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Joint Committee on Health debate -
Tuesday, 19 Oct 2021

BreastCheck Screening Programme and Improving Outcomes for Breast Cancer: Discussion

I welcome Deputy Ward, who is substituting for Deputy Cullinane, and Senator Ruane, who is also joining us this morning. There is one matter of housekeeping before calling on the witnesses. Are the draft minutes of our private meetings on 7 and 14 September agreed to? Agreed.

I welcome the following representatives from the Health Service Executive, who will update the committee on the BreastCheck screening programme and improving outcomes for breast cancer with the national cancer control programme, NCCP: Professor Risteárd Ó Laoide, national director, national cancer control programme; Ms Fiona Murphy, chief executive, national screening service; Professor Fidelma Flanagan, lead clinical director for BreastCheck national screening service and consultant radiologist at the Mater hospital; Professor Arnold Hill, surgical oncology clinical adviser, national cancer control programme and breast cancer surgeon at the RCSI Hospitals Group at Beaumont Hospital; and Mr. Martin O'Sullivan, chairman, breast cancer leads group in the NCCP and consultant surgeon in Cork University Hospital.

Members now have the option of being physically present in the committee room or may join the meeting remotely from Leinster House. Members and all in attendance are asked to exercise personal responsibility in respect of protecting themselves and others from the risk of contracting Covid-19. They are strongly advised to practise good hand hygiene and leave at least one vacant seat between them and others attending. They should also maintain an appropriate level of social distance during and after the meeting. Masks, preferably of medical grade, should be worn at all times during the meeting, except when speaking, and I ask for the members' full co-operation in this regard.

All witnesses are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against any person or entity either by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in respect of an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.

I call on Professor Ó Laoide to make his opening remarks.

Professor Risteárd Ó Laoide

Gabhaim míle buíochas leis an gcomhchoiste as an gcuireadh anseo inniu. I thank the joint committee for the invitation to meet it to discuss the BreastCheck screening programme and improving outcomes for breast cancer with the national cancer control programme. Thank you, Chairman, for introducing our witnesses, so I will not repeat that. I should point out that Mr. Martin O'Sullivan is joining us from Cork University Hospital and has to return to a theatre list at approximately 12.30 p.m. If there are issues relating to family history, I would be grateful if they could be directed to him prior to that time.

In this statement I will provide an overview of breast cancer in Ireland and outline the various approaches to improving services and outcomes along the entire breast cancer pathway, including screening.

I offer my thanks to everyone working in cancer services, including in hospitals, screening services and community services across the country, who have continued to provide quality care to their patients, particularly during the pandemic crises and the recent cyberattack. I also thank those involved in the charitable and voluntary sector who support people dealing with cancer. Our partnership approach with these organisations, as well as with our colleagues in the HSE, the Department of Health, the National Cancer Registry and a broad range of stakeholders across research, education and service delivery, strengthens our collective ability to face the challenges presented by cancer in Ireland today.

Breast cancer remains the most common cause of invasive cancer in women in Ireland. Approximately 3,500 new cases of breast cancer are diagnosed each year and the National Cancer Registry predicts this will rise to 4,650 by 2045. One in seven women in Ireland will be diagnosed with breast cancer in her lifetime. For each of these women, their diagnosis brings a worrying and uncertain time for them and their families. The incidence rate of breast cancer has increased over time, by approximately 2% per year between 1994 and 2008, partly due to improved levels of detection, but has levelled off since then. Crucially, however, mortality rates from breast cancer have shown a consistent downward trend, decreasing by some 2% each year from 1994 to 2016, supported by earlier diagnosis and improvements in treatment.

Breast cancer was the first of the cancer services to be centralised when the NCCP was established. The multidisciplinary care pathways implemented since then, supported by national clinical guidelines, screening, electronic referrals, rapid access clinics and cutting-edge research into cancer treatment, have significantly improved the level of care provided to women in Ireland. The cancer services have had clear policy direction through the three national cancer strategies initiated in 1996, 2006 and 2017. We are currently midway through the timeframe for the third strategy. Funding of €20 million in 2021 is helping to address historical deficits in the cancer service and the implementation of the cancer strategy. I acknowledge a separate amount of €12 million that has been allocated under the pandemic plan to address the impacts on cancer services of Covid-19 and the cyberattack.

It is estimated that approximately one quarter of breast cancers may be preventable through modifiable risk factors and environmental factors. The first line of defence against most disease, including cancer, is prevention through a healthy lifestyle, that is, not smoking, maintaining a healthy weight, limiting alcohol consumption and being active. Breast cancer awareness is an important tool in early detection of cancer and we welcome the focus breast cancer awareness month provides in this regard. Breast screening is one of a number of key strategies used in this country to improve breast cancer survival. Screening provides an opportunity to detect breast cancer at an early stage, thereby decreasing mortality and stage of disease at diagnosis. The benefits of early detection through population screening must be balanced, however, against potential harms of screening and ultimate affordability. Screening, therefore, targets those people most at risk of disease, based on best scientific evidence and international experience. BreastCheck invites well people for screening and is thus a non-urgent service. Each year, approximately one third of all breast cancers diagnosed in Ireland are detected through BreastCheck.

A pathway is being developed for the assessment and management of patients with a family risk of breast cancer, including recommendations for surveillance. This pathway reflects HIQA recommendations and best current international evidence. The NCCP and the national screening service are working together to explore a surveillance process for this patient cohort.

The majority of breast cancers are diagnosed through symptomatic breast disease clinics. Each year in Ireland, some 42,000 women are referred to such clinics by their GP and approximately half of them are triaged as urgent referrals. Between 2,500 and 3,000 of the women referred to the clinics will receive a subsequent diagnosis of breast cancer. The rate of cancer diagnosis among women triaged as urgent is 10% and is less than 1% for those triaged as non-urgent.

Most women with breast cancer will receive treatment in the form of surgery, radiotherapy, systemic anti-cancer therapy or a combination of those methodologies. Approximately 85% of women diagnosed with breast cancer have surgery and more than 70% receive radiotherapy. The role of systemic anti-cancer therapy has grown rapidly over the past ten years. Nine new systemic therapy treatments for breast cancer have been funded since 2012, with others now under consideration. Advances in genetic testing and molecular testing have driven more targeted treatment for patients. In addition, clinical trials translate research discoveries and knowledge into novel ways of treating patients. People with a diagnosis of breast cancer account for almost a quarter, or 23%, of people living with and beyond cancer in Ireland. The cancer strategy's particular focus on quality of life has led to targeted investment in psycho-oncology services and other supports.

Today, as a result of historical capacity issues, the Covid-19 crisis and the cyberattack, breast cancer services are facing many challenges. The past 18 months have been a particularly difficult time for people living with cancer and it goes without saying that the pandemic has had a significant impact on our ability to provide cancer services. It is important to note, however, that symptomatic breast disease clinics continued to operate throughout the period of the pandemic. Furthermore, the symptomatic breast service was significantly bolstered during this time through resources from temporarily paused screening services being diverted into symptomatic services. This ensured that urgent, at-risk patients were seen, diagnosed and treated quickly. The cyberattack had a particularly devastating effect on the continuity of cancer services and was a very difficult time for patients, their families and those providing their care.

Through the continued efforts of cancer service teams, innovative approaches have kept services operating through these challenges, including by way of extra evening and weekend clinics, extended working days, refitting of mobile screening units, pioneering changes to radiotherapy fractionation, virtual clinics, insourcing and outsourcing, and rapid development of clinical guidelines to support safe care. Míle buíochas as ucht bhur n-aird is bhur bhfoighne.

I thank Professor Ó Laoide. I will now take questions from members, beginning with an Seanadóir Conway.

I welcome our guests and acknowledge the great work they do at all times and particularly in the recent difficult period. I thank Professor Ó Laoide for the comprehensive overview he gave in his opening statement. I would like to drill down into some statistics, which I hope the witnesses can provide. How many people went through the screening service in 2019, before the pandemic, and how many went through it in 2020 and thus far in 2021? What is the position in terms of a catch-up programme, given that there are most likely people whose screenings did not happen because of the Covid-19 restrictions? I would like to start with those figures.

Professor Risteárd Ó Laoide

I ask my colleague, Professor Flanagan, to take that question.

Professor Fidelma Flanagan

I thank the committee for the invitation to attend the meeting today. The Covid period has been a particularly challenging and difficult 20 months for cancer screening services. The screening programme is targeted at a low general population, namely, people who are at lower risk of the disease. Unfortunately, faced with public health advice that we must limit our service, we had to pause the programme for nine months in total. The Senator asked specifically about the number of people we screened prior to the pandemic. A total of 170,000 women were screened prior to the Covid period. We then paused the programme for six months-----

To clarify, were 170,000 women screened in 2019?

Professor Fidelma Flanagan

Yes.

In 2020, bearing in mind that the service was operating for only three months, how many were screened?

Professor Fidelma Flanagan

In 2020, in the period before the Covid crisis and in the course of our recovery after the crisis, we screened more than 56,000 women.

In the first eight months of this year, we screened over 70,000 women. It is good news. Even in September, we screened 15,000 women, which was right back to where we were in the pre-pandemic period. That was a significant effort while we are still in the middle of a pandemic. We have made adaptations to our screening programme. We have made a lot of changes in the past 18 months to maximise the efficiency of screening and improve the experience. We are dealing with a high-risk population. These are women between the ages of 50 and 70. What we cannot do is bring healthy women into a screening programme and expose them to the risk of Covid.

I appreciate that.

Professor Fidelma Flanagan

We have to tread carefully and safely.

Has BreastCheck returned to pre-Covid capacity from September or are some capacity restrictions still in place?

Professor Fidelma Flanagan

We would always follow public health guidelines regarding what we can do during the pandemic. While our aim is to get back to a two-year programme, we are still in the pandemic and there are still adaptations and restrictions to which we must adhere to keep the process safe. Mammography is a very intimate procedure. It involves close contact between the patient and the radiographer. Most of our women are screened in mobile units, which are enclosed spaces. A significant effort has been made to keep our women safe along with the staff working in these environments. I am happy to say that in the past month, we have screened 15,000 women. We were at that level in September 2019. It will continue to be challenging.

As such, BreastCheck essentially returned to pre-pandemic levels this month.

Professor Fidelma Flanagan

Exactly.

Is there any differentiation between regions? Are there some regions of the country in which screening has not returned to pre-pandemic levels? Are any regional figures available?

Professor Fidelma Flanagan

We picked up where we left off. Screening is a rolling programme so we go into different areas. We are behind because we closed the programme for nine months. We continue where we left off and continue into these different areas. We move our mobile units accordingly. We leave different sites and move into the next site. We will always be behind by nine months or one year. It is really important to say that screening is for healthy, well women. The risk of breast cancer in that population is low. While we have lost the opportunity in that year to pick up early breast cancer, if women get the invitation to come to mammography, they must attend their appointment because the opportunity to pick up early breast cancer in that patient's journey still exists. My message, therefore, is that if women get their appointment, they should attend. If a woman feels symptoms, has any concern about something not feeling normal or feels a lump, she should not wait for her BreastCheck invitation but go to her doctor and be referred to our symptomatic services. That is the message we must get out rather than sitting and waiting knowing that we are already slightly behind in the screening process.

We would all echo that message. I know BreastCheck extended the age profile to women up to the age of 69. How is that going?

Professor Fidelma Flanagan

It is going really well. Prior to Covid, we had almost completely integrated and have now fully integrated our age range from 65 to 70-year-olds. Prior to the pandemic, we were offering screening to women aged between 50 and 70. That is evidence based. We follow the science in BreastCheck all the time. The incidence is obviously there in the older age group and we will always look to see whether we should be extending our programme beyond the current age range, which is 50 to 70. If one looks at the evidence, it looks like it is changing. It is dynamic. It looks like there are now conditional recommendations that perhaps we should offer screening to those over 70 and those under 50. We are definitely looking at that. We have been temporarily distracted given Covid and delivering the services but that is definitely on our radar.

I have a question about the family risk programme. I know the pathways have been identified in terms of the family risk programme. Could the witnesses update the committee on what progress has been made in terms of people who are deemed to be at risk because of family history? Where are we with that programme? I am also conscious that Professor Ó Laoide has to leave at 12.30 p.m. so I might give him the opportunity to address that question.

Professor Risteárd Ó Laoide

Does Mr. O'Sullivan wish to take that question?

Mr. Martin O'Sullivan

It is important to say that while family history is very important for the women who have a strong family history, it is not a big contributor to breast cancer in general. Less than 10% of breast cancers are related to family history. Some people might believe that this figure is less than 5%. To put that in context, there are a few issues we need to look at. For example, alcohol intake, weight gain, obesity and hormone replacement therapy, HRT, all increase risk of breast cancer and are probably far more important factors than family history. On the other hand, a regular exercise and dietary regime would reduce the risk. These issues are really important because they are what we call modifiable risk factors. People cannot do anything about your family history but they have control over things like maintaining a healthy weight, alcohol intake, HRT and so on.

The second thing in terms of family history is that it is worthwhile distinguishing between the BreastCheck programme Professor Flanagan has been talking about, which is probably best termed screening, and family history, which refers to looking at people who are at above average risk for developing a disease such as breast cancer. It is probably more appropriate to call that surveillance. It helps to distinguish between the two so that there is no confusion.

Is the NCCP engaging with family members at this time? Does it have a database of people who are at high risk because of their family history? Does the NCCP have this data collated through GPs? What is the process in terms of establishing this programme?

Mr. Martin O'Sullivan

There is no national database to this effect but all eight designated breast units are committed to and run a family history service. Some of these individual units will have a database. What the NCCP is hoping to do is streamline this process and standardise it better to ensure equality of access across the country. There are probably people who would benefit from having a family history assessment but who are not having it-----

What kind of timeframe are we looking at?

Mr. Martin O'Sullivan

Equally, there are probably people in the programme who might not be benefiting too much from it.

What kind of timeframe are we looking at for this body of work to be done?

Mr. Martin O'Sullivan

It is very hard to put a timeframe on it at present. This service development was definitely impacted by Covid-19 and the cyberattack. Negotiations with the national screening programme have commenced.

Has an office that is doing the work been established? I know it is difficult and challenging and we have been through a pandemic but is a team with targets and timelines working on this?

Mr. Martin O'Sullivan

There is a multidisciplinary team under the NCCP consisting of surgeons, radiologists, nurses, administrative staff, patient representatives and so on looking at this issue. As Professor Flanagan said, it is a moving target at times with new data coming out. A health technology assessment in 2013 made some recommendations. Algorithms have been made as to how we categorise these patients so we can categorise them as moderate risk, high risk-----

I am conscious of time but it would be appropriate if a document was prepared for this committee with the specific targets and timelines regarding when there will be some reporting on this because it is an important body of work. I am getting the sense that there are no timelines or the timelines are moving. There is probably a degree of urgency about this and I would appreciate it if Mr. O'Sullivan could come back to us with some information in due course.

Mr. Martin O'Sullivan

Sure.

On what is the extra €20 million that was made available being spent?

Professor Risteárd Ó Laoide

I will take that question.

The service developments for the year have been in the areas of surgical oncology, early diagnosis at rapid access clinics, radiation therapy, systemic therapy, cancer genetics and molecular diagnostics, survivorship and psycho-oncology, cancer prevention and enabling change in the governance of cancer services. We have recruited a total of 205 whole-time equivalents funded through this €20 million for service. Of those, 202 of the whole-time equivalents are now in position or there is recruitment in progress for them. There has been €14.4 million allocated with the remaining €5.6 million committed.

Has that €20 million been incorporated into the budget for 2022 or is additional money being sought?

Professor Risteárd Ó Laoide

We are seeking additional money on top of the €20 million and we are hopeful, in advancing the cancer strategy, there can be another €20 million in 2022.

Professor Risteárd Ó Laoide

Of the €20 million, €1.8 million was provided specifically for breast cancer services. From the pandemic money €1.9 million was specifically provided for cancer services to address the backlog and support the extra clinics over longer working days.

Apologies again to any guests who are cut off. We are supposed to be working within slots of ten minutes for questions and answers. People are not being rude but trying to get through their questions.

I thank the witnesses. I acknowledge the challenges they have experienced over the 20 months of the pandemic and the cyberattack on top of that, which did not help anybody at all.

I read this morning that approximately 300,000 cancer screenings were delayed last year as a result of the impact of Covid-19, as testing programmes were suspended in March 2020. As has been said, BreastCheck was suspended from March until October 2020 due to the initial lockdown. As witnesses have mentioned, BreastCheck invites mainly well people for screening but it is an effective process and picks up approximately one third of all breast cancer diagnosis in Ireland.

Will the witnesses outline some of the measures put in place to deal with these delays? Are cancer screenings back to full capacity? Are treatments for breast cancer now back to full capacity as well?

Professor Fidelma Flanagan

We paused the programme because the risk of having breast cancer in the general population is less than the risk of women who have a palpable lump or symptom. When there are limitations in resources, which we had when we had to close the programme, we diverted what we had to the symptomatic service and bolstered that service. As we said, we continued to deliver a symptomatic service right through the pandemic. Women who had a symptom and who were at a higher risk of breast cancer were able to attend those services.

Putting a figure on this, if we screen 1,000 women, we expect to pick up seven patients with breast cancer. If we assess, in our symptomatic services, 1,000 women, we will pick up 100 women with breast cancer. We had to provide the service in those areas where we knew the women would have a higher chance of having breast cancer. When we closed the programme, we diverted to the symptomatic service, and many of us, including me, as a radiologist, were diverted to the front line. Many of the radiographers and radiologists were diverted to the front line. We were all linked with host hospitals and dealing with the pandemic on the front line. It was absolutely appropriate that we stopped screening to divert to the symptomatic and front-line services.

While we were doing that, at BreastCheck we were adapting the service so we could hit the ground running once we got the green light to go again. We took off very cautiously and there were two recovery periods. The first had to be stopped because of the second wave of Covid-19 at Christmas and in my unit, more than two thirds of the people contracted Covid-19. Some people are still out with long Covid. It was a direct impact on the programme.

As I have said, this is a very intimate process, involving close contact with a high-risk population. When we started again, we were able to deliver screening. As I said earlier, we are right back to where we were before Covid-19. We are very proud of the people in the symptomatic services and in BreastCheck who under very difficult, stressful and challenging times could get us back here.

There is the question of what we did specifically to maximise the number of people coming for appointments. We rearranged our scheduling and introduced text messaging. We adapted mobile units so we could safely accommodate patients as they came in. We have also got the resources and funding for three more mobile units so when we go into a location we can move out quickly and try to get around.

There is no doubt the task is challenging and it will probably take at least three years to get around this round of screening. We know that. Nevertheless, our priority is to get back on track in screening. We encourage women to come along if they are asked. The opportunity for early detection is still there. People can still turn up for their mammogram and the opportunity to detect early breast cancer is still there. Women should turn up for their appointments and we have maximised the efficiencies we can bring about in the programme. All we want now is for people to turn up and we can get back on track.

We are still living in a pandemic and have restrictions. Even with the Covid-19 waves we see today, the future is going to be challenging. We are up to the task and have learned much. We follow public health guidelines. We will do the best we can.

I can see the rationale behind the targeted approach because of resources and the position of the time. Professor Flanagan mentioned being back to pre-Covid levels of screening, which is welcome, but are additional measures required to catch up on what was missed because of delays in the first place? For example, are people only being screened once every three years or is it twice every three years, as recommended?

Professor Fidelma Flanagan

We have lost a year and the fact we are back to pre-Covid levels while there are still restrictions suggests we are doing more with what we normally have. The measures we have taken to screen people have had an effect. We must accept that Covid-19 has had a major disruption to screening. We must accept it will take three years to get around this round. It will take years before we recover fully from this. Each time we go around our cohort of women, however, the backlog will be reduced and our absolute priority is to drop it back to the two-year programme. The future is bright and our changes are effective.

Emergency powers were put in place when the Covid-19 pandemic hit. For example, surge capacity was enabled by the HSE accessing private care and bringing it into public service. Did that have an impact on the programme or could that be required in future?

Professor Fidelma Flanagan

Absolutely. That is what makes our screening programme so unique among international programmes. We not only detect early breast cancers but are responsible for ensuring there is surgery and proper treatment at the end of it. That is unique to this country compared with other countries. We cannot invite healthy women for screening unless we can guarantee surgery and treatment at the far end.

When we started our host hospitals were on the front line in dealing with the major disruptions of Covid-19, so we could not guarantee surgery. We must keep a watchful eye that if we bring in a healthy population and detect breast cancer, we must have the facilities in which to operate. We must keep watching to see if that changes.

At the beginning of the pandemic there were many women in our system we needed to diagnose. Some of those were outsourced to the private system for surgery. We systematically worked through the women already in our system effectively. It is a primary concern that we cannot screen if we cannot provide the diagnostics and therapeutics at the other end. That is when we must watch our host hospitals and ensure facilities and capacity are there to deal with screening-detected cancer. At the same time we must be able to strengthen our symptomatic service and encourage women who have symptoms or feel a lump to go to that symptomatic service. Our most important achievement is providing access all through the pandemic for women who had a symptom.

Our number one goal is to continue to provide access to women who have symptoms going forward.

At a meeting of the Oireachtas Joint Committee on Disability Matters in March we heard from the Independent Living Movement Ireland that many disabled women's specific needs are not being addressed when they avail of BreastCheck or other screening programmes. The organisation specifically highlighted the issues women in wheelchairs have in accessing the scanners without adequate hoist equipment on hand. Has this issue been addressed in the meantime? Does the HSE have plans to do so? I was asked to bring that up.

Professor Fidelma Flanagan

Equity of service is our number one priority. It is one of our biggest and strongest points in BreastCheck. All our mobiles are fitted out for wheelchair access. In our static units, when people are recalled to assessment we provide special extended time periods to allow for special needs in terms of how we do the mammogram. We really reach out in this area to try to be an equitable service and I think we have achieved that. It is something we are actually quite proud of.

Are the mobile BreastCheck units which I see around the area wheelchair-accessible?

Professor Fidelma Flanagan

Yes, absolutely.

Okay. I thank the Chairman.

I think the point being made by the Independent Living Movement Ireland was there was a difficulty there in relation to getting up onto the mammogram machine. The representatives were talking about access to a hoist or whatever. Maybe that is something the HSE can look at.

Professor Fidelma Flanagan

I am not aware of the specifics of that but I know we have wheelchair access and special measures have been taken to facilitate women in wheelchairs and with special requirements. It is something we have spent a lot of-----

Okay. Maybe it is something up we can follow up with the officials on behalf of the group.

Professor Fidelma Flanagan

Yes. I can follow up on that if necessary.

I thank Professor Flanagan. Deputy Lahart is next.

I thank the Chairman and the HSE officials. Like others here I requested this briefing. I know it can come across, especially on Zoom or Teams, as though it is an interrogation. It is not intended as such. The officials have presented us with a really good narrative of some of the background issues. I have some quick-fire, statistics questions that require short answers, if possible. If the answers cannot be given right now that is not an issue. They may be supplied to the Chair and secretariat.

On the symptomatic service the officials spoke about, is that exclusively accessed through GPs?

Professor Risteárd Ó Laoide

I defer to my clinical colleagues and perhaps Professor Hill could come in here but the majority of cases are coming from the GP service. Some of them may come in the hospital itself from inter-consultant transfer. A patient that comes in for something else and then is identified as having a potential breast cancer would then be transferred within the hospital. However, the vast majority are from the GPs.

Professor Arnold Hill

That is correct. It is a GP-provided service. Of course if one has 3,000 staff in one institution they may end up being referred to the service within that hospital. Likewise, if one has 800 patients in an institution they will also be diagnosed with breast cancer when they have come in with something completely different. The vast majority are GP referrals.

Okay. One of the questions exercising many people who are advocates in this space is the age profile of those women who were screened for breast cancer. I found the officials' narrative this morning much more positive than the answer I got to a parliamentary question to the HSE. That was on reducing the age profile of women, or expanding it, basically. The officials have today said they will be actively looking at that for people over 70 years of age and for those under 50 years of age and that it is something that could be explored. In the answer, and also suggested in the opening statement this morning, there is reference to the dangers of expanding the breast cancer screening programme. Is that a concern about alarming the population? What are the misgivings the officials have about expanding it, aside from the cost imposition?

Professor Fidelma Flanagan

With any screening programme, it boils down to two main principles. First, what is the incidence of the disease in the population? This is a public health initiative to improve mortality by early detection so the first question is what the incidence is, and age is the biggest risk factor. The older one is, the more likely one is going to have breast cancer. For example, for a 30-year-old the incidence of breast cancer is around one in 200 while the incidence of breast cancer for 80-year-old ladies is one in ten. Thus, the biggest risk factor is an increase in age, so that is the background population.

The second principle of screening then is what the test is. The test in this case is the mammogram. It is a good test; it is not a perfect test. It will pick up most cancers but there are some it may not pick up. While it is very sensitive to breast cancer in early detection it is not that specific so in order to pick up a breast cancer one is going to have to take back a certain number of healthy women and subject them to extra tests, such as more X-rays, an ultrasound, a biopsy and even extra surgery. That is a really important harm this screening programme can do to healthy women. The other impact is that in order, for example, to pick up those seven patients with breast cancer out of 1,000, we probably take back about 50 or 60 women and subject them to that. It is well documented that the psychological and anxiety effects associated with calling back women, even if at the end of the day they do not have breast cancer, is very long-lasting. It can last for a year or even two and might have an impact on that woman turning up for her mammogram again in two years' time. Thus there is a huge balance between has this women got breast cancer, how many women do I need to take back and what is the impact on the women who do not have breast cancer but who I do have to take back. That is the balance we are looking at.

Okay. I thank Professor Flanagan.

Professor Fidelma Flanagan

If one puts those two things together, that is, the incidence of breast cancer and the effectiveness of one's test, there is absolute international evidence screening is very effective between 50 years of age and 70 years of age.

Okay, and on those principles of screening - because Professor Flanagan spent a lot of time on that-----

Professor Fidelma Flanagan

It is very complex, I am sorry, but to explain it and all the nuances-----

I get that. The professor is saying the principles of screening she outlined apply to all cancer screening.

Professor Fidelma Flanagan

Exactly.

I thank her for that because the parliamentary question response I got talked about the potential harms or risks to the population as a whole but it did not go on to elaborate on those. What Professor Flanagan has said is really useful and very helpful, that is, this could cause unneeded anxiety and alarm among the population. If the professor has more to say to us on that, please forward it by way of correspondence.

Professor Fidelma Flanagan

I would be happy to do that.

The parliamentary question response mentions something which was not in the opening statement this morning. It says the National Screening Advisory Committee, NSAC, is:

[...] currently finalising plans for its first ‘annual call’ which will be announced later this year. Applications for proposals for new population based screening programmes and modifications to existing programmes, such as a reduction in the age [which we have just mentioned] of those eligible for screening, will be welcomed from the public as well as the HSE [...].

Will the officials elaborate a little on that? How would people who are advocates or who have an interest in this space respond to that?

Professor Fidelma Flanagan

Is that to me? Ms Murphy might want to address that.

Ms Fiona Murphy

I thank the Deputy. The NSAC is a new committee which I believe has just finished its first year. It is chaired by Professor Niall O’Higgins and advises the Minister on all screening programmes. That includes the existing ones and also any recommendations for new screening programmes or indeed any major changes to existing programmes. It is a committee made up of experts in a range of fields. That includes cancer but there are other areas because the committee also looks at other areas, like screening of newborns.

That committee has just finalised its plans, which I understand should be out soon. There is more information on the NSAC on the Department of Health website.

The call will ask the public and the HSE whether there are other screening programmes we should look at, whether we should look at changes to existing programmes and what both the public and the HSE view as priorities. As the committee may be aware, last year the HSE considered additional newborn screening tests and modification to our diabetic retinopathy screening. This year it is being opened up much wider to ask the public and politicians. I understand that some applications are being put together to look at the age at which screening is carried out. The NSAC will seek applications over the next few months. I think the proposal is that at that point the NSAC will ask HIQA to assess those applications. There is a small team based in HIQA to do the evidence assessment. It will look at the literature and the science and ask us about the feasibility of setting up screening programmes, how difficult that would be and so on. It will then come back to the committee which will review the evidence and make a recommendation to the Minister.

I thank Ms Murphy.

Ms Fiona Murphy

I am afraid that is about as much of the detail of the matter as I know but I am sure the Department would be happy to send more.

No, that was a comprehensive and open response.

I have three or four further brief questions. There are approximately 700 deaths from breast cancer annually. Have the witnesses any statistics on how many of those mortalities fall into the age group of 49 and younger?

Professor Risteárd Ó Laoide

I do not have that information. I do not know whether Mr. O'Sullivan or Professor Hill can come in there.

Mr. Martin O'Sullivan

I am afraid I do not have that information.

Professor Arnold Hill

I do not either. It is-----

This seems to be a very difficult question to get answers to. If the NCCP is the group we should ask for this information, it is a priority that the witnesses get it.

Professor Risteárd Ó Laoide

Yes, certainly. We would be delighted to come back to the committee on that. We will work with the cancer registry on that to see if further data are available.

I thank Professor Ó Laoide. I would also like data on how many fall into the various age categories. That is what we are looking for, whether it is those aged 50 to 69 or under-50s.

How long, on average, do those women who access BreastCheck and who are over the age of 50 have to wait for the screening? If the witnesses do not have statistics on that but can supply them to the committee later, that would be useful.

Ms Fiona Murphy

I can answer that. In a usual round we will screen approximately 170,000 women every year. We send them out appointments so they do not wait. We send appointments based on where the mobile units are in the country and who has been waiting the longest. This is an opportunity for me to relay the message that if people are not going to take appointments, that is fine, but that if they let us know, we can offer the appointment to the next person on the list.

How long are the-----

Ms Fiona Murphy

Once a person gets an appointment, and if she gets called back for assessment - Professor Flanagan noted that a number of people will come back for assessment - that will be done within two weeks. If the person goes for surgery beyond that, that is within three weeks. It is a pretty quick process once somebody is in the system.

Once somebody is in the system. What is the longest someone waits to get into the system?

Ms Fiona Murphy

I am not sure I understand the question in that there is no wait time. It is a two-year screening programme. Once a person is screened, she will get called again two years later. She is not waiting in between times. Maybe Deputy Lahart is talking more about symptomatic services. Somebody referred from her GP as an urgent case is expected to be seen within two weeks, I understand. Professor Ó Laoide might wish to comment on the symptomatic service.

Professor Risteárd Ó Laoide

Regarding the symptomatic services, obviously capacity was significantly strained because of Covid and the cyberattack. In the symptomatic services all patients who are referred are triaged, and that is critical. The triage is done in the best way possible to ensure that urgent patients go and get a triple assessment. Of the patients who are referred to the breast clinic, approximately half are triaged as urgent and have that triple assessment done. Our percentage-----

If I may interrupt Professor Ó Laoide, I do not want to appear rude-----

Professor Risteárd Ó Laoide

No problem.

-----but how long is the longest it can take for-----

Professor Risteárd Ó Laoide

For the urgent patients-----

When a woman attends her GP and is referred, what is the longest referral period?

Professor Risteárd Ó Laoide

When a patient is referred to be seen urgently in the triple assessment clinic, TAC, our guidelines, our key performance indicators, KPIs, suggest that she should be seen within two weeks. In the past 18 months, this has been particularly difficult, but 90% of patients are seen within four weeks and the remainder within six weeks.

Is the St. James's screening clinic back up and running?

Professor Risteárd Ó Laoide

Is that the symptomatic service?

Professor Risteárd Ó Laoide

Yes, St. James's is running.

I have one final point. It seems to me that the cyberattack has been almost equally as intrusive as Covid. I have run out of time for further questions but I ask the witnesses to come back on the specific impact the cyberattack has had.

I did not get a chance at the start to thank the witnesses. I thank them for all the extra evenings, the weekend clinics and the extended working days. That was not lost on any member of the committee, and we are deeply appreciative of the flexibility and commitment health services staff have shown in trying to deal with the unprecedented consequences of Covid and the cyberattack on the services they provide for women.

Professor Risteárd Ó Laoide

I thank the Deputy. Radiation therapy and diagnostics were particularly affected by the cyberattack.

Why? In what way?

Professor Risteárd Ó Laoide

In radiation therapy because it is very IT-dependent and the radiation services actually stopped for a while, which did not happen at all during the cyberattack. The staff were able to continue the radiation but the service itself stopped. The cyberattack happened on a Friday and the physicists and IT professionals in the network, particularly in the St. Luke's radiation oncology network, spent the entire weekend working and had some of the service back up and running by, I think, Tuesday or Wednesday. Compared with international standards, that was the fastest recovery from a cyberattack on a radiation unit internationally. I thank the staff who worked tirelessly to bring that service together. They also helped the other units in Cork and Galway to bring their services back. It is quite a complicated, IT-intensive system. Diagnostics is dependent on systems such as the NIMIS IT imaging system, the path system for patient registrations, e-referrals, etc., so the staff in diagnostics were particularly affected. It was broader than that, though, and if the committee would like, we could send it a paper on the cyberattack.

I echo Deputy Lahart's comments in thanking all the witnesses for the incredible work all health services staff have done in the exceptionally difficult circumstances of recent years. I thank them also for their attendance today.

I wish to go back briefly to Professor Flanagan and to the issue Deputy Lahart raised about the lower age limit. I have just been contacted by some younger women in their 20s and early 30s who have a concern about this. There is a bit of a campaign running to lower the age at which screening is offered. Professor Flanagan has provided a very comprehensive reply, but what is the trend of the incidence generally? Are there grounds for concern with regard to breast cancers in younger women? Maybe Professor Flanagan could tell us about the trend there if there is one. Also, what is the practice elsewhere - say, in other European countries?

Professor Fidelma Flanagan

As I said, age is the biggest risk factor for breast cancer. While the incidence of breast cancer is less than one per 200 in the 30s age group, it is still very harrowing and dramatic for a young woman and her family, so it is hugely important we get this right. Looking just at population programmes - and screening is based on population - and the principles of screening, it is not internationally recommended that population screening picks up those women under the age of 45 at the moment. The evidence is that because the incidence in younger women is lower and because the harms of the test are high, the benefits to that individual patient or to the population are not sufficient to warrant doing screening in that age group.

Having said that, screening is only one part of a four-pronged approach that we must get our minds around. The first of those is breast awareness, education and modifying our own risk factors. Second is early detection through population screening in the evidence-based cohorts that we should be screening. Third is access, by which I mean that if a young woman feels the lump and has a symptom, she is then immediately supported, seen quickly by a GP and has immediate access to our symptomatic service. The fourth aspect in this regard is treatment, and we are strong on this in Ireland. We have up-to-date treatments, such as radiotherapy. If I were to offer advice to women across the board, regardless of age, those are the four strategies that we must hone in on and maximise if we are to have any effect on the rates of survival in this country.

Is there any evidence of an increase in the incidence of breast cancer among young women?

Professor Fidelma Flanagan

No. It is an exponential. I would point to the element of family history, however. Hereditary breast cancers turn up in the very young age group. That is another strategy that we are looking at. In our symptomatic service, we already provide family history clinics. As we talked about earlier, however, we must strengthen that area with screening and by improving surveillance. The percentage of women presenting in their 30s will perhaps have a greater likelihood of having a genetic predisposition and we must be able to provide a good service for those women.

There is no evidence of any increase among young women.

Professor Fidelma Flanagan

No.

Mention was made of public health advice. There seems to have been little of that recently concerning breast cancer. Are any campaigns planned in that regard for women right across the age groups?

Professor Fidelma Flanagan

In BreastCheck, we spend a huge amount of time and a great deal of resources on breast awareness campaigns and getting the message out there in our communications. We work in partnership with the other advocacy groups, such as the Irish Cancer Society and the Marie Keating Foundation, to try to get that message out to people. It is getting better with the new social media interfaces. We may not necessarily have been great at this in the past but this is now being undertaken in partnership with the symptomatic service, the screening service and advocacy groups to use the social media platforms which exist to be able to get the message out.

Professor Risteárd Ó Laoide

We are working with the screening service to provide breast health information resources. That is in development in collaboration with the screening service now.

I appreciate that, but I was referring to messaging-----

Professor Risteárd Ó Laoide

The other thing is that the NCCP is part of the Irish Cancer Prevention Network. We work with the Marie Keating Foundation and Breakthrough Cancer Research to help to increase public awareness through these organs. We are also involved with the Healthy Ireland strategy, the A Healthy Weight for Ireland policy action plan and the HSE's Reducing Harm, Supporting Recovery programme. We interact with all those other organisations raising awareness of issues related to cancer.

I will just point out that I have not been particularly conscious of seeing such campaigns.

Regarding the backlog, and I am short of time, I have three questions. When is it expected that a full catch-up will be achieved in the screening programmes? Is there much of an issue with no-shows in that regard? Are there geographic differences with the availability of services, and, if so, what areas are especially problematic?

Ms Fiona Murphy

I can pick up that question. As Professor Flanagan mentioned, last year we screened about 56,000 people, and that left us about 120,000 short. We aim to screen all those patients this year. We are about 6% ahead of where we expected to be this year. Despite the ongoing Covid-19 restrictions and limits in our capacity, we are just ahead of where we expected to be by now. It will take another year to get to the people from 2021. They will be screened in 2022. Within three years of 2022, we anticipate being back to the start and then we will begin the next round of screening.

I was not quite sure what the Deputy said in her second question. Could she repeat that?

I referred to an issue with no-shows.

Ms Fiona Murphy

About 15% to 20% of our women do not attend for screening when they are invited. We have now created a system where we send a text message reminder to encourage them to attend and to tell us if they cannot show up because they are busy that day, for example, and if they wish to change their appointment, that is no problem. We also encourage women to let us know if they are not going to show up because in the past we did not always know that was going to be the case and appointments would have gone to waste. We are now offering those appointments to other people.

Has that rate increased?

Ms Fiona Murphy

No, it is pretty much the same. It was interesting that it was much lower towards the end of 2020. We had uptake of about 87% to 90%. That might have been because so many people had stayed at home for all of 2020 and they were worried and then came forward in the October to December period. We are now back, however, to approximately 70% uptake. It is about 70% to 72%. All screening programmes need an uptake of at least 70% to be effective, so we do try to encourage people to participate.

We have a group of people who did not attend previously and never wish to come. The uptake among that cohort is always low. Instead of sending them repeated reminders that might just annoy them and use up our appointments, we ask them to contact us instead. We have shifted the way we work so that we are maximising the resources we have available for people. The text system has been fantastic because it gives people a reminder a day or two before the appointment. They might have forgotten, because we send out appointments quite early.

My third question concerned whether there was a geographic variation regarding access to services. Is that an issue?

Ms Fiona Murphy

No, not in respect of access. All areas in Ireland have screening at different times. Some areas have it under way almost permanently, while others have it available for three months out of every two years. We try to move the mobile screening centres around to ensure that we are in a location at the time that people will need them. We had a small issue in Donegal where we had a group of women who had been waiting a long time. Professor Flanagan's Eccles unit sent one of its mobiles up to Donegal for six or seven weeks to try to do some catch-up. A new mobile unit has now gone to Roscommon. We try to move such provision around. There is not any one particular area that stands out in this regard, but we are always conscious of the situation with rural areas especially. I refer to ensuring that our units being there for long enough to allow women to have access.

Turning to access to surgery and treatment then, are there geographic variations in that regard?

Ms Fiona Murphy

No. All surgery in all four units is done within the timeframe expected.

That is great. I thank the witnesses.

Professor Risteárd Ó Laoide

I am sorry, but I remind everyone that Mr. Martin O'Sullivan has to go to theatre at 12.30 p.m., so if there are further questions on the family history aspect, perhaps we could get those now.

Do any of the members have a question for Mr. O'Sullivan? I call Deputy Lahart.

There seemed to be a contradiction in the answers in that regard, and I do not mean deliberately so. In one of the first answers, if I heard it correctly, it was stated that family history was not really relevant. I got confused then, because a subsequent answer seemed to suggest that a predisposition to it was a factor. I ask for some clarification of that aspect.

Mr. Martin O'Sullivan

I can take that question. No, there was no suggestion that family history was not relevant. What I was saying at that time was that there are more important factors, such as alcohol intake, weight gain and perhaps HRT, that would increase the risk. Conversely, exercise and diet will reduce the risk of breast cancer. These are particularly important elements because they are modifiable risk factors, that is, people have control over them. The family history scenario is critically important for those who do have a family history in this regard. We can categorise these patients as being at moderate risk, high risk and high risk with a high chance of being a gene carrier or a proven gene carrier. There are two genes of interest in particular, namely, BRCA1 and BRCA2, and they result in an 80% to 85% chance of breast cancer being developed over the course of a lifetime. A strategy is in place to look after those women. They have significant needs involving counselling, genetics and gynaecology services, as well as the breast services. A group has been formed by the NCCP to try to look after those women. We are trying to standardise that kind of scenario in the family history programme.

Okay. Would Mr. O'Sullivan like to expand on the HRT aspect while he is with us? I refer to the danger faced by so many women who find it essential for a normal life to take HRT, and the existence of a link with cancer in that regard. Will Mr. O'Sullivan expand on that point?

Mr. Martin O'Sullivan

A study from two years ago indicated that the risk of breast cancer associated with hormone replacement therapy, HRT, was somewhat higher than we had previously realised. It particularly applies to what is called "combined HRT" and whether one takes it for five years or more. Like everything in life, I guess that one must weigh up the risk of breast cancer versus the quality-of-life issues associated with HRT. Obviously, the menopause can be a very challenging period for many women and it comes down to weighing up the quality of life with regard to improving symptoms versus the breast cancer risk. HRT will also decrease the risk of ovarian cancer and maybe gallstones, and may even reduce the risk of Alzheimer's disease in the long term. Again, it is about weighing up the benefits and the risks.

As a broad rule around good general advice, if a person is at high risk for breast cancer then she should explore complementary therapies or other options besides HRT. If HRT is needed, then it is needed. Some women do benefit hugely from having HRT.

Will Mr. O'Sullivan quantify the risk associated with alcohol in this regard?

Mr. Martin O'Sullivan

It is hard to do this from population-based studies, but it is estimated in some studies that breast cancers associated with alcohol intake can be as high as 10% or 12%.

Is that a high level of alcohol intake or moderate?

Mr. Martin O'Sullivan

Probably moderate. Obviously, high alcohol intake carries other problems such as liver disease and so on. Any alcohol probably is not good. There is probably no safe limit as such, but there are guidelines that indicate there are different levels of alcohol intake that are potentially safe for women and men. Alcohol is one big risk factor. The obesity epidemic that we are currently looking at in society is also a very big problem.

I thank all of our witnesses today for their ongoing work on the issue. It is very apt that this is breast cancer awareness month. I have a number of questions relating to the statements, the first of which is about the 3,500 cases of breast cancer that were diagnosed last year, or each year as stated. How many of those 3,500 cases are women under the age of 50?

Mr. Martin O'Sullivan

As a broad rule, 90% of breast cancers occur in people over the age of 45. That does not answer the Deputy specific question, but breast cancer is very uncommon in those under the age of 45.

I am aware that other European countries start screening from the age of 40, and particularly in Sweden. When Sweden introduced screening at the age of 40 it reduced the death rate by 26%. There is probably a trend, if there is evidence to back this up, that breast cancer has become more prevalent in those aged under 50. It would make sense that the screening would start at that age. What is the impediment to starting that screening programme from the age of 40? What resources would be needed to implement that screening age at 40?

Ms Fiona Murphy

Different parts of Sweden screen at different ages. Very few European countries start screening before the age of 50. A few countries go to 45. I am aware that Iceland starts screening at the age of 40, but they have in fact gone back to their Parliament to ask to increase the age back to 50 again because they found that screening from the age of 40 was not effective and that people were not turning up for screening. A screening service would need enough people to be coming.

I go back to Professor Flanagan's answer from earlier, that the incidence of screening from 40 to 50 is lower. Incidence really starts to increase at the age of 50. We are aware and looking very closely at whether incidence at the age of 45 would merit a screening programme. I do not believe there are many countries that would suggest the age of 40. The European Union guidelines currently say that everybody should start screening at 50, and that we should consider whether we should do that from 45. We mentioned earlier that those considerations are being looked at by the National Screening Advisory Committee, which advises the Government on the ages of screening, and will then tell us what to do and we would implement it.

On how much it would cost, we have not done that assessment yet. We would need to do that as part of the evidence review. It is very important to remember what Professor Flanagan said earlier, that the main barrier to screening under the age of 50 is the lower incidence. We would be at risk of doing more harm than good. While the test we currently use, which is a mammogram, is effective at 50, it is less effective at lower ages. We would also need to think about what test we could use. There are a lot of considerations to look into once one starts going below the menopausal age of approximately 50.

With regard to the triple assessment, and for our viewers, will the witnesses please explain the triple assessment and what that process is? What is the feasibility of getting the triple assessment for younger women?

Professor Risteárd Ó Laoide

I will ask Professor Hill to take that question.

Professor Arnold Hill

Triple assessment is when a woman is referred to us with a lump. She is examined, we get imaging at the same time, and we also do a diagnostic biopsy. There are the three components: the clinical component where the woman is examined; the imaging component; and then the analysis of the biopsy. That is the gold standard in diagnosing a breast cancer. This is why we set up triple assessment clinics and we identify patients who are most likely to have breast cancer to be in that very small selected cohort. We do that from the referral information we get from the GP.

If we go back to the original information that was given to the committee by Professor Flanagan, breast cancer is so rare in a 30-year-old that one would not set up a triple assessment clinic for 30-year-olds. It would be more beneficial to have a triple assessment clinic for someone who is of an older age and more likely to have breast cancer. When one is putting all those resources together, the clinician, the imaging, the radiologist and the pathologist, one needs to make sure that it is the most effective use of all those critical resources. We are more likely to have people of an older profile in a triple assessment clinic. One would never set up a triple assessment clinic for 30-year-olds because we would we would be seeing several thousand people but probably seeing a breast cancer there only once a year. That would not be a good use of our time or our resources.

I also have a question on the breast cancer genes 1 and 2, known as BRCA 1 and BRCA 2. What is the current position for women at risk of BRCA on access to genetic testing and genetic counselling?

Professor Arnold Hill

In our family history clinics, where patients are triaged into one of three categories, high risk, medium risk are low-risk, if a woman is high risk there are certain criteria by which she may be tested for the genes BRCA 1 and BRCA 2. It is very important to appropriately counsel people before doing this test because the implications are very significant, for the patient and the wider family. It is not just about the patient in front of one, it is all of her siblings and her children. It is a huge issue to do this test and they must be prepared for the implications of it. If someone is BRCA 1 or BRCA 2 positive the implications are so significant as the patient may consider bilateral mastectomy with reconstruction or may consider at the appropriate time bilateral oophorectomy. It is a really significant thing. It is a very specialised area. It is available to us for people who are triaged in the right category. Currently all of our tests get done in the UK, but these tests are becoming cheaper. A decade ago the test for the BRCA 1 or BRCA 2 would have cost €3,000. It is now down to around €300. With that, we will be able to make this test available to a wider cohort.

However, please be aware of the huge significance for the patient and family of ending up being BRCA 1 positive or BRCA 2 positive.

My final question, which I did not really know much about until I read a bit more about it, is on how breast cancer affects men. It is obviously a very small number of men. Of the 3,500 people diagnosed each year, what percentage of men are diagnosed with breast cancer? What is the mortality or recovery rate with regard to those men who get breast cancer?

Professor Arnold Hill

That is a great question. For every 200 women we diagnose with breast cancer, we diagnose one male. It is very rare, therefore, relatively speaking. For every 200 women we diagnose, we see one man with breast cancer. Indeed, BRCA 2 is a particular gene that is more likely to occur in men. In those families where we identify a mutation, particularly BRCA 2, it is very relevant for the males in that family. The Deputy can appreciate that it is rare in our workload overall. It is less than 1% but very relevant.

I do not say this blithely but would a man check his breasts as much as a woman? A woman would probably do so more than a man. What kinds of symptoms would a man have if he was presenting himself with possible complications?

Professor Arnold Hill

Again, a man would present with a lump. This is something we see frequently. The most common cause of a lump in a male is a term called gynecomastia, which is essentially breast tissue in a male. It commonly occurs with specific medications that are taken. In fact, in the young population, using cannabis is probably the commonest cause in a young teenager or 20-year-old. We see this frequently. They do not seem to know that; it is not written for them.

In males, however, their presentation is typically with a lump and the same diagnostic process goes on of doing a mammogram and an appropriate biopsy. It is a very small amount of our workload, however, given the percentage of one male breast cancer for every 200 females.

What is the mortality rate?

Professor Arnold Hill

It used to be believed back in the 1980s, because there was evidence to say so, that male breast cancer was associated with a worse prognosis. Now, the current literature would suggest that the outcome is the same for male and female breast cancers. That may be because the treatments for breast cancer have improved over the last two decades. We have much more effective therapies for breast cancer both in males and females. The current view, therefore, is that the outcome for male breast cancer is equivalent to female breast cancer.

I thank Professor Hill very much.

Again, the message is for men out there to check themselves. Professor Hill would recommend that is critically important.

Professor Arnold Hill

I think being breast aware goes for men as well.

Professor Risteárd Ó Laoide

I will add as well that some bracket testing is also done to support chemotherapy treatments and since May 2021, there has been an improved indication for a drug called Talazoparib, one of the poly ADP-ribose polymerase, PARP, inhibitors. We now direct germline bracket testing for cancer patients who are bracket positive and may then benefit from this drug. That is now available. That testing is done in St. James's Hospital and Beaumont Hospital.

Okay. I thank Professor Ó Laoide very much. I am going to move on. Mr. O'Sullivan is leaving the meeting. Again, I thank him for his contribution this morning.

Mr. Martin O'Sullivan

I thank the Chairman.

Deputy Durkan is next to speak.

Like others, I compliment all the witnesses for the tremendous work they have done pre- and post-Covid and that they continue to do. Our society owes them a great debt of gratitude for the dedication they have shown in that regard. All of them can take that on board.

With regard to the one in 200 people identified in the 30-year-old age cohort, what is the outcome to their treatment on average? Obviously, they are referred for treatment quickly. On average, what is the outcome?

Professor Risteárd Ó Laoide

Will Professor Hill take that one?

Professor Arnold Hill

Can I just clarify that the Deputy is talking about a 30-year-old female patient who is diagnosed with breast cancer?

Yes or in that cohort.

Professor Arnold Hill

To put it in perspective, young breast cancer at that age - we would say 30 years of age is very young - is very rare. We would see a small number of those each year. The factors that contribute to outcome in breast cancer are the same in a 30-year-old as in an 80-year-old. The two most important factors are the size of the tumour and whether the lymph nodes under the arm are involved with cancer. They are the two most important factors that will determine the outcome. The outcome for a 30-year-old with a very small tumour and a 30-year-old with a very large tumour will be predicated by those two important features of their cancer, which are the size of the tumour and the presence of lymph node status. Age itself does not say that the outcome is particularly worse. The difficulty is that sometimes a 30-year-old may present later but that is down to the individual.

Professor Arnold Hill

It varies in each case we see. Because it is such a rare entity in a 30-year-old, it may be that some people may not have been aware of coming for attention at that early stage. They may present somewhat later. There are very small numbers of these each year in the country. There would probably be less than 20 30-year-olds in the country each year with breast cancer whereas we have approximately 3,500 breast cancers each year. It is, therefore, a very small number.

I thank Professor Hill. On average, how long would those detected as suspected of having breast cancer have to wait for treatment? Again, on average, what is the outcome?

Professor Arnold Hill

The treatment for breast cancer once a person is diagnosed is, I must say, very effective and timely. As the Deputy knows, in breast cancer there are many pathways in which people may be treated. Sometimes we choose to give chemotherapy first and sometimes we go with surgery. Access to all those services in the eight centres are very appropriate, however. We have key performance indicators. The National Cancer Control Programme, NCCP, monitors these. Once a person is diagnosed, our health service does a really good job in access to surgery and access to chemotherapy. That has been the case for the last number of years.

For a woman who is diagnosed as being in need of treatment, for example, which is a very traumatic experience for anybody, of course, what in general is the best message Professor Hill can give to someone regarding the outcome, treatment and options he said are available?

Professor Arnold Hill

The first message is that we know the outcome for breast cancer is improving, definitely compared with two decades ago where we may have had a 72% overall survival rate from breast cancer. It is now up at 85%. The treatment outcome for breast cancer is, therefore, improving.

The treatments for breast cancer are much more personalised. If somebody gets chemotherapy now, it is because we know that the specific tumour has been assessed and we know that patient will benefit with very good scientific data. The treatment outcome is, therefore, much more personalised. That is important for women to know.

Of course, the long-term outcome and survival from breast cancer is still related to the stage at which they present. If it is a bigger tumour and it is more advanced, therefore, the outcome is more guarded than for someone who presents with an earlier tumour.

With regard to catching up on screening arising from the pause period during Covid-19, from what has already been said, the presumption is that we will catch up probably halfway through next year or around the second or third quarter. Are the witnesses satisfied that is attainable and achievable given the ongoing screening now taking place?

Ms Fiona Murphy

At the moment, we are slightly ahead of schedule for this year. We are approximately 6% ahead of where we thought we would be by now. If we continue to be able to screen as rapidly as we are doing at the moment and if we get our mobile services going around the country, we hope to have screened all the women who did not get screened in 2020 this year, with all the 2021 people being screened next year. I am saying that on the basis that we do not have another Covid outbreak of significant concern and there are no further restrictions. We are all hoping restrictions can be lifted even further, which would allow us to screen a few more people every day. We try to get some 40 people through our mobile services every day; most of them are managing 36 or 37 patients at this time. We are still slightly below pre-pandemic levels but nearly back to that number. Every two or three patients we can add into the mobile service, multiplied by the 24 mobile units around the country, allows us to catch up a little further. By the end of 2022, we anticipate being able to go back to a two-year round for our next round of screening.

What kind of follow-up is there in respect of women who do not show up for screening? Is contact made with a view to following up on their appointments and is such follow-up happening?

Ms Fiona Murphy

We follow up on missed appointments by offering another appointment and sending reminder letters. We have been asking those individuals to contact us directly if they want to receive an appointment at a time and in a location that would suit them. Sometimes, they will have missed the mobile service because it has moved on to somewhere else but we will try to accommodate them outside their county or at one of our four centres. We will do almost anything to facilitate people who could not attend an appointment. We will bend over backwards, where we can, to make sure an appointment is available for them.

On the other hand, some people do not want to come for screening because they believe their risk level is such that they do not need to attend. That is okay and they can withdraw from screening. The numbers involved are very small. We find that uptake is generally low for people who have not attended for screening before. We are always campaigning to get that first screen done between the ages of 50 and 52. We want women to understand that although screening is an intimate examination and can be uncomfortable for a short period, it is nothing to be scared of. Our radiographers are really experienced in helping women to have a good experience when they come for screening. We tend to find that once they come for the first appointment, they are more willing to come back. Our uptake on repeats, that is, second and further screenings, is much higher than for first appointments. We are always encouraging people to come at least once in the expectation that they will find it is not bad as they feared. Then we will get them to come back again.

I have one more question. Do the witnesses have evidence as to what outcomes are likely in the case of women who do not show up for screening for whatever reason but are subsequently screened? Is there any evidence to suggest that early detection could have been of benefit in their cases, or did the delayed screening not make any difference?

Professor Fidelma Flanagan

The impact of a screening programme, whether people attend or do not attend, is far-reaching. Not only does it have an impact on women who attend, because of the opportunity to pick up early diagnoses, but the evidence is very clear that in a society where there is screening, it raises all boats. Even for women who attend for screening only intermittently, it is better than not attending at all. The aim of screening is to detect early breast cancer before it becomes symptomatic. It is an opportunity that always should be availed of and encouraged. Much of the work we do is to ensure that even if women have not attended for their first appointment, the opportunity is always there on subsequent appointments. Screening is a journey, involving not just one mammogram but a series of mammograms. Even if women have not come for one appointment, we encourage them to come for the next one. We want them to contact us to see whether they are on the population register and getting their invitations. They should not be afraid to make a telephone call if they have missed their appointment because we can easily accommodate them if they are on our system.

Reference was made to one of the major efficiencies we have implemented to maximise appointments. In the past, we used to offer people a second appointment if they did not turn up. We found, however, that take-up was less than 30%. We now maximise first appointments and invite those women to call us in order that we can make an appointment knowing they will turn up, rather than offering an appointment while expecting that they will not turn up. That has been a really positive development.

We would like to think we will be back to full screening after we get through this round, but it will take three years to get this round done. There are confounding factors. One of the challenges we have at the moment is the worldwide deficit of radiologists, specifically breast radiologists. That is probably going to be one of the greatest difficulties we have into the future in delivering these programmes. If everything stays as it is, we have a good chance of getting back to our two-yearly programme, but we need to address some of the challenges we anticipate as we move ahead.

I appreciate that. It seems to me there is a need for an early alert system in regard to personnel shortages in areas such as radiology or any other group in the medical field. An alert system would let the public and system know of such shortages in time, so that arrangements can be made or encouraged to get more people into that particular area.

I have a question following on from that point. Earlier this year, there were 20 vacant positions in BreastCheck, including senior radiographer roles, as well as five vacant consultant positions. Is that still the case?

Professor Fidelma Flanagan

There are 21 breast radiologists working in BreastCheck. Many of them, including me, work in the symptomatic service as well. Currently, there are four vacant positions and two further radiologists are on extended leave. That represents a 20% deficit in our current workforce. Next year, we anticipate at least two or three further retirements. We have been very much aware of this issue in BreastCheck for a number of years. In the past, we have dealt with deficiencies in our workforce in radiography with ongoing rolling recruitment and advertising and training campaigns. It is very much on our radar and we offer training programmes for junior radiologists. However, we are up against it because there is a worldwide shortage. Screening radiology is seen to be a challenging job in a challenging environment and younger radiologists are not necessarily choosing it as their career. It is a multifactorial issue that will not be resolved by throwing money at it. The problem is deep-rooted and it presents a real challenge to the future of this programme if there is not a change in this regard.

Professor Risteárd Ó Laoide

As a radiologist, I am familiar with this terrain. The radiology deficit is even more widespread than the breast screening service. In fact, it is a major issue throughout the health services. I liken it to electricity in a system; if there is not the diagnostic capacity throughout a system, there is going to be a significant problem. The chief clinical officers in the HSE have just commenced a time-limited study to look at demand capacity in this area. The deficit has a far-reaching effect for all our health services. We work with the national doctors training and planning unit within the HSE and with faculty radiologists to try to forecast the number of radiologists we need in the future. There are currently 125 trainees within the programme, with 25 coming off it each year. The amount of outpatient imaging being done is increasing and will continue to increase. Subspecialisation is also increasing, which reduces the output of radiologists because the work has got significantly more complicated and complex. We are looking at things like skills mix and changing radiographic and nursing roles etc. within the service.

While we do not know what it will do, the other issue on the horizon is artificial intelligence, which is obviously something we have to keep an eye on. I agree with Professor Flanagan, and want to stress, that this is a fundamental issue that we will have to look at in the health service.

If we are talking in terms of broadening the scheme at some stage, it is a key factor. I call Senator Lynn Ruane, who is taking the slot for Independent Senator Frances Black.

I thank Senator Black for giving over her slot to me today. I wrote recently to the committee to ask it to begin to look at this module in the next while and I am very grateful to the committee for inviting me today.

A few comments have confused me a little today. Mention was made of “below the age of 40”, “below the age of 35” or even “below the age of 50”. Breast cancer has been called uncommon and very rare, yet, in preparation for today's session, I sent out seven links for this meeting to people known personally to me who are all at different stages of recovery from breast cancer, and who are between the ages of 25 and 35. In my head, if something is so rare, I wonder why there are seven women personally known to me in my life, all between the ages of 25 and 35, in this position. One would think I would know fewer people than that. How reliable are those numbers and statistics, and how is the data collated on the number of people below the age of 50 who have breast cancer? The number was not provided today as to how many people have it and it does not seem that this number is accessible. How can we be sure of the statistics and how can we be sure this falls into the bracket of "rare"?

As an add-on to that question, has there been an increase in the past five years in the number of women being diagnosed with breast cancer under the age of 50 and as low as the age range of 25 to 35?

Professor Arnold Hill

I thank the Senator, who made a very important point. We are all familiar, as she said, with people who are very young when they get breast cancer, and it is very traumatic. We rely for our statistics on the National Cancer Registry Ireland, which has a website, www.ncri.ie, and it can break it down by age. I reiterate that it is important when someone gets it at a young age, but there are a lot of women of an older age who get breast cancer. We can get the Senator the exact figures by each age from NCRI as that information is available. The point I made was that, proportionately, women around the age of 30 are a small component overall but, as she said, it is very important. She knows several people and, for their extended families, it has a massive impact on their lives. I have great sympathy with what the Senator is saying and it is very true, but I do not think there is anything inaccurate in what we are saying in regard to the percentage of women overall with breast cancer.

Are there statistics relating to the demographics of the women? The submission mentions prevention and awareness and it speaks to environmental factors. Is the class of the women a factor in the high number of women I know in this regard, if we take in environmental factors?

Professor Arnold Hill

I do not think we have any strong data to support that. I hear what the Senator is saying and we have looked a lot at whether socioeconomic grouping or where somebody physically lives influences their risk of breast cancer, but we do not think that is a strong predictor.

We spoke to the anxieties that would be caused by having to bring healthy women back for screening if we were to lower the age. Is there something else that can be done? The witnesses spoke about other tests. Can other tests, such as ultrasounds, be used to capture the women who are in that lower age bracket? There is also the narrative out there that age is the biggest risk factor. In some way, this may lead to a situation where not many women will present themselves when they have a lump because, in their heads, they feel that 50 and above is when they are most likely to get breast cancer. If lowering the age of mandatory screening is such a big issue economically or in terms of anxiety, what else can be done in respect of education and prevention, such as using ultrasound, but also in changing the messaging about who can be impacted and affected by breast cancer, given there are so many women under the age of 50?

Professor Arnold Hill

Professor Flanagan might want to talk about ultrasound.

Professor Fidelma Flanagan

The Senator has raised fundamental and important points. Many women think they do not get breast cancer before 50 because that is when the screening programme starts, and that is an important point. We are improving on that but just because the screening programme starts at 50 does not mean that people do not get breast cancer under 50. The message to people under 50 is that they can get breast cancer.

People need to understand what is normal so they can pick up what is abnormal, and that is what breast awareness is about. We should use any platform we can to empower women to understand, to be breast healthy and to know what is normal, without creating too much anxiety around it. Even recently, with film stars or singers dying, there has been a huge worry out there and many people are very worried about their risk of breast cancer. It is our job and society's job to put that into context and to be able to support women who are concerned. It is also that they can attend their GP and their nurse practitioner and get the proper advice, and to be able to be supported along that journey. Then, if there is a concern on the part of the GP, our job, working in the hospitals and these symptomatic services, is to be ready and available to support them and to provide access to women who have a symptom and who are concerned, and to provide whatever is seen internationally as the best way forward.

For women in their 30s with a high family risk of breast cancer, for example, a breast MRI is proven to be the best imaging technique to use if they have a genetic predisposition. That can all be sorted out once people address their concern and go to their doctor. If there is any concern about that, they go forward. Our job is to provide ready access and, after that, we can further advise and direct either an MRI or a breast ultrasound. Generally, we do not offer mammography as part of our tools to women under the age of 35. We generally use ultrasound and, for people who have a strong predilection to breast cancer, we would offer MRIs scans. Clinical examination is also very important. I do not know if that answers the question.

With regard to the quality of life of cancer patients in regard to their after-care or their life going forward, many women report ongoing issues for a long time, whether in regard to pain, sleep or all of those issues that come along. What comes up a lot in communities such as mine is access to supports that somebody might need, especially for one-parent families and even in regard to the type of housing people live in, access to mental health supports and pain management, and so on. In that regard, what types of services and supports do the witnesses feel are needed in terms of quality of life for patients in recovery?

Professor Risteárd Ó Laoide

There is a psycho-oncology and survivorship group within the NCCP, which helps on a number of these issues. We developed a psycho-oncology model of care in 2020 and that is being rolled out so that there are psycho-oncology units in all the cancer centres. We also implemented a national cancer survivor needs assessment, which was published in 2019. There are various programmes, such as Together 4 Cancer Concern, which is a helpline that helps people with anxiety on cancer, and also the Survive and Thrive programme, which we run. Some 400 patients have participated in that and it is now being done remotely because of the pandemic. In 2020, we filled six new posts in oncology and 19 new posts in 2021.

Eight physiotherapists, three dieticians, three speech and language workers and seven clinical nurse specialists were allocated to survivorship in 2021. We are also working with the voluntary sector in this area in trying to ensure that there is equality of care within that sector in respect of providing help to people in the survivorship space. Perhaps Professor Hill or Professor Flanagan might wish to comment on the specifics for patients in this regard.

Professor Arnold Hill

One of the key things we want to achieve is to allow people to get back to a normal life and to ensure that we are no longer intruding into their health. Getting back to living normally is part of beating breast cancer and that is very much what we aspire to. When treatment is over, therefore, there must be appropriate monitoring. We are seeing much more of that with survival increasing. We now have people who have been survivors for ten and 15 years, and things are improving in that regard. Our main focus, then, is on getting people back to living a normal life.

I thank Professor Hill and all the witnesses for their contributions. There was a great deal of information in them and I learned a lot. Hopefully, we can keep going in this direction and keep pushing to lower the age, regardless of what the witnesses have said to me.

I call Deputy Colm Burke.

I thank all our witnesses for their work in dealing with this issue during a difficult time. Returning to the issue of access to services during the pandemic and referrals from GPs, there was a difficulty with access to all medical services over the past 20 months and that included access to GPs and laboratories. If a GP were to refer someone for an assessment now, what would be the time from referral to assessment? Are there different delays in each area? I would like some clarity on those aspects.

Professor Risteárd Ó Laoide

As I mentioned earlier, the symptomatic breast service sees 42,000 patients each year. About 3,500 people were being referred each month, but that number has been increasing in recent weeks. We are now getting between 4,500 and 5,000 referrals each month to the symptomatic breast service. The key issue in this regard is a background of strained capacity within our system. That was recognised in 2018. The number of attendances has been progressively increasing since the initiation of the breast cancer symptomatic units. The impact of Covid-19 further decreased that capacity due to the infection prevention and control measures and in respect of our access to diagnostics. There was also impact due to the potential for staff to be redeployed because of Covid-19 and because of staff contracting Covid-19. As the Deputy recognises, then, there is a background difficulty in this respect.

Attendance has been increasing, however, as I said, to between 4,000 and 5,000 each month. Triage is central to how we deal with that increase. As urgent requirements are the most important to address, we triage our patients and about half are triaged as urgent cases. As I said earlier, 90% of those patients are then seen within four weeks and all of them within six weeks. The incidence of cancer in the urgent group is about 10%, which is a significant level. The incidence of cancer is less than 1% in the group of patients triaged as non-urgent and that is akin to the background rate of incidence of cancer in a screened population. The patients in that group are further triaged into people who may need mammography only, those who might need a clinical review and ultrasound, including the younger patients we discussed earlier, or patients who may have an initial clinical review and who are then-----

I am sorry to interrupt, but regarding people referred to the service by GPs, is there evidence that cancer is being detected at a more advanced stage because of the various delays? I refer to people who may have been delayed in getting to their GP or who may have had difficulty in getting access. Is there evidence now to show that we are coming across more cases at a more advanced stage?

Professor Risteárd Ó Laoide

We do not have any statistical evidence for that at this stage. There is anecdotal evidence that some of the cases are more advanced, certainly regarding other types of cancers. Professor Hill may wish to comment on the situation with breast cancer specifically. To clarify, we will get the data on this issue. The information comes from National Cancer Registry Ireland and there is a two-year lag before we will get it. There is a concern in Ireland and internationally that the impact of Covid-19 for the last 18 months, compounded by the cyberattack here, will lead to the upstaging of cancers. That is our sense of things but we do not have the data in that regard yet. They will come from National Cancer Registry Ireland.

Professor Ó Laoide said that one third of the cases coming through the system are being identified through BreastCheck. That means that two thirds are technically people who were referred in by GPs. Do we now need to initiate a programme to highlight this issue? I refer to people who may have concerns but who keep delaying going to see their GPs. Do we need to instigate an information campaign to ensure that people will decide to go to their GPs at an earlier stage than has happened in the last 12 to 18 months?

Professor Risteárd Ó Laoide

Yes, the Deputy is raising an important issue which arose in our earlier discussions concerning a public awareness campaign. We are working with several agencies to do that. It is also important to say that if someone is in the non-urgent category, that is, has a low risk of breast cancer, then we must and should tell the patients that if they have suspicious symptoms indicative of breast cancer, they need to go to their GP immediately and that they will then be seen as part of the urgent category.

Professor Arnold Hill

On the question concerning whether people are presenting at a more advanced stage since the onset of Covid-19, we do not have the data yet, as Professor Ó Laoide said. There are anecdotal reports of some patients coming in with more advanced disease, but we must wait until we get the full data in this regard.

The Deputy is correct regarding an information campaign. We are in October, which is breast cancer awareness month. Several information campaigns are running urging people to see their GP if they have any symptoms. Our referrals are certainly up this month. We are busier and that is probably because of the awareness campaigns. That is a good thing from a public health perspective and it is important to keep that message out there. We will have to wait to see the data, though, before we can truly answer the question regarding whether Covid-19 has led to more advanced presentations of breast cancer.

Moving on to the issue of the change in demographics that will occur in the years to come, that shift will result in us having more people over the age of 50, just as we will also have more people over the age of 65. Therefore, we must start planning now for that increase in those age demographics and the resulting effects. What level of planning is now being undertaken by the existing services, the HSE and the Department of Health? I am talking about planning to increase the numbers of staff and to also ensure that we are continually updating equipment in the context of access to services. Where are we in that process?

Professor Risteárd Ó Laoide

Part of the National Cancer Strategy 2017-2026 pertained to workforce planning. Contained within that were references to demographics and changes to come in the incidence of cancer as a whole that will occur in our population up to 2045. The estimated additional staffing required over the lifetime of the strategy was more than 1,000 people. So far, from 2017 to 2020, an additional 200 positions have been added across the cancer services. I am glad to say that the additional funding we got in 2021 has allowed another 200 positions to be created across the cancer services. We hope to continue this process with additional funding in 2022. The national cancer strategy has outlined that pathway in depth.

It is also important to say that we are working with other organisations, such as the various faculties in colleges, the national doctors training and planning unit and the nursing office within the HSE and pharmacy professionals, to develop a wide-ranging workforce plan for all staff within the cancer services. This initiative will require funding and that is why continued year-on-year funding will be necessary throughout the life of the cancer strategy. We are hopeful that will continue.

Professor Ó Laoide spoke about increasing staffing. It is great to increase staff, but those staff must have pro rata access to facilities and equipment.

Is such staff access to equipment and facilities being delivered at this stage?

Professor Risteárd Ó Laoide

There are various stages, for example, there is systemic chemotherapy and anti-cancer treatment units. We are working with the various cancer centres and the systemic anti-cancer therapy, SACT, units around the country to develop plans to increase their capacity to deliver chemotherapy. This is very important and we work with the estates group in the HSE on that. We mentioned radiology already. The capacity of the imaging system and radiology generally to provide the services is very important. We are working centrally in the HSE on that issue.

Another issue is theatre access. Professor Hill might comment on that. There are development plans to develop theatres in the various units. Covid-19 has separated out the pathways for non-Covid and Covid care. That may take a long time to go. There is some evidence that it is best that we separate out cancer care. We are looking into that with our estates group. Professor Hill might want to add to that.

Ms Fiona Murphy

I might add a comment before Professor Hill comes in. With respect to screening services, Government funding last year allowed us to increase our mobile units by a further three, which represents more than a 10% increase in our mobile capacity. That included all the equipment that goes into the mobile units. We have a rolling capital plan. We plan five to seven years ahead to take account of what major equipment we might need in the future. That allowed us to increase the age range from 64 up to 69 during the last five or six years. As the Deputy rightly said, planning ahead for infrastructure is as big an element as planning for staffing. We need to have both. I agree completely with Professor Ó Laoide that theatre access is our endpoint. Therefore, we must make sure we have access before we start inviting more people for screening. It is all part of one long system. Each part of that system and pathway needs to be in place. I will pass over to Professor Hill.

Professor Arnold Hill

I echo those comments. We also need to plan for theatre capacity as well as the other supports that are needed. In terms of planning for the future, Professor Flanagan spoke about the challenges in recruiting radiologists. That is a really serious issue for the next five years. Addressing it is multifactorial. It is not simply a matter of putting up a hand and saying we need more. We must create the right environment and understand the environment in terms of why it is not an attractive career specialty in the current climate. There are many issues to be examined to address that. It is really important for breast services for the future.

Is there a delay in surgery being carried out as a result of a delay in accessing theatres? Why type of delays are occurring in the centres throughout the country?

Professor Arnold Hill

For breast cancer patients, access to theatre is still adequate. We are getting our patients operated on on time and in an appropriate fashion. That is not a current issue but if our numbers expand we would need more access to theatre. That is in the context of planning for five to ten years’ time. When we note the number of cancers, we can see that by 2029 there will be a significant increase. We need to plan for that.

Professor Risteárd Ó Laoide

As Deputy Burke said, infrastructure and staff are needed. The various units, whether it be radiation oncology, systemic therapies, surgical oncology or medical oncology, we have models of care for those and we are working and planning for the years ahead. An interesting development during the Covid pandemic this year was that radiation oncology units got access to data from the UK on hypofractionation. That has been shown to be equally as effective as the previous radiation therapy that took place. It allows patients to come in for either one day a week for five weeks or five days in one week and their radiation is completed. Access to that data allowed staff in those units to roll out that therapy and equivalent outcomes have been shown for people coming for treatment every day for up to four to six weeks. That was a significant advance during Covid. Another advance, for example, was the roll-out of stereotactic ablative radiotherapy, which is a relatively new technique. Its roll-out was accelerated during Covid as it allows for a non-surgical alternative to treat smaller tumours. I am giving isolated examples of various developments that are taking place in the different specialties but we need to continue to fund this infrastructure, new technology and staffing.

If the witnesses wanted something delivered in the next 12 months, what would their priority be? Has a particular issue been delayed for some reason or other which we should be seeking to have prioritised?

Professor Risteárd Ó Laoide

I would say it would be screening. Apologies, Professor Flanagan, I will let you respond to that.

Ms Finola Flanagan

From the point of view of screening, I would echo what we have said. Screening is very well resourced. One of the principles of screening is that we do not embark on screening unless we have the capacity to do it and the up-to-date technology, as healthy women are invited for screening.

To respond to the Deputy's question on what is the most significant challenge to doing that, it is the radiology workforce. That will be a problem in delivering this service in the future. As Professor Hill and I have said, it is a challenging job. Currently, radiologists are not necessarily choosing it as a career. Considering the skill mix of other professionals perhaps is an answer or, indeed, artificial intelligence, but that is way down the line. The critical time will be in the next few years to try to keep the service going and to encourage our younger trainees to come into this as a specialty. That would be the challenge for us.

Professor Risteárd Ó Laoide

To respond to the Deputy's question, for breast services, there are a number of stages in the acute stage in a service that is stretched, has experienced the Covid pandemic and the health service cyberattack and that has tremendous staff who are probably tired at this stage, but we need to keep going. We have got pandemic funding, the safety net 2 agreement and the National Treatment Purchase Fund. We are using every resource possible to increase the access to diagnostics and diagnosis for patients. We are working in a concentrated effort on that with each of the cancer centres. We are also working in the medium term on the family history issue and the surveillance issue, and we have worked on the referral issue. We have new referral guidelines in situ this year, which, hopefully, will reduce the number of referrals from GPs to our symptomatic units, giving them more capacity. We are working on those three projects in the short to medium term and we need to complete those. If we stream those groups of patients we can have a much more efficient symptomatic breast service. The most important element people have mentioned is the diagnostic imaging capacity because of our radiology workforce. That is a much more difficult nut to crack. Throwing money at it will not help it. We need to develop a plan. Training is happening but we need to make it an attractive profession. We are looking at that in the context of the larger picture in the HSE generally for all services. I believe it is an international problem.

I thank the witnesses for those responses.

I want to bring in Senator Black.

I thank all the witnesses for their presentations. Like other colleagues, I want to thank them for the phenomenal work they have been doing during what has been a particularly challenging time for the health service.

Many issues have been covered and I thank the witnesses for the phenomenal information they have given us. The issue I wish to raise is the connection between breast cancer and alcohol consumption. We know there are some risk factors for breast cancer over which we have no control, for example, getting older, family history, etc. Considerable evidence has been come to the fore recently which shows that even low levels of alcohol consumption can increase a women’s risk of breast cancer. It is only one risk factor for developing breast cancer but the reality is that it is one that can be controlled.

It is estimated that one in eight breast cancer cases in Ireland is linked to alcohol, which is quite high. It is not well known that the risk of breast cancer is greater among women who start drinking at an early age. Women who drink two standard drinks a day through their teens and early twenties are three times more likely to develop breast cancer than those who do not drink. It is quite concerning that the Healthy Ireland survey found that just 16% of women aged between 15 and 24 are aware that alcohol can cause breast cancer, which is a very low number.

The NCCP carries out many awareness campaigns, and prevention is better than cure. Is there a need for a much stronger awareness campaign to ensure more people know of the impact that alcohol has on breast cancer, particularly for young women? There was an awareness campaign last year, but is more awareness raising and a stronger campaign required around the impact? The evidence is huge. Even low levels of alcohol consumption can increase a woman's risk of breast cancer. People need to know that.

Professor Risteárd Ó Laoide

Senator Black is absolutely right. We cannot do enough public awareness. More needs to be done on it. Certainly the NCCP will take that back and look at it. I have outlined earlier what we are involved in but I agree with the Senator. Bringing this message to schools is probably important to reach that age group. I do not have the exact details of this but the NCCP is involved in a webinar on cancer generally which is coming up shortly and will involve schools. I accept the point completely, prevention is key. As was said earlier 23% of cancers have modifiable risk factors and that message to young people may be best delivered through schools. The NCCP will look at that.

Professor Arnold Hill

My own view is there are so many other bad outcomes of alcohol - it is not just breast cancer, there is a whole list of things that alcohol has a bad outcome associated with - the education campaigns need to continue for all of them. That is a cultural thing within our country and our beliefs. Education is key.

Ms Fiona Murphy

The Senator has a good number of statistics and probably knows more than I know. There is also evidence of increased use of alcohol among women in the country over the past ten years so it is not just to try to go down from a neutral position. We are actually increasing our alcohol intake. Some of the public health advice is around minimum pricing or what we can do to encourage young people not to start drinking alcohol. Sometimes people associate that with heavy drinking whereas actually it is probably the wine that we have in the evening that we need to cut back on, and some of the now socially acceptable drinking that takes place. It is not a popular message. We already spoke today about our need to let people know that you can get cancer under the age of 50. Although screening does not start until 50, you still need to be aware, but not many young people are thinking that far ahead. On the other hand they know people who have been affected by diseases associated with alcohol, whether it is cancer or other diseases. I agree about the multiple impacts of alcohol, where one in eight of all cancers - not just breast cancer - is associated with alcohol. The more we can do to provide support for people who struggle not to drink but also get the message across that even moderate alcohol intake can unfortunately have a negative impact.

I agree it is not a popular message. Sometimes it makes you a killjoy even to talk about the impact of alcohol. Society needs to understand the negative impact of alcohol. Forgive me asking this if it has already been covered, it is around the family history clinics which is very interesting. If breast cancer is spotted in some family members and it could be genetic, how do you follow up with potential family members of someone who has breast cancer, how do you trace that?

Professor Arnold Hill

If somebody who is diagnosed carries a gene then their siblings have a 50% chance of carrying that gene. We follow up by invitation. When somebody in a family finds out that they carry a gene that caused them to get breast cancer that news will spread throughout the family. Then they will be invited for genetic testing. It is much simpler to test for it once you know the mutation that is in that family. The challenge is for each individual member who turns out to be BRCA1 or BRCA2 positive. It has huge implications for a woman's whole life, for herself and her children. It is a life changing event. She may end up having a bilateral mastectomy with a reconstruction or she may have bilateral oopherectomy, having her ovaries removed. It is an enormous change to your life so we do not take it lightly. Once a mutation is identified, it is very significant for the whole family.

I thank the witnesses for all the work they have done particularly over the past year and a half in extremely challenging times.

I have one question before we finish up. We all accept that screening works. I still cannot understand those people who have the chance of going for a screening and do not turn up. Three out of every ten people do not turn up. Has any survey been done as to why people do not turn up? I know one person who ended up subsequently dying of cancer, someone very close to me, who was not able to get time off work. I know of other people who said they had challenges finding someone to mind children, particularly in the case of lone parents. If the kids are at school there would be an opportunity there. If screening works, and we have heard the evidence today that the outcomes are much better for people who have had breast cancer than they were a number of years ago. That is the same in the case of any cancers. I have had cancer twice. I took an interest in my own health. If I had not done that it probably would not have been spotted. Is there anything we can do, such as surveys, for those people who for whatever reason do not turn up, to try to increase their participation? Are we satisfied that three out of every ten do not turn up? What is the view of NCCP on that? As a committee we thank all the witnesses, and all of those involved in the BreastCheck service. We are not being at all critical of those involved in the screening. We recognise the challenges facing them and everyone involved in the programme with the challenge of Covid-19. We also thank those involved in the charitable and voluntary end of things. I know of one group in my own constituency, Tallaght cancer support group, which is homeless at the moment and looking for a premises, so if anyone knows of a premises, please let us know. There are such groups all over Ireland which help people and it is important today, for the day that is in it, that we also recognise that.

The other positive message from our witnesses is that the survival rates are much better. The earlier you find the cancer the better your chance of survival. That is the message. To get back to the no-shows, is there anything else that we can do in that regard?

Does anyone wish to reply?

Professor Fidelma Flanagan

A really important question that exercises us all the time is why people do not come for their appointments. The Chairman has hit the nail on the head on a few reasons. A long time ago it used to be fear of the unknown. People were afraid to turn up and find out something. We are inviting people to come in from going about their business and from a normal environment. They may ask, "Why would I go for a mammogram?" An awful lot of this comes down to education at every level. It is a matter of promoting the good things about screening and trying to eliminate the fear about turning up. We do that and it is multifactorial. We spend a lot of time and energy looking at this. It is a matter of targeting the woman, her family, the GP and the healthcare nurse and the professionals. As for the woman herself, it is a matter of getting campaigns going and getting the message out there that this is a short visit and we are very efficient and effective. Most people have a normal mammogram. It is a matter of early detection and getting the message out there that you should come along for your mammogram, we will pick it up from there and your chances of moving along and having a normal life after a diagnosis are now very high. It is really a matter of overcoming that fear, better campaigns, improving communications and supporting people. Then, once the woman comes into the service, our job is to provide a very efficient, effective service in order that she will come back in two years' time. That is one element of it.

Another is our professionals. It is a matter of educating our GPs, who contact these women all the time through their daily clinics, to ask their patients whether they have had a mammogram yet and, if not, why not, and to spend time with the woman when she comes to the GP's practice.

Third, the people in the hospitals, professionals, the media and everybody else in society have a responsibility. This is a public health initiative. It is for the general population, including families and brothers and sisters. That message needs to get out there. We are doing a lot to try to get it out. We have a lot done and we have more to do. We will just keep at it. Our job is to make sure that we deliver this service and that it is the best it can be. After that, it is to try to get people to come and avail of it.

Ms Fiona Murphy

I will add to what Professor Flanagan has said about some of the things we try to do. We produce videos for people to show them what happens and what to expect so we reduce the fear of the mammogram. We produce easy-to-read leaflets. We have also translated a lot of that information into many languages and have worked with Translate Ireland to make sure we have information available for people whose first language might not be English. We also try, where we can, to enrol role models in certain communities who might encourage people. I refer to those communities that may find it harder to access our services, whether socio-economically disadvantaged communities or Traveller communities and so on. It is a matter of making sure that whatever is there, people can access it. One of the reasons for not availing of the service should not be that it is not there for them. Then, as Professor Flanagan said, it is a matter of education and explaining to people not to be scared of it. Breast cancer can be a terrifying diagnosis for people to receive, but the committee has heard today about the good outcomes that are achievable in breast cancer. It is a matter of trying to give people some balance in the information they get and, as Professor Flanagan said, encouraging them to come earlier. I am sorry to hear the Chairman was affected, but maybe he is one of those advocates to say, "Come early, come fast." Whether it is breast cancer or any other cancer, people should identify themselves to us as soon as they are worried about something.

That is great. If people miss their screening, they should not feel embarrassed-----

Ms Fiona Murphy

Not at all.

-----but get on to the service. If in doubt, get checked out. There are a lot of positive messages around us.

Again, I congratulate the witnesses on all the work they are doing and encourage them to keep it up. If they wish to come back to the committee on anything else, we would appreciate that. I thank the witnesses most sincerely for their attendance and helpful contributions.

The joint committee adjourned at 1.35 p.m. until 9.30 a.m. on Wednesday, 3 November 2021.
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