She is reported as saying that the stress was so great that she telephoned twice daily, but every day the queue was getting longer. The Minister was quoted as describing these developments as "unacceptable", as if he was somehow a disinterested and unconnected commentator. Would any of us like that treatment for our wives, daughters or mothers? We would not. I am not referring to a statistic, but a woman who went to the hospital.

We ask why the system is not working. All the review groups, committees etc. will not do the job. If the Minister stopped running around attending the opening of every envelope but started doing his job as Minister and concentrated his efforts, it would be helpful. Perhaps he should pick one area of health and say, "I will be like Noel Browne. I will bring imagination to bear on the issue and I will deal with it." Perhaps then we could come to terms with some of the problems that the lady I mentioned faced. She faced these problems despite the launching of a national strategy on cancer in 1996 and the announcement on an implementation strategy in 1997.

The effect of cancer on society is now devastating. If one third of all deaths of those aged under 65 are cancer-related, it means that 7,500 persons per year die from cancer in Ireland. This constitutes one quarter of all deaths every year and this figure has remained at that level for almost ten years. In 1995, the number of persons dying from ischaemic heart disease was 7,926 and this declined in 1999 to 6,876. There was no such decline in cancer deaths in the same period.

An average of 18,000 new cases of cancer are recorded annually and, on the basis of epidemiological data available, there are regional disparities in both the death rate and incidence, i.e., new cases of cancer, even after taking differences of age profile into account. Death rates from cancer are significantly higher in what was then the Eastern Health Board area than in the rest of the country. Death rates from cancer are significantly lower in the Southern, Western and North Western Health Board areas. Death rates for the major types of cancer show statistically significant variations between regions, but this has not given rise to strategies to combat those variations.

In the five years covered by this report, there were almost 20,000 new cases of cancer each year and 7,500 cancer deaths occurred annually. One in four deaths was due to cancer and in women under 65 almost half of the deaths that occurred were cancer-related. The report shows that there was no significant change in the risk of developing or dying from cancer, despite a strategy in 1996 and an implementation programme announced in 1997. It should be a matter of comfort that this is so, but it is not. Despite advances in medical treatment and technology and despite unprecedented resources being available to the Government, there has been a major systems failure, tantamount to an administrative paralysis in respect of cancer treatment.

Ireland's mortality rate from cancer compares unfavourably with the EU average. While our death rate from cancer has declined by almost 10% in the under 65 age group since 1970, it is still above the EU average and our mortality rate for the overall population, including those aged over 65, has been rising significantly since the late 1970s.

The Government's long-delayed health strategy was unveiled with a great fanfare late last year. In respect of cancer services, it leaves much to be desired, and holds out little hope that the next five-year report of the national cancer registry will show much improvement. While many of the aspirations in the plan are worthy, the Government's incompetence will prove its undoing. Many of the action points are nothing more than extensions of existing targets. For instance, agreement on cancer services will not be reached before 2003, despite the fact that the national cancer strategy was in place before this Government took office.

I call on the Minister to publish tables showing progress to date in meeting the targets set and his forecasts for the coming years. There is strong evidence that lifestyle and environmental factors play an important role. It is estimated that tobacco, alcohol and diet, the three major lifestyle risk factors, contribute to two thirds of all cancers in Europe.

The Government's health strategy promises that programmes for breast and cervical cancer screening will be extended nationally, but no target dates have been given. Currently, BreastCheck is only available in three out of eight health board areas and, by June 2001, only one third of the eligible women had been screened because of the lack of available staff. There are not enough radiographers to carry out the screening and a new course for radiographers is having difficulty because there are not enough lecturers to teach the students.

Women who present for breast screening under BreastCheck are guaranteed timeframes within which they will receive treatment should they require it. Despite the best efforts of the medical and nursing staff at breast disease clinics in many of our major hospitals, women who already have breast cancer symptoms can receive no such service guarantees.

The cancer strategy launched in 1996 by the previous Administration stated the obvious in showing the number of people that cancer kills. That strategy set the objective of reducing cancer among the under 65 age group by 15% in the ten years to 2004. Will these targets be met? I am sceptical about the announcements being made. For example, about 900 people per year die from secondary smoking, that is inhaling other people's smoke, particularly in public houses. I do not believe we have been strong enough in our willingness to tackle this issue.

I hope the Minster will take into account the issues I have raised. I hope we will see targets, dates and percentages set for a reduction in our cancer rates to below the European Union average and, I hope, below the Canadian average. There is no reason why we should not be able to achieve such objectives.

I would like to share my time with Deputy Gormley.

On a point of order, I was down for five minutes later on and I am delighted that the Deputy has allowed me time.

I am to be allowed ten minutes and Deputy Gormley is to be allowed five.

Is that agreed? Agreed.

When we look at this report, it is important to consider the experience of cancer patients during the stewardship of this particular Minister for Health and Children and this Government. A unique and certainly unprecedented event took place during that period. A woman was forced to go to court to gain access to cancer treatment that she was entitled to have, but was unable to access. Her name was Janet Byrne. She was able, primarily, to receive life-saving chemotherapy after the High Court heard she had been treated in the Mater Private Hospital. This was a case in which a woman desperately needed chemotherapy. The case was resolved by the hospital in question providing private care for the public patient. It shows the extent to which services to patients – citizens of this State – have been overstretched and under-resourced, to a point where a sick woman was forced to go to the court to avail of treatment that, under successive Governments, she has been entitled to receive.

Another example of the direct experience of individuals seeking cancer treatment occurred this year. Several Dublin hospitals had to cancel emergency cancer treatment as problems in the health system worsened. The Mater Hospital, for example, had to cancel cancer treatments for patients because there were so many emergencies in the accident and emergency unit that it did not have enough beds. This is a new phenomenon. In the past, cancer patients would have expected to have priority and be able to get access to specialists and hospital care. There is now a new phenomenon where they are either delayed or denied access to such treatment.

In April, there was a report in The Sunday Times of a 39 year old mother whose chemotherapy treatment for a cancerous lump in her neck at the Mater Hospital was cancelled each day for almost two weeks. She eventually secured a bed for the fifth of her seven life saving treatments late last week. She is quoted as saying: “The stress was so great I telephoned twice daily but every day the queue was getting longer.” That is the kind of issue we must address. At a time of unprecedented prosperity, the Government has failed to meet the needs of the sickest in our society.

An extraordinary statement was made by Mr. Séamus Ó Cathail, consultant radiotherapist at Cork University Hospital, who said that as many as 1,000 Irish people are dying unnecessarily of cancer every year because of inadequate treatment facilities, especially in the field of radiography. That is an issue that has not been resolved. There are major staff shortages in radiography which have not been addressed. That is a failure of preparation, planning and foresight by the Department and the Minister.

The analysis in this report is of great significance and is a welcome addition to the information already available. Those who prepared it deserve our thanks. The lack of information of the incidence, mortality, treatment and survival of major diseases is clearly an obstacle to devising effective strategies to combat them. I would like the Minister to clarify the accuracy of the figures. The report points out there are difficulties in documenting accurate figures. There are difficulties in starting up this kind of registry, of over-reporting of death certificates and also in terms of comparing ourselves with other countries. The registry adopted a measurement recommended by the International Agency for Research on Cancer, which, in terms of how it is used to measure cancers, shows a 5% reduction. It is obviously the recommended approach and means that multiple cancers are not itemised individually so that only one cancer is considered when suffered by one person. When we compare ourselves with other countries, we should be comparing like with like. We need to be sure of having that kind of accuracy.

One of the features of this report is a paradox. Where more screening is done, there is more evidence of the incidence of disease. Given that the levels of screening are remarkably low when compared to other European Union countries, how can we claim that the incidence of cancers is on a par with other countries? As screening picks up hidden levels of cancer, we cannot claim to have the knowledge of other countries with much better detection and screening. We have a partial breast screening programme, which is limited in that it is only carried out by a small number of health boards. Even in those health board regions, this excellent programme has been delayed because of a lack of foresight and planning in terms of staffing. No woman in my constituency of County Wicklow has yet been called under the BreastCheck programme. This is truly remarkable, considering the importance given to it by the Government.

The increased levels of prostate cancer indicate that we must have a screening programme for this cancer. The Minister talks about having a programme, but he should outline a target date for its commencement. The manner in which the programme, which should be a national one, is to be carried out must be defined. In yesterday's edition of The Irish Times, Mr. John Stratton, consultant gynaecological oncologist and obstetrician, is quoted as saying that the cervical cancer screening programme is still on a pilot basis. This is scandalous. Screening for this cancer is relatively easy and very effective. He goes on to say:

Cervical cancer is a preventable disease. No one should get it. They have halved the incidence of it in the UK by screening; in the United States they have reduced it by 80%. Why are they putting in a pilot project when it has been of proven benefit wherever it is set up properly?

This is a question the Minister must answer. Why can a woman not be screened unless she can afford to pay her general practitioner for it? This is a very simple early detection preventative measure the Minister could introduce. Does the Government simply not want to spend the money? It has a glitzy health strategy, but it cannot increase the number of medical cards for poor people and it will not allow women to avail of screening for cervical cancer. This is a serious issue that should be top of the priorities when the changes regarding cancer treatment are made.

This is a very important report which presents its analysis in a typically dry and bureaucratic way. In view of the cancer epidemic we are facing, I want to look at the root causes. The report does not go as far as I would like. I have often quoted the statistic from the World Health Organisation that 80% of cancers are environmentally linked. That is a fact. It relates to the chemicals we breathe, the food we eat, the water we drink, chemicals in our clothes and radiation.

The toxicity of chemicals is measured by their effect on the average human being. From studies into genetic engineering, we are discovering there is no such thing as an average human being. We all have varying genetic predispositions. Deputy Gay Mitchell mentioned his family and how prone they are to cancer. Each of us reacts differently to chemicals. One person might breathe in a particle of benzene with no effect, but it could cause cancer in another. That sort of analysis is missing. We now have the wherewithal to find out what is causing cancer in human beings and this must be done.

The Minister spoke of health promotion, which is vital in relation to our lifestyles, the amount we drink and smoke, etc. All of these activities clearly contribute to the increase in cancer. However there are cars on our streets emitting benzene, PM10s, volatile organic compounds, polycyclic aromatic hydrocarbons, which are known mutagens and carcinogens. That mix is quite complex. We also talk about the increase in the incidence of melanoma. What is causing that? We know that the erosion of the ozone layer has led to more UV radiation coming through to which those of us with fair skin are more susceptible. That has caused a major increase in the incidence of cancer.

More information is emerging daily on the increase in the incidence of breast cancer. It can be caused by the hormones in food which can account for a hormonal imbalance in human beings. Anti-perspirants that are dermally absorbed can also cause it. These are complex issues but they are not addressed.

The Minister and I may disagree about the impact of the presence of fluoride in water. Fluoride is a toxic substance which we all absorb all the time. According to the measurements of fluoride in studies carried out by Dr. Mansfield, in the case of most people, the measurements are way above the safe threshold. Not only do we absorb it when we drink water and consume food, but we dermally absorb it when taking a shower. Irrespective of what the Minister's mandarins tell him, I urge him to be cautious about this. Having examined the relevant data, I have no doubt that fluoride is something of which we need to be wary. I am certainly convinced it should not be in our drinking water.

We are absorbing a mix of chemicals to which we are exposed every day. They are contributing to the major increase in the incidence of cancer. The National Cancer Registry examines that development, but it does not properly examine the causes of it. For example, in Ringsend I am aware anecdotally of an increase in the incidences of severe thyroid problems and asthma, which are above the national average. We need to find out why this is the case. There has also been a major increase in the incidence of brain haemorrhages – I have raised this matter in the House. We need to investigate why there has been a major increase in those illnesses in that pocket? I have no doubt it is due to the large amount of industrial activity there and, above all else, to the city dump having been located there. Those who live close to old landfill sites that were not regulated were exposed to chemicals as a result of which they suffered and will continue to suffer.

I asked the Minister a question on 20 March 2001 concerning a set of endocrine disrupting chemicals, PCBs, dioxins etc. Pesticides have also caused major damage. The small bird population has fallen greatly, which is a good bio-marker of the effectiveness of those chemicals. They are killing all around them. If they are causing trouble for the small bird population, they are also causing trouble for human beings. We need to examine this matter much more carefully.

A report such as this can be produced and some people would immediately say that the findings of it must have something to do with Sellafield. Radiation from Sellafield is an issue affecting the east coast despite it having been denied time and again, but one development that has not been examined is the incidence of cobalt lodging in the sediment, which will come to the fore shortly.

I ask the Minister to examine the root causes of the increases in the incidence of cancer. We have a cancer culture not only here but throughout the west. It is a disease of affluence and will increase as we industrialise more. I ask the Minister to examine this matter more carefully.

I received a letter from a woman from Waterford who has asked that we forget about the "Bertie bowl" and raise the level of our cancer services to that of the best in Europe in order to save lives. That should be the aspiration of the Government, not the building of a stadium.

I am particularly interested in the National Cancer Registry's report as it relates to people over the age of 65. The report, which covers the years 1994 to 1998, finds that older people were much more likely to develop cancer, with the risk doubling in every successive decade of life. Some 60% of patients were aged over 65 at the time of diagnosis and the majority of cancer deaths, 72%, also occurred in those over the age of 65. The largest number of reported cases of cancer were in the 70 to 74 age group and the largest number of cancer deaths were also within that same age group. This age group accounts for 20% of all lung cancer cases and deaths and the largest number of prostate cancer cases, the second most common cancer is men. The report also finds, however, that over the five years covered only small changes in cancer incidence and mortality rates were recorded in the population aged 65 and over, one of which was statistically significant.

The report's findings that age at diagnosis has an impact on the cancer treatment provided was of very real interest to me. Older patients were less likely to receive cancer-specific treatment and when treated were less likely to receive surgery or combination therapy. The report recommends that these findings should be treated with caution, advising the possibility that higher levels of intercurrent illnesses and reduced physiological capacity associated with old age are discouraging clinicians from recommending aggressive treatment regimes to older people. Another possibility identified in the report is that some older people may themselves decide not to have certain treatment because of concerns about side effects or perceived lack of benefit. We must also acknowledge that in certain parts of the country some people do not present themselves at an early stage. The findings of the report in relation to treatment of the elderly are similar to findings reported from studies undertaken elsewhere in Europe and the US.

While the possible causes for the differing cancer treatment regimes based on age can be interpreted in a number of different ways, the report recommends that a better understanding of mechanisms underlying clinical decision making with regard to cancer treatment is required. To improve the quality of care for elderly patients, clinical guidelines and treatment protocols targeting elderly cancer patients should be developed and updated regularly.

I believe that the Government's initiatives on a range of issues will have a significant impact on these statistics over the coming years. The publication of the national cancer strategy in November 1996 gave a focus for the development of an integrated, co-ordinated and patient focused cancer service throughout the country. Since 1997, funding of €103 million has been invested, primarily by the Government, for the implementation of the recommendations of this strategy. We will probably see no improvements from that investment before the next report.

As recommended in the national cancer strategy, structures have been put in place at national and regional level to ensure that we develop the range of cancer services of a standard and quality which ensures the best service delivery possible. At national level, the National Cancer Forum continues to provide invaluable advice on how best to implement the recommendations of the strategy. At local level, regional directors of cancer services have been appointed in all health boards. These regional directors oversee the development of cancer services in their areas and are responsible for the preparation of regional cancer plans. The work of the regional directors is proving invaluable to the work of the National Cancer Forum and the ongoing implementation of the national cancer strategy.

The report of the National Advisory Committee on Palliative Care identified that over 95% of all patients availing of specialist palliative care services suffer from cancer and that the mortality rate is expected to rise in future years due to the ageing population. The report also identified that the number of people living with cancer is expected to rise as a result of earlier diagnosis, improved treatment and longer survival. Additional funding was provided in 2001 and 2002 to commence the implementation of the recommendations of that report.

A National Council for Specialist Palliative Care, representative of statutory and voluntary agencies, will be established to offer advice on the ongoing development and implementation of a national policy. As also recommended in the report, regional development committees for specialist palliative care are in the process of being established in each health board to prepare development plans for palliative care services in their area. As with the national council, these regional committees are fully representative of the appropriate statutory and voluntary agencies providing specialist palliative care services.

Cancer is not only being tackled at the diagnostic and treatment stages. This Government has identified a range of initiatives to tackle probable causes of incidence of cancer. This willingness to address the issue of cancer in the broadest sense will show demonstrable improvements in the incidence of cancer in the future. The Public Health (Tobacco) Bill, for example, which extends environmental controls on smoking to a range of public areas and public facilities not already covered by existing legislation, will impact on the incidence of lung cancer in the future. In this regard, the health strategy identifies a range of initiatives for the promotion of health and well-being, including enhanced health promotion initiatives aimed at addressing the risk factors associated with cancers, such as smoking, alcohol, diet and exercise.

The importance of the development of cancer services has been identified in the health strategy and a revised implementation plan for the national cancer strategy will be developed by the Department of Health and Children in conjunction with the national cancer forum for publication by the end of this year. Of the subgroups recently established by the forum to look at specific issues, I am particularly interested in the work of the subgroup on evidence based medicine and the subgroup on genetic screening. The subgroup on evidence based medicine is being asked to develop proposals to bring about rationalisation and standardisation of clinical guidelines for the treatment of patients with cancer for discussion by the forum. In the course of its work, this group will review all issues in relation to standards of treatment afforded to patients with cancer. The subgroup on genetic screening will review all issues in relation to screening, including screening for prostate cancer.

I am proud to be a member of a Government that is taking all measures necessary to ensure the development of the structures and services necessary to address the issue of cancer in a meaningful and significant manner. I am sure that in the next report we will see an amelioration in the situation regarding cancers in general.

I wish to share my time with Deputy Durkan.

Is that agreed? Agreed.

Of all the people who die in Ireland aged less than 65 years, one third die from cancer. We have the third highest cancer rate in Europe. Many of those who die are awaiting so-called elective treatment. Of those who die, one third have cancers which are preventable and one third have cancers which can be cured. It is an indictment of our system that two thirds of those who die from cancer could be saved.

Only 16% of cancer patients are receiving radiotherapy, while 50% could benefit from it. In the European Union, 66% of cancer patients have radiotherapy. One thousand people die each year due to inadequate treatment. There is extreme concern about this issue in my constituency. Representations have been made and meetings have taken place with the Minister for Health and Children about the Cappagh, Askeaton and Croagh area, where there is concern about the high level of cancers. The Mid-Western Health Board is examining the matter. Perhaps the Minister would outline the up to date position regarding the finalising of its report, which is due about now. It is feared there is a link between the incidence of cancer in that area and the animal health problems over a number of years in Askeaton and surrounding areas. There was a report on those problems by the environmental health agency which was not acceptable to the local people so it was referred abroad for analysis.

The professor of surgery in St. Vincent's Hospital, Dublin, Dr. Niall O'Higgins, told a conference on women and cancer in Dublin that 43% of women who develop breast cancer will die, compared to an EU average of 37%. Some EU countries have a breast cancer mortality rate of less than 30%. Still the Minister has not bitten the bullet on the need for rationalisation of breast cancer services. Like everything else, he has referred the report to one committee or another to examine.

Cervical cancer screening is available in only one health board area. In June last year in the Southern Health Board area, GPs could not carry out routine smear testing because the test kits were not available. The Government's health strategy states, in relation to the national cancer strategy, that services at local, regional and national levels will be agreed by the end of 2003. The national cancer strategy implementation plan was launched in 1997 but, due to Government inaction, patients will have to wait another two years before there is agreement on services. How much longer after that will it be before services are provided? In the meantime, cancer patients must undertake 400 mile round trips for radiotherapy.

The health strategy promised that a revised implementation plan would be published by the end of 2002. This is code for changing the goalposts because the original goals set in 1997 were not reached. The Minister for Health and Children launched the report of the national cancer registry and lauded the appointment of additional consultants and more spending. However, the cancer strategy launched in 1996 by the previous Administration stated that cancer kills about 7,500 people per year and an average of 18,000 new cases of cancer are recorded annually. That strategy set the objective of reducing cancer among those under 65 years by 15% by 2004. The question is whether these targets will be met.

I am sceptical of the Minister's bland announcement and I believe the targets are not being met. Approximately 900 people per year die from secondary smoking, that is, inhaling somebody else's smoke. Why is this allowed to continue? The Government launches its reports, initiatives and studies with great fanfare but where is the follow through? In the document, "Building Healthier Hearts", endorsed by the Government, it was proposed that tobacco be removed from the consumer price index to avoid a situation where increases in the price of cigarettes, necessary from a public health point of view, are vetoed because of their potential impact on the inflation figures. The Minister, Deputy Martin, advocates this change but his colleagues, the Minister for Finance and the Taoiseach, veto it. So much for discouraging smoking. Instead of real action, we get sponsorship of snooker tournaments with funds from the Department of Health of Children.

I am delighted to have the opportunity to speak on this issue. My only complaint is that there is such a short period to debate a major issue of national concern. It concerns, in the most personal way, thousands of people and will continue to do so.

It is about 15 years since I first promoted the notion of a national cancer registry and the need to provide adequate funding so it could identify the statistics necessary to put the spotlight on sensitive areas and come up with a plan to deal with them. I was interested in the contribution made by Deputy Gormley. He referred to the various environmental problems and the implications of toxins, dioxins and so forth. It was most interesting. The only way we can put hard statistics together, however, is by carrying out a comprehensive survey of a region and comparing it with another. The comparison should then be extended to the countries with the best record of controlling, combating and treating cancer and those with the lowest incidence of cancer. There probably are genetic reasons but with the correct statistics to hand we could isolate that element and get further information. The resources available to the national cancer registry at present are inadequate to do the type of job required.

In order to evaluate and combat a situation properly, it is necessary to put the statistics together in such a way that they can be generated immediately on a screen so a decision can be made on how to deal with it. That is also important for identifying causes. There are many locations here where people have concerns about the annual incidence of various cancers. To deal with that, we must give adequate resources to the national cancer registry to enable it to produce the statistics. The Minister will say, quite correctly, that extra resources have been provided, which is welcome, but not enough to make a real impact.

There are places in the world with extremely low incidence. The cause of this is either genetic or otherwise, and if we know the causes we can compare the statistics. The incidence of cancer in the Dublin area is higher than elsewhere. No one knows for certain the reasons for this. It might be that there is more assessment or earlier identification. It again comes down to how the national cancer registry can conduct research and publish the results to enable comparison. We will have achieved much in the fight against cancer if that we do that.

Air pollution is greater in urban areas than rural. Yet, in the previous report – I have not had the opportunity to study the present one – Donegal and Kildare had similar incidences of cancer and populations and age profiles. We will only achieve results by comparing different counties. Tipperary North Riding and Tipperary South Riding have populations similar to north and south Kildare. However, the nearer to Dublin the greater the incidence.

I am sorry there is so little time to debate this subject as it merits longer discussion and Members could make valuable contributions. I call for increased resources for the registry so that it can better do its job.

I am delighted to have even a brief opportunity to discuss this report. My father contracted cancer, which may be the reason I am in the House, but it is why I am interested in this subject. Every Deputy believes that his or her area has the highest rate of incidence of any particular cancer, but we begin to question that when we have more information. Therefore, I welcome the report but regret that it only covers 1994 to 1998 and hope that we may get more up to date reports. It is important that it covers the time trends, variations in cancer risks, geographic differences, treatment and survival, as well as new and old cancers.

The Minister outlined the major investment in cancer services by the Government since the implementation of the cancer strategy in 1997. Over €103 million was invested since 1997 in the development of appropriate services for treatment and care of people with cancer. This enabled the funding of 62 additional consultant posts with support staff throughout the country, including eight additional consultant surgeons with a special interest in breast surgery. Having worked with Europa Donna, I know that this is very important to it and to Irish women.

The national cancer registry report shows a clear divergence between female incidence and mortality rates in relation to breast cancer with a statistically significant upward trend in its incidence under 65 years and downward trend in mortality rates in all age groups combined. As the Minister stated, this divergence is expected to continue as a result of the continued improvement in treatment and the work of BreastCheck, the national breast screening programme.

The report of the national cancer forum sub-group on the development of services for sympto matic breast disease was published in March 2000. The Minister reported on the extensive consultations which took place in the past year between his Department and the health boards on the best way to develop symptomatic breast disease services in their functional areas. As others have said, this is difficult to resolve as everyone wants the best service in his or her own area. However, we must consider not the area but what is best for the woman concerned, and in light of that hard decisions must be taken.

The North-Western Health Board's proposals, in line with the recommendations of the sub-group's report, include the appointment of a consultant general surgeon with a special interest in breast surgery at Letterkenny with a sessional commitment to Altnagelvin Hospital in Derry. This is unique as it is the first time that a surgeon will be appointed with North-South sessional commitments, which is an important aspect of the Good Friday Agreement. I am glad that financial clearance has issued for this post with seven sessions in Letterkenny and four in Altnagelvin The latter sessions will include two triple assessment clinics, one operating session and one follow-up session.

The board will also develop at Letterkenny a fully equipped breast unit which will include stereotactile mammography and local laboratory facilities, which will enable triple assessment to take place there. It is important that radiology services are provided on both sites and protocols and standards of care will be cross-Border to ensure the best international standards, alongside developing auditing and evaluation mechanisms. This is a very exciting development for women in the north-west and I compliment the Minister on advancing it.

These initiatives will be complemented by other North-South initiatives, particularly on cancer research. Under an October 1999 memorandum of understanding with the US national cancer institute, a cancer consortium was established representing the NCI and the health Departments, North and South, with the objectives of creating an all-Ireland infrastructure for cancer research and clinical cancer investigations, to formalise and facilitate intersections with Irish cancer research communities and to develop joint programmes in and to enhance the infrastructure for clinical cancer research with the anticipated outcome of improved patient care. Among the key areas for development are co-operation between the cancer registries, the establishment of a robust clinical trials network linking the three participants, the creation of communication links by way of Telesynergy links and support for a scholar exchange programme.

On 1 May 2001 the two cancer registries published the first all-Ireland cancer incidence and mortality report. This is particularly important to my constituency in the north west region, where Donegal is north of the North. Regular meetings take place to standardise data collection between registries to facilitate other projects throughout the island. Offering patients access to new treatments for cancer is increasingly seen as a guarantee of high quality treatment. Participation in high quality clinical trials is a characteristic of the world's leading cancer centres. Ireland as a whole is an attractive place to conduct these as the population is genetically homogenous and there is a good information base within extended families. Stimulated by the cancer consortium, consideration is being given to the most appropriate models for the development of a clinical trials infrastructure here, given the multiplicity of cancer treatment units and the requirement to co-ordinate activities in them. The intention is to fund some centres to conduct such trials at the level already achieved in Belfast City Hospital and to fund an all-Ireland group to co-ordinate the trial activity. Four awards were announced under this initiative by the health research board in November 2001 to St. Vincent's and St. Luke's in Dublin, UCH Galway, Cork University Hospital and Beaumont Hospital, Dublin. Two planning grants were awarded to the Mater Hospital, Dublin, and Limerick Regional Hospital.

Telesynergy is an advanced video conferencing facility which enables clinicians, researchers and educators to communicate in real time over long distances, which is of great relevance to my constituency and to the cases cited by Deputy Durkan, where people must make round trips of 400 miles. Telesynergy will be of great use in supporting clinical trial activity, in consulting on rare or difficult cancers and in postgraduate medical training through its rapid data transmission and high resolution imaging transfer of pathological material. Funding for the facility has been provided in St. Luke's Hospital, Dublin, and Belfast City Hospital.

A further essential part of developing a proper research capacity of international standard involves the need to develop in-staff development. A scholar exchange programme was outlined in the memorandum of understanding. The consortium is focused on short-term visits of professionals working in cancer and longer-term fellowships for those wishing to become professional leaders in their fields. The Government will continue to strive to ensure the provision of appropriate standards of treatment and care to patients with cancer. I join my colleagues in welcoming the fifth report of the National Cancer Registry. It will be invaluable to the Department of Health and Children and the National Cancer Forum in their report on the revised implementation plan for the national cancer strategy, as set out in the health strategy.

As a convenor of the Oireachtas committee on health, I could continue for the rest of the day on the issue of cancer. Our committee is working on the causes of lung cancer with respect to the tobacco issue and I had a chance to outline our concerns on Second Stage of the Tobacco Bill. I compliment the Minister on this motion and on the fact that we are to take Report and Final Stages of the Tobacco Bill. That will bring in stringent controls on the sale of tobacco and in other areas.

At the time of the first cancer strategy in 1996 there was a north-south divide along a line from Dublin to Galway. I felt very annoyed by that and expressed my views here about it. I am delighted that links with the north-west and the Administration and Executive in the North have ensured that real, substantive movement has occurred to develop cancer services. People from the north-west are now truly getting the advantages of the services they need.

I also compliment the North-Western Health Board on assisting those with cancer who must travel to Dublin for treatment by subsidising flights from Carrickfinn and Derry to Dublin. The Friends of Letterkenny General Hospital have also done great work by fundraising for a bus service, which gives a little comfort to people who badly need it and who must make long treks to Dublin because we lack facilities in the area.

This is a critical debate because there is widespread fear and anxiety throughout the country among young and old about the ravaging effects of cancer. I do not always agree with Deputy Gormley but he made a valid point about trying to identify some of the sources and causes of cancer. One is the high radon level in our national schools. The Radiological Protection Institute of Ireland has surveyed 4,000 schools and some work has been done to remedy the effects of radon gas in schools. There is a recognised method of dealing with it which costs money. However, not only are there high levels of radon in schools and other institutions, there is a high level of radon in some domestic dwellings. The difficulty is that insufficient effort is being made by both the Department of the Environment and Local Government and, presumably, the RPII to deal with the issue effectively once and for all.

There is no question about the link between cancers and radon levels. For that reason I emphasise for the Minister of State and the Department how vitally important it is to deal with this. I and other Deputies have raised it constantly over the years – we are weary of doing so. It is particularly bad in some parts of Clare, such as the national schools in the Burren area. Some but not all have been dealt with and there is now an emergency.

I emphasise the valuable work being done by some of the voluntary organisations. I was involved in a campaign a weekend ago with Dr. Willie Walsh, the Bishop of Killaloe, and the West Clare Cancer Support Group. It is organised by a young man whose friend suffered a tragedy due to cancer, Willie McGrath of Kilkee, and he has organised a huge number of events, collecting €100,000 in one afternoon to help provide facilities for those suffering from cancer. I do not need to tell the Leas-Cheann Comhairle of the effects cancer can have on families and the depression it can cause across communities. In dealing with the symptoms and effects of some of the causes of cancer and in dealing with the problems the strategy has identified, it is vitally important that the main focus from the research point of view must be directed at establishing the links between radon and cancer, for example, and dealing with those so that effective remedies can be found.

If one cannot deal with the national schools, attended by young people, which have high levels of radon that may inflict cancer on those children in later life, the strategy, no matter how it is presented, will be a failure. We have many statistics and facts and much valuable work is being done by professionals, but there has to be more partnership between local voluntary organisations and the professionals providing services so they can all be in a position to make life easier for those suffering from cancer. We must find ways to deal with these matters, which are causing widespread anxiety and concern in every constituency.

We in Ennis were concerned by the decision not to renew the mammography equipment in Ennis General Hospital, which was mainly provided by voluntary effort from the local communities. The health board has responded and I record our appreciation of the Minister, his staff and the Mid-Western Health Board for their investment in that unit in Ennis. There is a need to proceed urgently with the centres of excellence suggested by the committee set up to examine these matters, particularly when dealing with breast, lung and prostate cancer. These are causing widespread dismay in communities and every possible effort must be made, particularly in funding research and applying EU directives which have not been implemented in Irish law. There is a raft of legislation at EU level dealing with patients receiving treatment which may affect their physical well-being.

I reiterate the necessity to deal with the causes of cancers, which are not being dealt with effectively. There must be better co-operation between voluntary organisations, people who work in cancer support groups, the Department and the health boards to provide badly needed services for people who suffer from cancer.

I join with my colleague, the Minister for Health and Children, and other Deputies who spoke on this debate in welcoming the publication of the fifth report of the National Cancer Registry. The report marks a significant milestone in cancer surveillance in Ireland. It presents comprehensive data in treatment and survival patterns nationally between 1994 and 1998. However, it is important to reiterate that the data presented refers to a period which predates the significant investment made in cancer services, particularly by the Government, since the implementation of the national cancer strategy in 1997. The initial investment in cancer services focused on the development of structures and processes required to improve the delivery of services to patients with cancer. It takes time for these structures to be developed and for the investment to be reflected in cancer treatment services. The data reported in the National Cancer Registry's report reflects only one year since investment under the national cancer strategy and a three year period prior to that.

As the Minister pointed out, the report identifies that there was no significant change in the risk of developing or dying from cancer between 1994 and 1998. The incidence of cancer in Ireland was similar to that in England, but below that in Scotland, Wales or Northern Ireland. Most cancers had an incidence close to the European average. As regards treatment, the report states that most patients received cancer specific treatment. Cancer survival five years after diagnosis was 43%. Diagnosis at a younger age for all cancers conferred survival advantage for both men and women, although the magnitude of the advantage varied with the cancer type. One of the most important factors influencing survival was the stage of the cancer, that is, how advanced the cancer was when detected.

The Minister reported today on the major developments in the treatment and care of patients with cancer which have taken place since the launch in November 1996 of the national cancer strategy. The principal objectives of the strategy are to take all measures to reduce rates of illness and death from cancer and to ensure that those who develop the disease receive the most effective treatment and care. The commitments in the action plan of March 1997 have been funded and have either been implemented or are in the course of implementation.

From 1997 to date more than €103 million has been invested in the development of appropriate treatment and care services for people with cancer. That includes the provision of €23.5 million this year which was allocated between all health boards for the continuing development of oncology and haematology services, for oncology drug treatments and for the continuing development of symptomatic breast disease services. As the Minister reported, this funding has enabled the appointment of 62 additional consultant posts in key areas together with support staff, including eight additional consultant surgeon posts with a special interest in breast surgery. In 2000, national screening programmes for both breast and cervical cancer were initiated on a phased basis and both BreastCheck, the national breast screening programme, and the national cervical screening programme are currently in discussion with health boards concerning expansion of the programmes nationwide.

The Minister has identified the need for comprehensive and strengthened legislative measures to tackle tobacco use as his number one public health priority. The Public Health (Tobacco) Bill was introduced in the Oireachtas last December and the target date for its enactment is Easter 2002. The Bill confers enabling powers on the Minister for Health and Children to extend environmental controls on smoking to a range of public areas and facilities not already covered by existing legislation. The Ireland-Northern Ireland US National Cancer Institute Consortium, established in October 1999, has resulted in the development of joint cancer research projects, scholar exchange programmes and a range of other collaborative activities.

In the context of the national health strategy, the National Cancer Forum continues to play an important role in relation to the planning, development and implementation of cancer services for the country. Areas such as protocols for the care and treatment of cancer patients, information requirements, audit and evaluation of our services, genetic issues and further screening programmes, are important component parts of the appropriate future development of cancer services. The forum, as the established expert advisory body, will report to the Minister on these issues. To facilitate the process, forum sub-groups have recently been established on generic screening, generic symptomatic disease, genetics, evaluation and outcomes and evidence based medicine.

In recognition of the need to further develop cancer services, the national health strategy identifies a range of specific cancer-related actions to be achieved over the next seven years. Actions on major lifestyle factors targeted in the national cancer strategy will be enhanced. The Public Health (Tobacco) Bill will be enacted and implemented as a matter of urgency. A reduction in smoking will continue to be targeted through Government fiscal policies. The programmes of screening for breast and cervical cancer will be extended nationally. A national palliative care service will be developed. The strategy has also identified the need for the preparation by the end of 2002 of a revised implementation plan for the national cancer strategy. The plan will be prepared by the Department in conjunction with the National Cancer Forum and will set out the key areas to be targeted for the development of cancer services over the next seven years. This will have regard to existing policies in the areas of symptomatic breast disease and palliative care and the forthcoming recommendations of the expert group on radiotherapy services.

As regards the sub-groups of the forum, the proposed implementation plan for the national cancer strategy will set out the structures in terms of how the National Cancer Forum will support the strategy and give a focus to the work of the sub-groups. Their overall purpose will be to support the Department in framing the implementation plan in conjunction with the National Cancer Forum. Following publication of the national plan, individual health boards, in consultation with the National Cancer Forum, will develop new regional cancer plans which will identify additional requirements for the development of integrated evidence based treatment and palliative services for people with cancer.

As regards directing the way in which investment takes place, ensuring integration of services and that the objectives of the cancer strategy are realised, the health strategy provides a significant opportunity for the forum to shape its work. It is also intended that the National Cancer Forum will work with the national hospitals agency and the health information and quality authority to ensure service quality, accessibility and responsiveness.

We are all conscious of the effect cancer has on our family members. We have also lost Members of this House to cancer in recent years. It is a commitment of both the Opposition and of Government to constantly strive to ensure quality services for cancer in this country. The framework set out in the health strategy will ensure we are successful in our endeavours to provide the necessary information and the co-ordinated services to ensure positive results in our ongoing campaign against cancer.

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