I welcome members of the Irish Cancer Society delegation: Dr. John Kennedy, medical oncologist at St. James's Hospital and board member of the society; Professor Walter Prendiville, consultant gynaecologist at the Coombe Women's Hospital, and Mr. John McCormack, the society's chief executive. I think that we will be joined later by Ms Jane Curtin.
Cancer Screening Programme: Presentation.
No, she will not attend today's meeting.
Before I ask members of the delegation to make their presentation, I draw their attention to the fact that committee members have absolute privilege but the same privilege does not apply to witnesses who appear before the committee. I also remind committee members of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable.
Although it would be fair to say that many groups have wanted to make presentations to us on this issue in the past few months, it was obvious to the committee that we should hear a presentation from the Irish Cancer Society as quickly as possible. The Joint Committee on Health and Children has been annoyed and concerned at the slow roll-out of the national screening programme and we see it as an important part of our brief to ensure that the roll-out is moved along.
Statistics that have been put to us recently are cause for alarm. For example, whereas the number of Irish women eligible to be screened is in the region of 1 million, only 7,000 women are currently being screened each year in the mid-western area. Another statistic, which was presented at last year's national cervical screening conference, shows that without a screening programme, Ireland's mortality levels from cervical cancer will reach 6,000 a year by 2030. Perhaps the delegation will highlight the implications of not rolling out a national screening programme in the near future.
According to the cancer services unit at the Department of Health and Children, a national cervical screening programme would cost €25 million to set up and maintain each year. This figure includes paying the general practitioners and nurses involved in the scheme. I would not be too concerned about the money factor because it is obvious that something so important should not be tied just to a monetary statistic. I suppose the most worrying statistic is that Ireland continues to have the highest incidence and mortality rate for cervical cancer in western Europe. Those few statistics demonstrate, and have done so for some time, the importance of the national roll-out of a screening programme.
Perhaps the delegation will confirm whether those facts are right and advise us how we can ensure that we do not have to wait much longer for a national screening programme. We need to create the necessary political will. After the presentation committee members will raise queries, make suggestions or ask for further information.
Professor Walter Prendiville
I thank the committee for inviting us to make this presentation. I am chairman of the Irish Cancer Society's cervical screening committee and a consultant at the Coombe Women's Hospital and Tallaght Hospital. I am president elect of the British Society for Colposcopy and Cervical Pathology.
This presentation was put together with a lot of support from colleagues — Grainne Flannelly, Emanuel Diakomanolis, Patrick Walker, Marion O'Reilly and Jim Gallagher in particular have helped me with the preparation of these slides.
Cervical screening prevents cancer. Well organised screening programmes have a proven track record in reducing the incidence and mortality rates for cervical cancer. An opportunistic screen does not work. We do opportunistic screening; we take the opportunity to take a smear from people who ask for it.
What causes cervical cancer? This is a complex question but, essentially, the cancer is caused by an inadequate immune response to a ubiquitous human papilloma virus. By "ubiquitous", I mean that nearly everyone gets it. In particular, HPV types 16 and 18 are causative of cervical cancer. HPV is present in virtually all cancers of the cervix and in almost all pre-cancer smears. A negative test for HPV virtually negates the risk of cervical cancer. The natural history of cervical cancer involves a move from a normal cervix to a HPV-infected cervix to pre-cancer to cancer.
The vast majority of people infected with HPV are infected only transiently. The virus regresses to normal and remains entirely innocent, with no future prognostic implications. A small number of people will develop a pre-cancerous state and a smaller number will develop cancer. HPV is present in 20 to 25% of women under the age of 30. It would be present in 80% of those same women if they were to continue to be tested. Virtually everybody gets HPV. It is not a marker of promiscuity or sexual activity. However, after the age of 30, one's immune system deals with it. Only about 3 or 4% of people have HPV after that time.
Where does cervical cancer start? I will quickly draw on the flip chart the anatomy of the female genital tract for those who might not be familiar with it. The lines represent the cervix, the cervical canal, the top of the vagina and the inside of the womb. The lining is glandular. Like the gum, it produces mucus. It looks red and is thin. However, the lining of the vagina is skin like and is 20 or 30 layers deep. It has no glands in it and is quite different. The two meet in a tiny piece of skin, which is called the transformation zone. That is where cervical cancer starts — it starts nowhere else. It starts in a tiny piece of skin at the opening to the neck of the womb. That piece of skin is fully visible.
The transformation zone can be seen in the great majority of young women. It can be smeared, examined and a biopsy taken. The cervix is entirely accessible. Cervical cancer has a really long pre-invasive stage. That is one reason that cervical screening works so well. By contrast, in the case of breast and ovary cancer, we screen for cancer. The big difference with cervical screening is that we are looking for something ten or 15 years before the onset of cancer. That is why cervical screening works so much better than any other screening intervention in female pathology. Treatment is simple and preventive. One is not treating cancer but preventing it, and the treatment works. Regular testing of an entire population is what we need to do, not the opportunistic testing of low-risk women.
We currently use cervical cytology or a smear as the intervention in cervical screening. We are getting better at our sampling techniques. Currently we are evaluating automation and it is likely that in many western countries, HPV will be incorporated into a screening programme for women over the age of 35.
The slides I am showing are of nice normal smears, normal cells with small nuclei. The next are of slightly abnormal cells with larger nuclei. The following are of moderately abnormal cells. The next are more sinister, seriously abnormal cells, big, dark and dense, showing some of the features of early cancer.
I now show a slide of a normal cervix, a normal transformation zone, completely visible. Normal vaginal skin can be seen, a normal glandular lining, and the transformation zone is a "halfway house" , where cancer starts and from where we take a smear. The slide of a slightly different cervix shows a small transformation zone, fully visible, just inside the canal. The next slide shows a slightly larger transformation zone stained with white. The density of the whiteness and other features of this slide allow one to identify where cervical pre-cancer starts. Within the transformation zone, when it is severely abnormal, one can see particular vessel patterns that a colposcope will allow one to examine, measure and assess with a degree of precision that is relatively accurate.
On the next slide one can see what we are trying to prevent, namely cervical cancer. The game is over at this stage. This is a bleeding, ulcerative, necrotic tumour, no longer at the stage of preventive therapy. This is cancer and the chance of serious morbidity and death is high.
Since 1999 the European Commission has been at one in regard to the advantages of screening programmes and has advocated that cytology or cervical smear screening programmes should be introduced. In 2004 the European Commission decided that successful screening programmes were essential but the commitment of national governments was needed to support the programme and adequate resources made available. In Ireland in 1995 a policy for women's health was developed and in 1996 a report on cervical screening was published. In 1999 there was an interim report of the national expert advisory group.
I returned to Ireland in 1991. A committee of the Department of Health was sitting at that time and made exactly the same recommendations to the Department as were made in the most recent report. There is no disagreement among any of the experts who have looked at this subject. There is no disagreement among the epidemiologists, pathologists, gynaecologists or the Department of Health officials who examined this subject. Everyone agrees we need to establish a cervical screening programme.
A national office has been established in Limerick where free screening is offered to women between 25 and 60. There is an active register of 87,000 names and about 70% of eligible women have been screened. Nationwide, quality assurance measures for smear takes, laboratories and colposcopy clinics have been established.
The most important slide shows that 70,000 women in the mid-western health board area have been screened, but the figure for the women who should have been screened approaches 1 million. Even if these women are screened every day for the next ten years, that will not affect the risk of cervical cancer or death from cancer among the majority of Irish women. Various studies have examined how often women are being screened outside Limerick — 50% according to the ESRI in 1994, 40% according to Ailish Ní Riain, a GP who conducted a GUM clinic study, and about 20% of a sample group of female GPs, gynaecologists and midwives. That latter study was done in 2000 by Fiona Lyons.
Who is currently being screened? A very large number of young women with little risk of developing cancer are being screened too frequently. They represent a small proportion of the women at risk and we are not effecting a reduction in cervical cancer. Every woman between the age of 25 and 60 should be screened. We know that will achieve a reduction in cancer. That would generate a number of smears almost identical to the number we currently do, but in a more representative cross-section of ages in Ireland.
We know that cervical screening reduces the incidence of cancer, reduces the number of women who die from cancer and detects cancers at an earlier stage. The UK introduced a cervical screening programme in 1989 after which the death and cancer incidence rates plummeted by about 7% per year. It is the same story whether one looks at cancer incidence or mortality. I now show a slide which is slightly out of date. It shows cervical cancer incidence, with Ireland's figures indicated in red, and England and Wales in green. This is not quite up to date but one can see that we have now overtaken the UK in terms of rates of cervical cancer and death from it. That is true for every UK region.
Julian Peto was perhaps the most respected cancer epidemiologist in the UK and he has calculated that if the screening programme was not implemented in the UK there would have been, by the year 2030, about 11,000 cases and 6,000 deaths among women born after 1950. Effectively, one in 65 women would be dying from cervical cancer, similar statistics to that prevailing in India and the poorest parts of South America.
Mortality rates in the UK have greatly reduced since the introduction of an organised screening programme. Our death rates were half that of the UK in the 1970s but have slowly and consistently risen since that time. As our own Harry Comber has cogently argued, the absence of a population-based screening programme is the most plausible and indeed the only explanation for these differences in trends. Women present with cancer in Ireland not just more often but later, when they have symptoms. Often, that is too late. They present later in terms of the stage of the disease, how far it has spread from the small transformation zone I described. Opportunistic screening is not performing well in Ireland. There is an increase in mortality from cervical cancer during the same 20 years, when the natural history and understanding of what causes cervical cancer has become crystal clear. A high proportion of women in Ireland present late.
Since February 2005 the Irish Cancer Society has campaigned intensively for the roll-out of a national programme through press briefings, press releases, one to one meetings with Deputies and Senators, presentations to the Department of Health and Children and a presentation of 55,000 signatures — which with more resources could double or treble — to the Tánaiste on 1 February last. The Tánaiste has asked the HSE for an implementation plan for a national programme roll-out. All the necessary elements — call or recall, smear taking, HPV testing, laboratory organisation and investigation and treatment services — need to be quality assured. It is only proper that the great work done by Jim Gallagher and Marion O'Reilly in establishing a quality assurance programme for the laboratories and colposcopy services should be recognised. That programme will be ready by the time the roll-out has occurred.
I do not have the authority to talk about GP negotiations on payments for smears. I understand the issue is being included in the Labour Relations Commission negotiations. In the UK, payments to GPs are tagged to the proportion of women screened in a GP's practice, and they get a significant additional amount if they reach more than 80%. It is only by reaching a figure of more than 80% that a reduction in cervical cancer incidence can be effected.
If the green light were given today, we would anticipate it would be about 18 months before our programme starts. We have not yet heard of any additional budget being identified. The next steps are political.
So far I have been enthusiastic and optimistic in this regard but must now offer a word of caution. The ingredients for a successful cervical screening programme are that the smear-takers are educated and skilful, the laboratories organised, skilful and quality-assured, the screening authorities organised and in place, and the colposcopy clinics similarly quality-assured and sufficiently resourced. Mistakes will happen in a cervical screening programme. Members may have heard of two recent court cases taken against laboratories and hospitals because smears did not recognise a cancer. No screening programme on the planet at this stage argues that it is able to recognise every cervical pre-cancer. One must examine a smear that has between 200,000 and 400,000 cells on it. Even automation, when perfected, will miss some. Smears are estimated to miss between 10% and 30% of abnormalities. However, the natural history being 15 years and smears or HPV tests occurring every three to four years means that the chance of missing abnormality is reduced profoundly over time, to almost zero. Appropriate HPV testing in women over 35 will virtually eliminate it.
However, the Department of Health and Children must take some steps to educate the public about the nature of screening. It is not a diagnostic test that is absolutely right or wrong but a screening programme. A smear does not protect one, but frequent tests do. Systematic screening will save lives — measurably so, and in a defined period. Incorporating HPV testing in women over 30 or, more likely, 35, will detect almost all cervical pre-cancer. Incorporating HPV testing post-treatment and in borderline smears will further reduce the number of women who need unnecessary investigations.
I have the further good news that vaccination is on the way. Two large companies have produced a vaccine that appears to work against the two viruses that are the most common causative agents for cervical cancer. It is likely to take a generation to have any effect. It does not preclude screening, and, as members can imagine, the vaccination of teenagers — boys and girls — is likely to be contentious. It is a long way from being the answer.
Systematic screening works and the infrastructure is well established, but the programme will not be able to start until 18 months after the announcement; we must begin now. Only a minority of Irish women have access to organised cervical screening. Irish women have a significantly greater chance of developing and dying from cervical cancer than UK counterparts. The Irish Cancer Society advocated the establishment of a nationwide screening programme and would like to help in any way that it can those politicians who support that ambition.
I thank Professor Prendiville. I take it that he has made an initial presentation and we may go to the committee now. Before we do, so many members wish to speak that I should perhaps assure them that they will all have the opportunity. It is a very important morning. I take it from the very powerful presentation and one-to-one direct representations to politicians, be they Deputies or Senators — very important in themselves — that the key message is that systematic screening will save lives. That is our starting point this morning and makes matters very clear. The figure that Professor Prendiville has just confirmed, that 6,000 women may die unnecessarily between now and 2030, must also focus our attention on where we move from here.
Professor Prendiville
That is the UK figure. Proportionate——
Proportionately, working on the UK figures.
With that in mind, we must wonder why it is taking so long to roll out the programme. I wish to have members properly involved in the discussion, starting with Deputy Neville. Deputy Twomey has also indicated, as has Deputy McManus, after which we shall have Deputies Devins, Fiona O'Malley and Connolly. Everyone will get a chance. It is very important that we take our time. Let us have quick questions first, however, since Deputy Neville must attend the Order of Business, which is why I have let him in now.
I am from Limerick and therefore aware of what has been happening there. Mr. McCormack mentioned medical cards. Screening is not covered by them, and I recently raised that vital issue. If a GP diagnoses a problem, it is covered by a medical card. However, ongoing screening such as Professor Prendiville has suggested is not covered. Some 35% of people who can least afford screening do not have that facility, since it is not covered by the medical card, and that should be addressed soon.
We have got the question, and we will return for a response. I want to try to keep moving.
I compliment the deputation and in particular thank ProfessorPrendiville, who has long been a champion of women's health. Having listened to the presentation, I am very angry at what is not happening. Professor Prendiville and the Irish Cancer Society have been making this case for years without anything moving on. It is shameful that women's health is being endangered in this way. This technology is simple, seems to be good value for money, and can be implemented, but that has not happened, except for a tiny minority of women. The most stunning slide in the presentation was the pyramid showing those women who have access compared with those who do not. It is absolutely shameful, and I suggest that the first thing on the agenda when we meet the Minister for Health and Children, Deputy Harney, in March be that we deal with this issue once and for all.
What has been presented contains all the elements. We know how it is done, how to ensure the best quality, that GPs will be able to provide the service if they are paid, and that there is already a model in the mid-west. Is it just a lack of funds that is causing the logjam? Recently I tabled a question to the Minister for Health and Children on the pittance of an additional €9 million being invested in cancer services. I wanted to know how much of it was going to cervical cancer screening, and the Minister could not even answer the question. She has referred it to the HSE. It has gone into the black hole, and we may get an answer in six months.
This is about money, or the lack of it, literally putting women's lives at risk. They are dying and suffering great ill health while causing great expense to the health service as a consequence. We have seen BreastCheck, and it is another scandal that it has not been developed across the country.
Of eligible women in the mid-west, 90% are on the register. Why is the figure not 100%, and why is it only 70% — very good, but still off the mark — for screening? Are many high-risk women not being seen, or is it the very low-risk women who are not being screened? On the implementation of screening, is the capacity in place at primary care level? Is it possible to do it while maintaining quality? Professor Prendiville said that it would take 18 months for the programme to begin. Does he mean that it would take 18 months to begin nationwide? BreastCheck is still limited to certain regions, and the west and south west have remained completely out of the loop.
I thank Professor Prendiville for attending today.
Nothing that Professor Prendiville has said this morning is new to the Department of Health and Children. Some 30% to 40% of the population are opportunistically screened at present, at a cost of somewhere between €10 million and €15 million. The instance of cervical cancer is increasing. Has that been a total waste of money every year? If this programme is rolled out, we are talking about an additional €10 million or €12 million, on top of that €50 million which would give us a proper screening programme that will work. For half that amount of money there is an opportunity to provide screening that is not working. Perhaps Professor Prendiville might clarify that point.
As regards payments, the Taoiseach, in November 2000, gave instructions that everybody over 70 was to get a medical card. By 1 July 2001 everybody over 70 in Ireland had a medical card. Therefore I do not believe negotiations with GPs should hold up anything. Where there is the will, it can certainly be achieved within a six or seven-month period. As he knows the payments for GPs in the Limerick region currently are totally separate from the GMS and have nothing to do with it. They depend on agreement reached locally which might easily be expanded. The point Deputy Neville was making, in effect, was that cervical screening could be accommodated on special claim forms for GPs and this could be negotiated quite separately, as with the over-70s, without recourse to the Labour Relations Commission. As regards the payment to GPs, that could be negotiated within a three or four-month period.
However, once the diagnosis is made, regardless of what Professor Prendiville has said about the ten to 15 year period over which it develops from CIN to full-blown cancer, the anxiety factor for women is a major issue. If a woman knows that she has had an abnormal smear, where a repeat smear is required in six months time or where she needs to attend a coposcopy clinic, there should be a rapid movement from the time of diagnosis even where her life may not be at risk. It is not easy for a GP to tell his or her patient in the surgery that she might have to wait five years and not five months. Whatever we do, the facilities must be brought up to scratch so that there is a rapid follow-up, in the event of an abnormal smear.
What does Professor Prendiville believe is needed? Does he believe more coposcopy clinics are required or more laboratory facilities? The problem of payments to GPs can be resolved quickly because most of the preparatory work has been done. Professor Prendiville says the quality assurance aspects have more or less been completed as well. How long would it take to establish a patient register, and how would it work?
I thank Professor Prendiville for a most illuminating presentation. I have a few questions which basically follow on from what has been said already. Everybody on the committee supports the immediate roll-out of cervical screening. It is somewhat disappointing, however, that the pilot study in Limerick showed only a 70% uptake, which as the professor said, is not really at the level we would have liked. Can the professor say why that is so? In my experience some women believe that a cervical smear is a painful or slightly awkward procedure. Should there be a strong PR campaign to put forward the fact that this is a routine non-painful procedure?
There is some evidence that sometimes the aggressiveness of the cancer can develop much quicker than the normal five to ten year roll-out. Is there any way of predicting from the initial smear whether it is a CIN 1, one of the more aggressive types, or are repeat smears required to determine the natural history of the condition?
I am somewhat taken aback to learn that it will take 18 months from agreement on a roll-out to the time of putting it in place. As Deputy Twomey has said, I do not believe the GPs will be a stumbling block, and their surgeries are the ideal locations in which to do the smears. However, in Sligo there was a problem in having technicians in the local laboratory who were suitably qualified, to do that. Is this because the backup facilities would take this length of time to put in place? Eighteen months is too long, based on the evidence presented to the committee today.
Professor Prendiville
I thank the Deputies for their supportive comments. I will make a couple of comments to try to deal with some of the questions and then attempt to answer others more specifically. Probably the best international epidemiological body is the IARC, the international agency for research into cancer in France. It has estimated that the rate of cancer in any country will be reduced by about 60% if a smear is done every ten years. This will be increased to 81% if a smear is done every five years, 90% if it is done every three years and 91% if done every year. Therefore the reward between three and five years is profound and the advantage to doing it annually is minimal. It increases the number of interventions and tests and is expensive etc. The single most important factor of any skin programme in terms of success is coverage. Trying to focus on any high risk group, the young, medical card holders or other people simply does not work. There is no longer a high risk category. It is just a question of someone average being in a sexual relationship. There is no high risk proportion of the population that may be targeted, and which will yield a reward.
At the moment it is true we are doing a great many smears, but on young women far too frequently and those are at a very low risk. They are in the phase of getting mildly abnormal smears that revert to normal. They are having unnecessary intervention and drowning the laboratory and colposcopy services. For that reason in the UK, since very few cancers will be picked up below the age of 25, they have stopped screening women below that age. The age of onset for screening now in the UK is 25 and we should, almost certainly, do the same.
Is that all?
Professor Prendiville
I am referring to cervical screening.
I mean opportunistic cases as well.
Professor Prendiville
Opportunistic screening tends to disappear once a programme is implemented because people get called to come back. If they know they are not supposed to have a test before the age of 25 they do not get anxious because the newspaper and magazines are telling them they should. They are trying to sell papers rather than attempting to institute a programme. If a programme is established and everyone knows that the time to start is at age 25, and to have the test every three or four years, that will become the norm. Some people will undoubtedly have a smear outside the programme, and that is their right.
They can pay for it.
Professor Prendiville
Perhaps they can pay for it, exactly. As to how long it takes to a roll out a programme, that is not my area of expertise. However, that is what the regional office in Limerick estimates. We have a particular difficulty in Ireland in not having a national database to tap into to identify the women at risk and their addresses and write to them. Limerick has not managed to get 80% because it had to generate a database over time through general practitioners etc. Not having a national database that we have permission to access is a small problem, but several countries have worked in a similar manner, Australia for example, and they have managed to generate a database over time that covers the great majority of the population. Limerick had got to 90% of the people on the register. It has not quite got to 80% in terms of uptake, however, and that is a multi-factorial——
Is this due to the fact that it has not got the qualified or eligible women on its database?
Professor Prendiville
That is an important factor. Also, it had to recruit general practitioners to the programme and that takes some time. It had to train people to take smears who had not done this already and the laboratory had to be suitably orchestrated. There is a quite a good deal involved in the organisation of a screening programme. In this instance the time delay factor is not 18 months, but the past 15 years. If we were to say 18 months from now, most pathologists and colposcopists would jump with delight, because that would mean a major inroad into cervical cancer in Ireland.
This means the question of patient registration is crucial, does it not?
Professor Prendiville
I agree it means that patient registration to the programme database is crucial, but that has not been a problem in other countries. Undoubtedly, there is a need for education and a need to announce the programme and to recruit general practitioners to it, but that is not something that is likely to be a block. The financial reward to the GP for taking a smear is not a matter I can address as that is an ongoing question.
We have seen, as regards BreastCheck and the Limerick project as well what I refer to as the white envelope syndrome. Any white envelope that comes in the door marked private and confidential tends to get put in the bin. That is a fact of life, as regards screening programmes. The way to get around that, as happens in the UK, is that women receive a letter inviting them to have a cervical smear test. If they do not respond they get a reminder letter and if they do not respond to this, they get a phone call offering them counselling on the issues of cervical cancer. That is the way the women of Ireland should be treated. If they do not respond to that, they get a reminder letter. If they do not respond to that, they get a phone call offering them counselling on the issues surrounding cervical cancer. That is the way the women of Ireland should be treated. There should be a proper service whereby women who have concerns about coming for screening and who do not understand about HPV ultimately get a phone call from the screening programme to alleviate their concerns.
The Irish Cancer Society is working this week with the Irish cervical screening programme in Limerick setting up stands in shopping centres in areas where there has been a slow take-up. There will always be regions identified where a slow take up occurs. People who are trained to do so will discuss with women the issues around cervical cancer. There is also a cohort of women who do not respond to the BreastCheck letter. There exists a system whereby they are contacted and any of their concerns about it are alleviated.
What about the more aggressive form of cancer?
Professor Prendiville
It is true that there are some cancers that progress rapidly. In any pathology, there is a range whereby some will go quickly and some will take a long time. It is true that cervical screening will never prevent all cancers. We will need a vaccination programme for that. The screening programme is specifically interested in detecting squamous pre-cancer. A very uncommon glandular form is much less easy to recognise at cytology. These are examples of very uncommon cancers, less than 5%, that the screening programme may not identify. Screening programmes will reduce the death rates and the incidence rates of cervical cancer by half or by more. In British Columbia it was by about 80%. That said, it will not reduce it to zero.
Dr. John Kennedy
Regarding the duration of time to roll this out, it is much more important that we get it right than we get it rolled out in 18 months. There are all kinds of subtleties in this. We will be asking normal people to undergo a test, and when one asks them to do that, one has placed a huge onus upon oneself to ensure that one is getting it right. It is important, therefore, that the appropriate infrastructure be put in place to ensure it will happen perfectly. BreastCheck is a classic example of that. It has an excellent infrastructure in place, is very well organised and provides a superb service. It is important that we get this initiative right as well rather than just ensuring it is rolled out in 18 months. I would be surprised if it were rolled out in that time.
There are all kinds of hidden and unanticipated problems with such services. For example, there have been problems in the UK getting people to train in cytopathology because the main outlet for such training is the cervical screening programme. There have been issues of witch-hunting for smears that were previously inappropriately missed and where people ultimately went on to get cancer. That has acted as a great caution to people training in cytopathology in the UK. It has been difficult to get technicians to go from regular pathology into screening programmes because there is no overtime. There are many subtleties in setting up a programme that requires experience to do it properly. The timeline should not be as important as getting it right.
Members asked how the committee could help with this project. There are two elements to establishing such a project, namely, the political will to make decisions and programme management. We are very pleased that the political decision has been made and that the political will exists. We need the programme management and we should urge that it be put in place as soon as possible to make the necessary arrangements. The committee could play an important role in that.
The cervical screening programme is not available to people who have a medical card. We are all shocked by the number of people who do not avail of cervical screening. How much does it cost? Someone who feels well and does not have to go to a doctor will be put off by the cost. That is a natural reaction. How much evidence is there to show that women are similar to the old gentleman one cannot get to go to the doctor?
Would it be possible to run the cervical screening programme in conjunction with the breast screening programme? When one gets the patient in the door, one should get as many programmes done as possible. The message is being sent out that screening prevents deaths from cancer. In the UK, there has been a 7% annual reduction in the number of deaths of people who have availed of cervical screening. That message has not been sent out so we must keep selling it.
When will the vaccine come on stream, at what age will people get it, what is the cost factor and how soon will that programme be rolled out? The witnesses said that there may be difficulties with it. Should we target specific groups of people? Does it run in families or is it completely random? Deputy Devins said that the treatment is simple and painless. The programme should be included among the medical card treatments. I will have to read the witnesses' answer in the record as I must go up to the Chamber.
I thank the witnesses for their presentation. I have heard it before and the case is compelling. I do not understand why this is not a priority. It is clear it will deliver results if we have it. It is a cost effective way of protecting people's health. I was concerned by the low take-up in Limerick. Why is that the case? If it were to be run nationally, we would naturally assume that this take-up would be a bit of a problem.
The Irish Cancer Society's communication skills are excellent. I saw the presentation for the first time in Buswell's Hotel 18 months ago and it was extraordinary. Why have the rest of the population not seen it? I do not understand why women are not clamouring to get this rolled out. It is sensible and it is clear how the results are delivered.
It was stated that everyone is likely to get this papilloma virus. Does that mean it is triggered when someone becomes sexually active? Is the vaccine a solution to the problem? Will it only be for sexually active women? Professor Prendiville said that if a programme of vaccination is adopted, it may be part of the solution. He did not say it does not preclude having a smear. Are there two issues running on an ongoing basis? If it is decided that the vaccine, as a preventative measure, is the best way to deal with this, does it also mean screening and smear tests must be done regularly?
The professor spoke about women over the age of 30. Are women safer after 30? That is where I got confused. In response to one of the questions, Professor Prendiville stated he is afraid the wrong people will be targeted and that the laboratories will be swamped by the cases of people who are not at high risk. That muddied the message in a way.
Professor Prendiville
I will clarify that point. Early work on the vaccine suggests that it works in regard to HPV types 16 and 18 — the types that are currently the primary agents causing cervical cancer. It is difficult at this time to translate that information into a completely successful vaccination programme. However, it is the hope of the vaccination community that vaccinating boys and girls before they are sexually active will negate the risk of cervical cancer. We are a long way from that at this time but vaccination holds real promise for the great majority of cervical cancers. However, what the viruses will do is hard to anticipate.
With regard to age, young women very rarely get cervical cancer. The great majority of women are exposed to a virus in their twenties and the great majority of those clear that virus without harm. A small proportion of women do not deal with the virus and it stays with them, and a small proportion of these women develop an abnormal smear in their late twenties to late thirties. By the time most women reach their thirties they have cleared the virus and it is uncommon in women over 35. That is why a test at that stage, particularly a negative test, is very powerful, whereas a positive test means nothing for a normal woman at 23 or 24.
Were there other questions?
What about the low take-up rate?
Professor Prendiville
When a programme is confined to a specific geographic area and one cannot announce a national advertising or education programme, there will not be high take-up rates. That experience was mirrored in the United Kingdom, where, when regional programmes were introduced, the take-up for them was much lower than for national programmes.
Some people claim that women will not want to take part in a programme. While that is undoubtedly the case when the take-up is low, the experience in the UK and Australia and Canada is that when high numbers take part in programme, everybody wants to take part. There is probably a threshold but one cannot approach that threshold without a comprehensive, nationwide consensus approach to the uptake of cervical screening.
Dr. Kennedy
We will never screen everybody on the planet. However, if more than 80% of the target population is screened, this will have an enormous impact on the rates of mortality from the disease. Incentivisation of primary care and general practice is very important. In the UK, GPs are incentivised and get a significant extra payment if more than 80% of their target population is screened appropriately and regularly. In Northern Ireland, a different mechanism operates whereby GPs get a payment if more than 60% of the target population is screened and a higher payment if more than 80% is screened. However, the take-up is lower in Northern Ireland and we think this is because the incentivisation bar is lower.
If the incentivisation bar was at approximately 80% for GPs, we anticipate that given public relations information, an education programme and the announcement of a national programme, there is no reason we cannot have more than 80% of eligible people screened at appropriate intervals through the programme.
The national programme will seek to reduce the rates of mortality from cervical cancer, which is currently approximately 75 per year. We believe the lives of 50 women, with an average age of 45, could be saved each year.
One aspect of the work of the Irish Cancer Society is the provision of immediate cash assistance to families going through cancer diagnosis. The Irish Cancer Society receives letters, perhaps one a month, from families of young women in their late thirties or early forties who have died from metastatic cervical cancer. The letters ask the society for, say, €400 for counselling for the surviving teenagers of the family. It is this type of death, which is wholly preventable, that we are trying to prevent. There are so many deaths from cancer that it is difficult to prevent totally, although mortality has improved, but lives can be saved among this cohort of women.
In addition to reducing mortality, we are also trying to reduce the incidence of invasive cervical cancer, of which there are approximately 200 cases per year. Many of the women involved might not die from the cancer but they will have life-changing treatments, such as hysterectomies and radiotherapy, with major implications for fertility. The management of these conditions also imposes serious costs on the health services and a national screening programme would help to reduce those costs.
National cervical screening ticks every box in terms of effectiveness, cost effectiveness and proper care for the women of Ireland.
I compliment the Irish Cancer Society for organising the petition and for the presentation of the 55,000 names to the Tánaiste, which was of great significance in her decision to announce the implementation plan. Following the society's promotion of the subject, I issued a press release to women in my area who did not necessarily have access in this regard. Some 55,000 people were prepared to log on to a website to call for this petition. I offered the facility to people to use the computer in my office or to telephone the office so that we could log on for them. The number of telephone calls which resulted in recent days due to that press release was staggering. The total number for the petition could have been far higher than 55,000. When that number of people feels strongly about an issue, they will get a result.
More than 20 years ago many UK companies carried out cervical screening programmes here through the workplace — I worked in one such workplace. Given that we are discussing efforts to increase the number of women who would avail of such a programme, it is important to note that all women in a workplace will go for such screening because it is a facility which is operated for them. It is a good way of rolling out a programme. That facility was available in many companies at that time yet, 20 years on, we are discussing the roll-out of a national programme. In addition to the operation of the national programme, screening could be promoted through companies.
With regard to the Tánaiste's request for the implementation plan from the HSE, was a timescale given for when the plan might come about? Dr. Kennedy referred to BreastCheck and how necessary it is to have proper infrastructure. In the west, where I come from, BreastCheck is not operational. I appreciate that Dr. Kennedy thinks it a wonderful programme where it operates effectively, but it does not operate at all in some areas. I assure the delegation that the women of the west are aware of the proposed programme and do not intend to be left out or left to the end of the queue on this occasion.
One of the most staggering points in today's presentation is the proportion of female GPs and gynaecologists who have not been screened. Many women like to go to a female doctor and some of us get to visit gynaecologists at different stages. If 19% of those doctors have not been screened, it suggests a lack of awareness or a lazy attitude. If they are not impressing upon their patients the importance——
Women have been let down by the State and successive Governments. Women have not been educated about these issues. Nobody has explained properly to them what HPV involves and how it happens. This is why we are seeing such a low take-up. There has been a complete failure to provide proper educational campaigns on the issue and, unfortunately, women have not been great in coming forward and talking about it, whereas they have with regard to breast cancer. BreastCheck will become operational in the west — it is promised within the next 12 to 18 months.
Unfortunately, women have not been as mobilised with regard to cervical cancer as with other cancers. The 60,000-name petition and the campaign has helped but we need more women to bang the table to ensure that this programme is rolled out as soon as possible.
Professor Prendiville
Thirty years ago, the evidence suggested that cancer was caused by a sexually transmitted disease and was more prevalent in the promiscuous. We now know this is not the case. However, as a result of that perception, which remained after the reality was understood, women who were not promiscuous felt they were not at risk, or felt that to go for a smear might identify them as being potentially at risk and might reflect upon their sexual behaviour. It is now clear that one cannot identify a high-risk population — there are no high-risk groups in any meaningful sense — and that the great majority of cases occur in absolutely normal women. As a result of this, the uptake by women of cervical screening worldwide, whether cytology or HPP, is increasing profoundly. The low uptake evident five years ago here and some 15 years ago in the United Kingdom is gone. If we can educate people about the realities of the disease, the stigma to which I referred will no longer exist. There will no longer be that perception and the uptake will be far higher.
I thank the delegation. I take Mr. McCormack's point that the State has let women down in regard to the provision of cervical screening services. Many different groups appear before Oireachtas committees and we do not want such meetings to be seen as wasted or useless exercises. It has been mentioned that the Tánaiste and Minister for Health and Children, Deputy Harney, will come before the committee in the coming weeks. In advance of that meeting, we will take on board the points made by the delegates. Chief among these is the fact that while 1 million women are eligible, only 7,000 present for cervical screening. Also significant is the figure mentioned of 50 to 75 unnecessary deaths annually and the cost estimate of €25 million to roll out a national screening programme.
We want to commit ourselves to a national screening programme as one of our priorities. It is important to stress that it is not good enough merely to listen to the delegates' presentation and then allow them to wonder whether anything will happen next. We are serious in our recognition of the import of this presentation and intend to monitor progress at six-monthly intervals. Deputy Cooper-Flynn wondered what our attitude would be if, as is the case with the screening programme, a company had begun rolling out a programme some 20 years ago and we were still wondering whether it will finally happen in six months or a year. It is important that we continue to press this case given that it will take 18 months to put into operation once it is approved. There is nothing to prevent the rolling out of the national educational programme in the meantime; there are no major cost prohibitions in this regard. The evidence presented today means it is nothing short of a scandal if we do nothing.
The Tánaiste told us when she came before the committee that the provision of a national screening programme is one of her priorities. I accept her word. However, it is up to us to convince the delegates that today's work has not been just another meeting. Deputy Fiona O'Malley observed that it is 18 months since the Irish Cancer Society made its presentation in Buswell's Hotel and we have still not moved on. This committee is not in the business of making false promises and we recognise the major input of the Irish Cancer Society. We will abide by our commitment to invite the delegation back in six months to inform it of what has been done in the interval.
We want to see something come of this. Unlike other presentations made to the committee, this relates to an area in which there is no doubt that action will ensure lives can be saved. There is not such certainty in regard to other issues with which the committee must deal. In this instance, however, the scientific evidence exists to make the case for action. I will ask the clerk to the committee, Ms Gina Long, to invite the delegates back in six months. This means they will not be waiting for a telephone call but will be certain of when they will return to discuss the progress made.
I thank the Chairman.
The Tánaiste intended to invite the delegates back in six months to discuss progress.
I stress that this is not a political issue. To be fair, this is part of the Tánaiste's brief to the committee. It is on her working paper for when she comes before the committee in March and it is something about which she does not need to be reminded. It is for the committee, however, to ensure this is a priority. One must consider the major successes of the economy and the fact that it would take only some €25 million to resolve this issue. It is important that we take action.
Sitting suspended at 10.45 a.m. and resumed at 11.10 a.m.