JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Wednesday, 25 Apr 2007

Cervical Cancer: Discussion with All Ireland Cancer Foundation.

Vice Chairman

We will now have a discussion with the All Ireland Cancer Foundation on the topic of cervical cancer. I welcome Dr. Henrietta Campbell and Professor Walter Prendeville from the All Ireland Cancer Foundation and ask them to commence their presentation. Members may then ask questions.

I draw attention to the fact that while members of this committee have absolute privilege, the same privilege does not extend to witnesses appearing before the committee. Members are reminded of the parliamentary practice that they should not comment on, criticise or make charges against any person outside the House or an official either by name or in such a way that would make him or her identifiable.

Dr. Henrietta Campbell

I thank the committee for inviting the All Ireland Cancer Foundation to this hearing. We are a relatively new charity, registered in Northern Ireland, the Republic of Ireland and the US. We are committed to raising the standard of care for cancer patients across the island of Ireland, and to bring the level of success for treatment of cancer up to that of our European partners and the US. From the work we have been doing, we know that if we can do that, we will save at least 1,000 lives each year.

Cancer means many things. There are many types of cancer and the foundation has prioritised its work in the short term to focus on the areas where most can be done with least effort, which is always the best way to start. Cervical cancer is a major issue across Ireland because of a lack of screening, certainly in the Republic of Ireland, which results in at least 70 or more women dying each year unnecessarily. The programme has been implemented and is in place in Northern Ireland for the past 20 years with great success, though there is still much to do.

In my previous role as chief medical officer in Northern Ireland and as chairman of the UK national cancer screening committee, I know the difficulty of implementing and running well-managed cervical screening programmes. I understand and have seen that they are life-saving, but they are difficult to implement. They need to be implemented properly. We all understand that such programmes need to be implemented in the Republic speedily and with high quality.

Even with a cervical screening programme in place, the women who fall through the net tend to be from the most deprived populations. As members may know, cervical cancer is one of the cancers that affect younger rather than older women. The incidence of cervical cancer peaks when women are in their late 30s, often when they are most burdened with the responsibilities of looking after children and a home.

While the medical profession recognises the importance of cervical screening and understands the deficit in a well-run programme, it was almost miraculous when we began to understand that cervical cancer was caused by a virus, which in time may be prevented through the development of a vaccine. In a very short time we have seen this become a reality.

I will hand over to Professor Walter Prendeville who I have known for some time as an international leader in the field of cervical cancer. He is well known across the UK and is president of the British Colposcopy Society. The national screening committee in the UK looks to the society as one of the great arbiters of truth in cervical cancer. I am delighted Professor Prendeville has come to support the work of the All Ireland Cancer Foundation in promoting cervical screening and the early implementation of the vaccine programme.

Professor Walter Prendeville

I will spend a few moments outlining the causes and implications of cervical cancer. Cervical cancer is caused by the persistence of a high risk virus called HPV virus. Almost all normal woman will get an ontogenic HPV infection in their 20s. It is ubiquitous and up to 80% or more will get it. That is a problem in terms of screening young women for that virus. We do not totally understand why it clears up in the majority of cases, yet the virus persists in some women.

When women reach the ages of between 30 and 35, the prevalence of this virus diminishes significantly to between 5% to 15% of the population. Testing for the virus is an opportunity to identify whether the cause of cancer is the HPV virus. Testing for the presence of the virus through borderline smears or after somebody has been treated for pre-cancer and perhaps as part of a primary screening programme will happen in the UK and everywhere else in the next five years.

As we do not have a screening programme for cervical cancer in Ireland, our rates of cervical cancer are higher than those in the UK, most of France, Italy and Germany. It is fair to say that women with cervical cancer is Ireland suffer more than women with cervical cancer elsewhere. Doctors in the UK have difficulty in training to carry out operations on women with cervical cancer because the disease has been caught at an earlier stage. Unfortunately that does not happen here, so cervical cancer presents later.

Cervical cancer is a morbid cancer which spreads to local organs, such as the bladder and the bowl, distant organs are then affected. If cervical cancer is not caught in the early stages, it becomes difficult to treat and causes much suffering. The treatment causes suffering and is ineffective in late stages. There is no doubt that the answer to dealing with cervical cancer is through prevention — recognising the disease early before it is a cancer, which is almost a contradiction. Cervical screening allows us to recognise the disease ten to 15 years before it is cancer. Treatment at that stage is relatively non-morbid and highly effective.

Unlike the breast, when one is looking for cancer in the cervix one is looking for abnormal cells that have not escaped from a tiny piece of skin on the neck of the womb. Removing that tiny piece of skin or destroying it is almost always curative and preventive. It is a wonderful cancer to challenge because one can see it, treat it and prevent it ten years before it can do harm. There is very good evidence for that.

If implemented in young girls, and perhaps boys, the vaccination programme is likely to prevent 70% of cervical cancer but no more, because the current vaccines are only directed towards two of the types, although they are by far the most common types. A good screening programme will prevent 70% of cervical cancers. The two together are very likely to prevent 95% of cancers. It is for public health doctors to decide how best to get value for money and to work out that equation. The advent of the vaccination offers a whole new dimension. We may be able to eradicate this disease worldwide. However, it should not stop us urgently rolling out the cervical screening programme. That is the message I would like to put across.

I would prefer to answer questions than to ramble on, if that is acceptable, Chairman.

Vice Chairman

At present we have a pilot cervical screening project in the mid-west area. Does that use the Pap smear test?

Professor Prendeville

Yes. The pilot programme in Limerick is a smear-based screening programme. The fact that the smears are now taken in a bottle rather than smeared onto a slide means that the potential to test for the virus is there, if the organising committee so decide. It would be an easy thing to do.

Vice Chairman

Does the pilot project test for the virus?

Professor Prendeville

No. They are looking at the changes in the cells that are caused by the virus.

Vice Chairman

Is the test for the virus a more accurate test or a more expensive one?

Professor Prendeville

There are two answers to that. It is more expensive but negotiations with the company mean that it could be a cost-effective intervention. However, at any one time 25% of women under 30 will have this virus and it will be acquired by 80%, cumulatively, by the time they are 30. Getting the virus is quite normal. Therefore, testing young women is not particularly useful because the virus will be found in a large number of people and they will simply be terrorised.

Until now most screening programmes have suggested using smears, perhaps up to the age of 35, and thereafter doing primary screening for the virus. This is the practice in countries such as Finland and the United Kingdom which are ahead of us. Whether or not we should go straight to virus testing is still being debated. The important thing is that samples are taken.

Senator Henry

I have a long interest in this issue. One of the first questions to answer is how the virus is spread. We must be factual about this. I am sometimes asked if it is spread on towels or if it can be acquired by using tampons, for example. It is important to say it is spread by sexual intercourse.

Professor Prendeville

Absolutely.

Senator Henry

Neither Professor Prendeville nor Dr. Campbell mentioned that. It is important to make it clear to people that they will not get cervical cancer from a towel or from tampons.

Professor Prendeville

I do not stress the link with sexuality because there is much rubbish in the public domain concerning a link between promiscuity and this virus. The virus does not only affect people who are promiscuous. It affects virtually everybody. It is a normal phenomenon, but it is sexually transmitted.

Senator Henry

We must have clarity about this sort of thing. Otherwise people will have the most bizarre notions as to how things can be spread.

It is disappointing that the screening programme has not been rolled out. I was in the Seanad over ten years ago when the legislation for the pilot programme was brought forward. What surprises me is that people in other parts of the country have not sued the Government for failing to ensure their cancers would be detected early when it is perfectly possible to do so and provide early treatment. I knew women who died of cervical cancer in their 40s at a time when they had great responsibilities in their lives. It is very difficult to deal with cancer once it has progressed. As a committee, we should do everything in our power to encourage the immediate extension of the screening programme. I am worried that so many smear cells are being send abroad for diagnosis. This is unfortunate, not only from a cost perspective but also because Irish laboratory workers will not gain experience in dealing with such cases. That is a great pity.

The vaccination programme affects only 70% of persons because there are two viruses involved. It is unfortunate that some — especially in the USA — have tried to say that if one vaccinates girls, it will only encourage them to be promiscuous. They can be totally monogamous but if their partner is not, they can contract the virus. However, that is not an argument against vaccination. We must ensure the screening programme is up and running before the vaccination programme and create a vaccination register to ensure we know who has been vaccinated. Dr. Campbell can speak about that matter much better than I can.

Vice Chairman

We will bank the questions asked. I welcome Ms Morton who was held up in traffic.

Ms Pamela Morton

It was a delayed Ryanair flight.

Vice Chairman

No comment.

Deputy Connolly

I thank the delegates for their presentation. I note that cervical cancer is one of those cancers which are preventable, a fact which in itself should make people sit up and take notice. People dread any form of cancer, but where it is preventable, they have a responsibility to present themselves for a clinical smear test. The cancer is also rare in the sense that it is visible; cancers are often not obvious until symptoms present. It is also the case that sometimes men will not present for tests. Does the same apply to women? In the case of breast cancer screening, the target population is notified to attend for tests. Is there is notification in the case of cervical cancer screening?

There are two methods of prevention. The vaccine and the screening programme each have a 70% success rate; together they have a success rate of 95%. The statistics cannot be ignored, given that prevention is better than cure. Whenever the word "vaccine" is mentioned, it tends to be linked with side effects. Are there side effects to this vaccine? What is the level of availability? Is the vaccine available on demand or will it be rolled out as part of a national programme? What is the cost involved? There is a great responsibility on us to highlight the problem and on women to present themselves for a smear test.

Vice Chairman

Has the pilot study identified any particular problems with roll out nationally; if so, what are they? Can the delegates summarise for members the ideal programme approach? Should there be a combination of screening and vaccination? At what ages should this be done? Do the delegates have any idea of the cost of the programmes before we make a recommendation?

Dr. Campbell

Those are the questions we hoped members would ask. We will take them in the round and I will ensure Ms Morton will have an opportunity to speak. Ms Morton is from Jo's Trust, a cancer charity which focuses specifically on cervical cancer. She has wide experience of many of the issues raised.

We should feel we have let down those women who have died over the past ten to 15 years because there has been no cervical screening programme in place. However, the opportunity now arises for us to outline that we are putting in place a cervical screening programme which will be of the highest quality, using the best new evidence and newest technology and that we are also putting in place a vaccination programme on an all-island basis. These are two different target audiences: the screening programme is for women aged 20 years upwards and the vaccine programme is aimed at children of school going age and including older people along the way.

Implementation of a proper screening programme will not detract from our ability to put in place a vaccination programme or vice versa. They are two separate and identified populations. We should say with confidence that we are a people who can step forward and take the lead with other developed countries in implementing a programme of preventing cervical cancer. I will ask Ms Morton to deal with the question on the side effects of the vaccine and what is happening in that regard. Dr. Prendeville will then outline the position of the screening programme in terms of who and what issues are involved and what has been identified from the pilot study.

Ms Morton

The clinical data available to us, specifically through Gardasil, the licensed vaccine in the UK and Europe, is that the efficacy of the vaccine has shocked the scientific world in that it has been proven to be 100% effective against types 16 and 18 which cause 75% of all cancers and 90% effective against types 6 and 11 which are low risk for cervical cancer but cause 90% of genital warts. It is a modern vaccine. There is a duty on us to explain to the public that this is a safe vaccine in terms of its construction. The more one learns about human papillomavirus, the more one realises what a stable virus it is. It dates back to when dinosaurs existed. It is an incredibly stable but very common virus. Gardasil and Cervix, when licensed later in the year, will protect against 75% of all cervical cancers.

On screening and the vaccination programmes, women in the UK are fortunate to have access to a free screening programme. However, for the 11th year running fewer women in the UK are attending for their free smear test. This amounts to approximately 1 million women. This issue is of major concern to me. I come from Ireland but have lived in the UK for 20 years. I have been working with Jo's Trust for seven years and have seen the impact of cervical cancer on women and, specifically — this hurts me most — young women who are mothers. Three women in Ireland, one from Galway, one from Limerick and one from Clare of approximately 33 years of age will not be alive this June. These women have never had a smear test. They all have young families and have presented with a vast cervical cancer. We are all aware that the mortality rate in Ireland for this type of cancer is high per 100,000 people compared with the UK.

Ireland should at this stage be engaging in a debate about running parallel screening and vaccination programmes. We are in the unique position of having a naive population. Therefore, the impact of vaccination and screening will be incredibly powerful. We must enter into this debate. I have found it difficult to enter into debate or even a discussion in respect of the introduction of a vaccination programme. I wholly understand that screening has been talked about for some 12 years. Five investigations are currently ongoing in respect of why we should have a screening programme. It is obvious why we should have a screening programme and we should ask why it has taken so long to implement one.

Deputy Connolly

Ms Morton constantly refers to women presenting for cervical screening tests. Are these women notified and asked to attend or is it a voluntary exercise?

Ms Morton

In the UK?

Deputy Connolly

No, in Ireland.

Ms Morton

The majority of women do not know anything about attending for screening.

Professor Prendeville

The programme in the United Kingdom and anywhere screening has been effective has a call and recall element. Women are included in a register and invited to be screened. That is what happens in Limerick. In the rest of the country women have a smear test if their doctor takes the opportunity to offer it or they ask for it when attending family planning or pregnancy clinics. That means we take a lot of smear samples from women when they are very young and the chance of them having cervical cancer or serious pre-cancer is very slight. If we rolled out the programme across all age brackets, we would be taking the same number of samples but would be far more effective in reducing the incidence of cervical cancer.

Deputy Connolly

What prevents that?

Professor Prendeville

The Government has not implemented a programme, although it has been advised for over a decade by a number of national cervical screening committees to do so. It is now committed to implementing one. In answer to one of the other questions regarding the problems revealed in Limerick, any cervical screening programme presents a challenge. It will only work if there are two important ingredients, a quality assurance programme and coverage of more than 80% of the target group. Having a national register of women of the appropriate age and calling and recalling them such that there is 80% coverage is a real challenge. However, it has been a challenge in every other country that has adopted a cervical screening programme. It is no different here. There may be slightly different challenges but none is insurmountable.

Senator Henry

Setting up such a register presents a very big problem because we do not yet have a population register.

Professor Prendeville

It is a problem. Australia got around it by developing a register of cervical cancer prevention eligible women. That was also done in Limerick. It was not impossible. What is necessary is coverage and quality assurance.

Vice Chairman

What does Professor Prendeville mean by coverage?

Professor Prendeville

If there is not coverage of 80% or more of the population across the appropriate age range, we cannot effect a serious reduction in the incidence of cervical cancer; if there is, we can.

Vice Chairman

Effectively, one needs the names and addresses of women in the appropriate age group. One must write to them; they come for their smear test and one must test 80% of them.

Professor Prendeville

Yes. There are strategies for targeting the other 20%. There is self-sampling for HPV testing in the small number who do not want to come. A number of strategies to improve coverage have recently been revealed to be effective. Coverage is important.

Vice Chairman

Do we have enough cytologists and technicians?

Professor Prendeville

The cytology quality assurance committee of the previous cervical screening programme piloted in Limerick addressed and continues to address that issue. There is a problem with cytoscreeners. However, a number of optimistic developments are on the horizon. One is that automation of cytology screening is proving valuable and effective. It is very likely it will reduce the need to have as many screeners; because of the recognised need, a number of laboratories have tried to recruit new cytoscreeners. It is another challenge but not an insurmountable one.

Vice Chairman

What about cost?

Dr. Campbell

I was coming to that matter. I realise is one of the questions we have not yet tackled. In money terms, the vaccine costs approximately €120 per shot. In a vaccination programme a young woman would need three shots. It sounds expensive. However, the proper question members of the committee will come back with as politicians is: how cost effective is the vaccine? There have been population studies of its cost effectiveness. Even at the current cost which will come down as more countries buy the vaccine, it has been shown to be cost effective because cervical cancer is a very expensive one to treat in terms of the radical surgery and follow-up care needed. The cost effectiveness debate has empowered politicians across Europe — in France, Germany, Italy, Norway and other countries — to make the decision to implement the vaccine programme. It is the same in Australia, Canada and right across the United States. Although it is expensive, its cost effectiveness is absolute.

Deputy Connolly

I do not doubt that the vaccine is cost effective. Will the vaccine be available to those who choose to go to their general practitioners to get it?

Dr. Campbell

Yes.

Deputy Connolly

A person can choose to purchase the vaccine for €360, three shots at €120 each, but would it be made available to a person with a medical card if doing so were cost effective?

Professor Prendeville

The Deputy is right in that general practitioners are prescribing the vaccine to those who desire it, particularly parents who want their children vaccinated, in respect of whom it is most useful. Whether it will be offered to the entire country or medical hard holders is a decision that will be made by Government. The vaccination is before the national vaccines committee, the deliberations of which are likely to influence the decision.

Deputy Connolly

Did I understand Professor Prendeville correctly in that parents have their children vaccinated?

Professor Prendeville

We need to vaccinate people who are HPV naive, those who have not encountered the virus. It is likely to be most effective among 11 and 12 year old children. Its preventative effect will not be seen by people in government currently because it will be 20 years or 30 years before the disease is prevented.

Deputy Connolly

Have we seen the effect of the vaccine in other countries?

Professor Prendeville

Yes.

Deputy Connolly

The programme must have been running elsewhere for 30 years or 40 years.

Professor Prendeville

No, the programmes have not shown a reduction in cervical cancer rates after 30 years of the vaccine because it has not been available for that long. They have shown that women who were HPV naive and received the vaccine did not get cervical cancer compared to those who were not HPV-vaccinated and got cervical cancer. The protective effect was profound, namely, 100% against viruses 16 and 18, which are the most important. We have four and a half years of data showing consistently high preventative levels, data that will be followed.

Deputy Connolly

Is there any point in a mature woman buying the vaccine or in giving it to adults with medical cards?

Dr. Campbell

That is one of the important research questions. A number of strains of HPV can cause cancer, but a 25 year old woman who is sexually active may only have been infected with one or two strains. The exciting question for the future is that of a multivalent vaccine that tackles and protects against a number of the strains of the human papilloma virus. There are signs that vaccines may be able to protect sexually active women in the older cohort in future. For us, the current target must be the population of young women before they become sexually active or are at risk of acquiring the virus.

Deputy Connolly

When the vaccine was introduced in other countries, were there any major ethical issues concerning parents taking decisions for 14 or 15 year olds? It may present as a significant problem.

Ms Morton

The highest degree of that matter has been seen in America where there is a right wing Christian majority. Some months ago, we conducted a poll in the United Kingdom to flush out the debates. Of the 2,500 parents of 12 year old daughters we targeted in Scotland, Wales, Northern Ireland and England, 80% would have no problem with vaccinating their daughters against two HPV types that could cause cervical cancer. Only 4% were against vaccinating their daughters, largely those who were against vaccination. The 80% figure was much higher than expected.

Approximately two months ago, Professor Jane Wardle of Cancer Research UK conducted a similar poll in which she found that 78% of parents had no problems with vaccination, endorsing our poll. The psycho-social impact of the sexual element did not hinder their answers. They were positive about the vaccination and wanted to protect their daughters against a cancer that was preventable or, if acquired, could cause terrible tragedies.

Senator Henry

Returning to cervical screening, if we could give the foundation money tomorrow, would it have the staff available to start on an all-island basis? How much money would the Minister for Health and Children need to provide?

Professor Prendeville

The pilot programme in Limerick has established some clear ground rules. In anticipation of the difficulties both organisational and cytoscreener, etc., considerable work has been done on quality assurance, coverage and laboratory facilities. While it would be a challenge, the Irish cervical screening programme would be able to deliver a screening programme if it were implemented at the beginning of next year or the end of this year.

Senator Henry

Does Professor Prendeville have any idea of costs?

Professor Prendeville

Costs are more difficult to quantify because it depends on how much the smear takers are paid, how much the test costs and how much the organisation costs. I will not answer the question because it depends on how much the general practitioners are awarded for taking the smear. The cost of processing it is relatively small. I will not be drawn further on the matter.

Senator Henry

I wish the foundation luck. It has been terribly disappointing to see this matter drag on. Women with young children have lost their lives — in some cases they have been caring for parents as well as young children. That loss of life has been so avoidable. Are many cases discovered at routine antenatal clinics?

Professor Prendeville

No, most women who present with cancer have not had a smear. That is the classic scenario here and abroad.

Senator Henry

Does it mean that if they already had children, no smear was ever taken at an antenatal clinic?

Professor Prendeville

There are a number of problems of carrying out a smear antenatally. However, that is a form of opportunistic screening. The answer is to have systematic call and recall, which eliminates the need to carry it out antenatally, as it would already have been done.

Vice Chairman

In summary, Professor Prendeville proposes an immediate roll-out of the national screening programme and also implementation of the vaccination programme in girls up to the age of 12 who have not had sexual relations.

Professor Prendeville

Absolutely.

Vice Chairman

The committee will endorse that and will make that recommendation to the Minister for Health and Children, and the HSE as a matter of urgency. I thank the witnesses for coming and particularly Ms Morton who travelled from the UK. They have given us a comprehensive presentation on this important issue and have responded to the questions raised by the members. As this is the last committee meeting before the Dáil goes into recess, shall we say, it is quite an historic one.

Professor Prendeville

It was a pleasure.

Dr. Campbell

I thank the committee for giving us the opportunity. I will leave some information on the All Ireland Cancer Foundation. If members need to make contact with us again, we would be delighted to facilitate them.

Vice Chairman

That is much appreciated.

The joint committee adjourned at 10.50 a.m. sine die.